Global HPV vaccination programs and coverage rates: a systematic review

Summary

Background

Many countries have included the human papillomavirus (HPV) vaccine in their national immunization programs. However, comprehensive studies on global HPV vaccination coverage remain scarce. This study aims to provide an in-depth overview of the current status of global HPV immunization programs and assess HPV vaccination coverage worldwide.

Methods

In this study, we performed a comprehensive search of the PubMed and Embase databases (from their inception to February 28, 2025), websites, the WHO database, to identify HPV vaccination policies and coverage rate data from all 194 WHO member states. Studies included in our analysis reported population-based HPV vaccination coverage rates. Additionally, we analyzed trends in HPV vaccination coverage from 2010 to 2023 and evaluated cervical cancer incidence rates during the same period in 15 early-adopter countries of HPV vaccines. Subgroup analyses were conducted by sex and age. The systematic review was prospectively registered in PROSPERO (registration number: CRD42023488463).

Findings

As of February 28, 2025, 148 WHO member states have incorporated the HPV vaccine into their national immunization programs. 132 countries reported HPV vaccination coverage estimates for the first dose and 129 countries reported full doses in 2023, and the weighted average coverage of the first and full dose of HPV vaccination in girls aged 9–14 years were 61.6% (95% CI: 50.9%–71.8%) and 47.6% (39.7%–57.4%) respectively. Among 132 countries, fifteen countries (11%) achieved 90% coverage for the first dose. Upper-middle income countries presented the highest coverage, with 71.7% (95% CI: 59.1%–78.6%) for the first dose. Age-specific analysis revealed that vaccination coverage of China peaked in women in 20–24 age group and was lowest in 9–14. Time trend analysis demonstrated that in most assessed countries, cervical cancer incidence is showing a declining trend.

Interpretation

Global HPV vaccination coverage remains significantly below the target of 90%. Strategies to effectively enhance HPV vaccination coverage must be identified, developed, and implemented to address this gap.

Funding

CAMS Innovation Fund for Medical Sciences (2021-I2M-1–004, 2023-I2M-3-019); National High Level Hospital Clinical Research Funding (2022-PUMCH-D-003); Supported by Sanming Project of Medicine in Shenzhen (SZSM202311011).

Research in context.

Evidence before this study

In 2020, the World Health Organization (WHO) launched a global initiative to accelerate the elimination of cervical cancer and set interim targets for 2030, one of which is for 90% of girls to complete human papillomavirus (HPV) vaccination before the age of fifteen. Although the HPV vaccine has been available since 2006, and many countries have gradually introduced it into their national immunization programs, there is still no ongoing, accurate estimate of coverage rates. Previous studies on global HPV vaccination coverage have been conducted, but these studies are far from current and lack comprehensive analyses.

Added value of this study

We analyzed the most recent 2023 data on HPV vaccination coverage by country and target age for the first dose, full dose coverage rate. For countries that have not included the HPV vaccine in their national immunization programs, we analyzed their current HPV vaccination situation in detail, including ongoing and planned HPV vaccination pilot projects. We conducted sex-specific and age-specific analyses, along with time-trend analyses of HPV vaccination coverage and corresponding cervical cancer incidence rates among women aged 20–29 years in the respective years.

Implications of all the available evidence

The results of the study show that as of February 2025, a total of 148 WHO member States have incorporated HPV vaccines into their national immunization programs, offering free HPV vaccines to their primary target populations, and the global coverage rate of the first dose of HPV vaccine for girls in 2023 is 27%, and the full dose coverage rate is 20%. The introduction and widespread adoption of HPV vaccines continue to face substantial financial challenges in certain low- and lower-middle-income countries. Addressing health inequities will require leadership at both global and national levels to improve access to HPV vaccination for all women and expedite the elimination of cervical cancer as a major public health issue.

Introduction

Cervical cancer is one of the most common cancers among women. According to GLOBOCAN 2022 data, the incidence and mortality of cervical cancer both rank fourth globally among women.¹ Persistent infection with high-risk human papillomavirus (hrHPV) is a key factor in the occurrence of cervical precancerous lesions and cervical cancer, more than 90% of cervical cancers are related to hrHPV.2, 3, 4 HPV vaccination can effectively prevent cervical cancer.5, 6, 7 Since the introduction of the HPV vaccine in 2006, many countries have gradually adopted its use. In 2020, the World Health Organization (WHO) proposed the ‘Global Strategy to Accelerate the Elimination of Cervical Cancer,’ committed by 194 countries, with one of its key 2030 targets being to ensure that 90% of girls complete HPV vaccination by the age of 15.⁸ HPV vaccination is essential for the elimination of cervical cancer, particularly in low-income countries with a high disease burden and limited cervical cancer screening and treatment programs.⁹ Monitoring HPV vaccination coverage is crucial for evaluating the effectiveness of vaccination and the potential impact of the HPV vaccine on related diseases. However, there is currently limited research on global HPV vaccination coverage rates. This study aims to provide a comprehensive overview of global HPV vaccination policies, analyze the global HPV vaccination coverage rates, examine the temporal trends of HPV vaccination coverage and incidence rates of cervical cancer in the female population in corresponding years, thereby offering evidence for future immunization policy formulation.

Methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The protocol for this systematic review was prospectively registered in PROSPERO (registration number: CRD42023488463).

Search strategy and selection-inclusion/exclusion criteria

In this systematic review, we provide a comprehensive analysis of WHO database estimates of global HPV vaccination coverage rates derived from administrative and survey data reported annually to WHO via the WHO/UNICEF Joint Reporting Form (JRF).¹⁰ Additional information is systematically retrieved from other public websites and the PubMed and Embase databases to identify global HPV vaccination status and coverage rates.

We systematically searched scientific literature published in PubMed and Embase databases (from their inception until February 28, 2025), using search terms related to “human papillomavirus”, “vaccination coverage”, “vaccination rate”, “vaccination uptake”, etc., without language restrictions. The detailed search strategy is provided in Supplementary Table S1.

The data sources on HPV vaccination coverage included in the literature consist of official estimates and survey data. Studies included must specify the region, vaccination period, basic characteristics of the target population (e.g., age, sex), and the HPV vaccination coverage rate. The survey must describe the specific survey methodology. The following studies were excluded: conference abstracts or those without full-text availability, studies focusing on vaccination rates of specific populations, research on the knowledge, attitudes, and behaviors of patients or healthcare providers, influencing factors of vaccination and the effects of interventions, studies limited to small-scale regions (such as a community or a school), studies that did not specify the vaccination start and end times or the characteristics of the vaccinated population. Data were extracted by four independent researchers, and differences were resolved through discussion.

Data extraction and quality assessment

For the literature searched in the database, we extracted the following data: author, publication year, journal name, country, study type, sample size; age at vaccination, sex, HPV vaccine trade name, HPV vaccine characteristics, payment method, dose of vaccination, HPV vaccination coverage rate, etc. The risk of bias in the included studies was evaluated using the Appraisal tool for Cross Sectional Studies (AXIS tool) (Supplementary Table S6).¹¹

Data analysis

As defined by the WHO, a Member State is recognized as having an HPV vaccination program if it reports through the JRF that HPV vaccination is officially integrated into its national immunization program, either at the national or subnational level. WHO has established two key coverage indicators for HPV vaccination: (1) The performance coverage rate of the HPV vaccination program, which describes the vaccination coverage according to the national schedule and the eligibility criteria for each calendar year (target population planned up to age 14). (2) The HPV vaccination coverage by age 15, referring to the proportion of individuals who reached the age of 15 during the reporting year and had received the HPV vaccine at any time between the ages of nine and fourteen, up to any point in that calendar year. This study primarily examines WHO estimates of HPV vaccination program performance, focusing on the coverage of the first dose and full dose (the second or third dose for 2-dose or 3-dose schedules respectively).

We calculated global and regional coverage rates weighted by the population size of each country. The weights were derived from official population estimates provided by the United Nations (UN) Population Division.¹² Countries without data on vaccination rates and regional classifications were not included in the calculations. Bootstrap 95% confidence intervals were estimated using the percentile method (3000 replications). Estimates were aggregated by different regional groupings: the UN Sustainable Development Goals (SDGs) classification, WHO regions, and income levels using the World Bank classification.13, 14, 15

In addition, age-specific and sex-specific data on HPV vaccination coverage were supplemented through a literature search from PubMed and Embase database. When multiple sources of information were not inconsistent, official estimates were prioritized, and if official estimates were not available, the most representative sample was selected. When multiple studies used the same data source, the original research literature was considered authoritative. The data used for the analysis of vaccination coverage rates by sex and age in each country were drawn from the same data source or from the same study. We also considered time trends of the first dose and full dose vaccination coverage and cervical cancer incidence rates in the corresponding years from 2010 to 2023 in 15 countries that included HPV vaccine in the national immunization programs at the earliest in 2006–2008 (as HPV vaccination coverage estimates of WHO database were available from 2010 onward). Estimates of cervical cancer incidence rates for each country were obtained from the Global Burden of Disease (GBD) 2023 database, which is a global research project led by the Institute for Health Metrics and Evaluation (IHME), aiming to comprehensively assess health issues worldwide, including the incidence, mortality, disability rates, and risk factors of diseases. All data analyses were conducted using R (version 4.2.3).

Ethics

Ethics approval was not required as this study used only de-identified, publicly available secondary data.

Role of the funding source

The funders of the study had no role in the study design, data collection, data analysis, data interpretation, writing of the manuscript, or decision to submit the manuscript.

Results

A total of 3707 studies were identified based on the search criteria from PubMed and Embase databases. After removing duplicates, 1212 articles were excluded. The titles and abstracts of the remaining 2495 articles were screened, leading to the exclusion of an additional 2225 studies. Full-text evaluation was conducted on the remaining 270 articles, from which data were extracted for 143 studies from PubMed and Embase. Combined with data of the websites, 15 articles of PubMed and Embase databases, WHO data, and one report were ultimately included for data analysis. Fig. 1 showed the specific search and screening process. Detailed characteristics and assessments of risk of bias for each included study were presented in the Supplementary Tables S2 and S6, respectively.

Fig. 1.

Study selection. PRISMA flow diagram of study selection. This WHO database is the about Human Papillomavirus (HPV) vaccination coverage. The data represent administrative and official HPV vaccination coverage reported annually through the WHO/UNICEF Joint Reporting Form on Immunization (JRF). 1 report is from the United Nations Population Fund 2023 report. Abbreviation: WHO, World Health Organization.

Fig. 2 presented key milestones in the development of the HPV vaccination. This timeline highlights key milestones in the development, approval, and global implementation of HPV vaccines from 2006 to 2025, including the U.S. Food and Drug Administration (FDA) approvals, WHO Position papers, and the incorporation of the HPV vaccines into national immunization programs. As illustrated in Fig. 3 and Supplementary Table S7, by February 28, 2025, 148 (76%) of the 194 WHO member States have included the HPV vaccine in their national immunization programs, and two of these countries are included at subnational level. Among the 148 countries, nine implemented HPV vaccination programs during 2006–2007, and five countries introduced the vaccine in 2024–2025. Notably, 2019 represented a peak year for HPV vaccine adoption, with 17 (11%) countries integrating it into their national immunization programs. Of the 148 countries, 72 (49%) countries limited vaccination to females, whereas the remaining 76 (51%) implemented vaccination programs for both sexes. 67 (45%) countries adopted a one-dose HPV vaccination schedule, while 4 (3%) implemented a two-dose schedule with a twelve-month interval, and 73 (49%) adopted a two-dose schedule with a six-month interval. Regarding vaccine delivery methods, 80 (54%) countries utilized school-based delivery, 29 (20%) countries employed health facility-based delivery, and 18 (12%) countries implemented both delivery methods.

Fig. 2.

Key milestones in the development of the HPV vaccination. Abbreviations: FDA, Food and Drug Administration, WHO, World Health Organization. HPV, Human Papillomavirus.

Fig. 3.

Global status of the HPV vaccine introduction into national immunization programs by year of introduction in 2024.

For the 46 countries that have not yet incorporated HPV vaccine into their national immunization programs, we conducted a comprehensive web search to identify the status of HPV vaccination in these countries. Currently, 13 (28%) countries have initiated or are planning pilot/demonstration projects, while 33 (72%) countries have not yet undertaken such initiatives. (Fig. 3, Supplementary Table S3). Eleven of the thirteen countries have completed one or more pilot/demonstration projects, while two countries plan to launch HPV vaccination projects nationwide or at subnational level within this year. For countries that have not yet implemented or planned HPV vaccination pilot/demonstration projects, such as Ukraine, the primary recommendation is for girls aged 9–14 to receive the HPV vaccine at their own expense.

Fig. 4a and Table 1 present the first-dose HPV vaccination coverage for girls in the target age group in 2023 and global and regional coverage weighted by the population size of each country, respectively.¹⁴ 132 of the 148 countries reported the coverage data, with 15 countries (Bhutan, Burkina Faso, Cabo Verde, Cambodia, Cook Islands, Denmark, Iceland, Niue, Norway, Portugal, Sweden, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan) achieving 90% coverage. We estimated that the first dose of the HPV vaccination across 132 countries was 61.6% (95% CI: 50.9%–71.8%). HPV vaccination coverage was estimated to be highest in Upper-middle income countries, at 71.7% (95% CI: 59.1%–78.6%) and lowest in Lower-middle income countries, at 46.4% (95% CI: 34.0%–72.1%). In high-income and upper-middle income countries, HPV vaccination coverage for the first dose ranges from 1% to 99%, with Grenada covering only 1%. All low-income and lower-middle-income countries have vaccination coverage rates above 18%. SDG regions of Latin America and the Caribbean (71.0%, 95% CI: 60.8%–80.5%) presented the highest coverage estimates.

Fig. 4.

(a) First dose program coverage of HPV vaccination for girls by country income level in 2023; (b). Full dose program coverage of HPV vaccination for girls by country income level in 2023. The program coverage in the figure is the WHO recommended vaccination coverage for different ages within the 9–14-year age group, depending on the target population of each program in each country. Income level information is not available for two countries (Cook Islands, Niue).

Table 1.

The estimated global and regional HPV vaccination coverage rates for women in 2023, based on the program performance coverage indicators.

	First dose (HPV 1)			Full dose (HPV c)
	Countries with data (N)	Coverage (weighted by population size)		Countries with data (N)	Coverage (weighted by population size)
		%	95% CI		%	95% CI
Global
Womena	132a	61.6	50.9–71.8	129	47.6	39.7–57.4
Men	55	57.9	47.9–64.3	51	46.1	37.9–53.9
Coverage by country income level
Upper-middle income	39	71.7	59.1–78.6	38	48.9	34.0–64.4
Low-income	11	71.1	60.0–88.0	9	52.7	32.6–84.3
High income	50	68.1	59.7–73.6	51	55.3	50.1–63.7
Lower-middle income	30	46.4	34.0–72.1	29	39.9	28.4–63.3
Coverage by SDG regions
Latin America and the Caribbean	28	71.0	60.8–80.5	28	61.8	49.9–68.3
Oceania	14	70.6	62.9–74.8	14	69.2	57.8–70.7
Europe and Northern America	38	68.6	59.3–73.2	38	55.8	50.5–65.6
Eastern and South-Eastern Asia	11	63.4	39.5–79.9	10	31.6	19.1–57.5
Sub-Saharan Africa	28	58.5	42.7–78.0	26	47.9	35.1–70.2
Northern Africa and Western Asia	5	55.5	45.2–65.6	6	44.4	39.1–55.0
Central and Southern Asia	7	36.3	22.4–92.4	7	35.4	22.0–92.7
Coverage by WHO region
Region of the Americas	30	72.1	63.2–79.3	29	59.5	51.7–67.8
European region	43	67.1	58.7–75.9	43	60.9	51.7–71.5
African region	28	58.5	43.5–77.7	26	47.9	35.1–70.4
Eastern Mediterranean region	2	58.0	42.0–71.0	3	41.7	39.0–54.0
South-East Asia region	7	57.3	23.9–80.2	7	28.9	18.6–51.7
Western Pacific region	22	48.3	34.0–79.7	21	33.3	16.2–74.4

128 countries reported both the first dose and full dose of HPV vaccination coverage, 4 countries reported only the first dose coverage, and 1 country reported only full dose of HPV vaccination coverage. Bootstrap 95% CIs were estimated using the percentile method (3000 replications).

Abbreviations: 95% CI, 95% confidence interval. N, number; HPV1, HPV vaccine first dose program coverage; HPVc, HPV vaccine full dose program coverage; SDG, Sustainable Development Goal; WHO, World Health Organization.

^aDue to limited data of men, the analyses for coverage by SDG regions, coverage by country income level, and coverage by WHO region were all analyzed among women. Income level information is not available for two countries.

Fig. 4b and Table 1 illustrate the full dose coverage rates of HPV vaccination across 129 countries. Eleven countries (Burkina Faso, Cabo Verde, Cambodia, Cyprus, Niue, Norway, Portugal, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan) have achieved 90% coverage for the full doses. High income countries (55.3%, 95% CI: 50.1%–63.7%), low-income countries (52.7%, 95% CI: 32.6%–84.3%), and lower-middle-income countries, (39.9%, 95% CI: 28.4%–63.3%), upper-middle income countries (48.9%, 95% CI: 34.0%–64.4%) presented the coverage estimates. In high-income group, Norway reported the highest coverage rates at 94%. In upper-middle income countries, only Turkmenistan achieved 90% of the target, with a vaccination rate of 99%, while six countries had a vaccination rate below 10%. All low-income and lower-middle-income countries had vaccination coverage rates above 10%. HPV vaccination coverage was estimated to be highest in SDG regions of Oceania, at 69.2% (95% CI: 57.8%–70.7%), and lowest in Eastern and South-Eastern Asia, at 31.6% (95% CI: 19.1%–57.5%).

For countries that have not yet incorporated the HPV vaccine into their national immunization programs, their vaccination coverage was not included in the WHO database. We obtained the most recent data on HPV vaccination coverage rates of China and Vietnam. In 2022, the first-dose HPV vaccination coverage rate among girls aged 9–14 in China was only 4%, with a full-dose coverage of 0.3%.¹⁶ In Vietnam, as of 2023, only 12% of women and girls aged 15–29 received the HPV vaccine.¹⁷

The global HPV vaccination coverage rate of 2023 is 27% for girls with the first dose and 20% for full doses. For boys, the first dose and full dose coverage are 7% and 6%, respectively.¹⁸ And HPV vaccination coverage by age 15 is 20% for women receiving the first dose and 15% for the full doses. For men, the coverage by age 15 is 7% for the first dose and 5% for the full doses (Supplementary Tables S8 and S9). By analyzing the vaccination rates of countries with available data, the first-dose HPV vaccination coverage for boys in the target age group was 57.9% (95% CI: 47.9%–64.3%), and the full-dose vaccination coverage was 46.1% (95% CI: 37.9%–53.9%), both lower than the corresponding coverage rates for girls (Table 1). Compared to upper-middle-income and lower-middle-income countries, HPV vaccination coverage among boys in high-income countries are higher but remain significantly lower than those among girls (Supplementary Figure S1). The result is similar to the sex-specific vaccination coverage of five countries obtained through our literature review (Supplementary Table S4).

Supplementary Table S5 shows age-specific HPV vaccination coverage rates for females across different dose numbers in twelve countries from published literature. The coverage rate of first-dose HPV vaccination varies by age group across countries. In China, vaccination coverage peaked in women in the 20–24 age group and was lowest in the 9–14 ages. In Australia, vaccination coverage was highest among women in the 14–15 age group and lowest among women in the 20–26 ages. For full dose coverage rates, women in the 20–29 age group presented the highest coverage in China and South Korea, and China had the lowest coverage in the 9–14-year age group. In contrast, the vaccination coverage rates among women over 20 years old were relatively low in Australia, France, and Switzerland.

Fig. 5a and b present the temporal trends of the first-dose and full-dose HPV vaccination rates in 15 early-adopter countries of HPV vaccines, along with cervical cancer incidence rates in women aged 20–29 during the same years. Overall, HPV vaccination coverage rates showed varying trends across countries as years progress. For the first-dose HPV vaccination coverage, Belgium, France, Germany, Luxembourg, New Zealand, Spain, Switzerland, and the United States showed an upward trend over time. Vaccination coverage in Australia, Portugal, and the United Kingdom remained stable. Denmark, Palau, Panama, and San Marino presented high fluctuations in vaccination coverage. Full-dose vaccination coverage in these countries showed a similar trend compared to the first dose coverage. Time trend analysis demonstrated that in most assessed countries, cervical cancer incidence is showing a declining trend (Supplementary Table S10).

Fig. 5.

(a) Time trends of first dose program coverage of HPV vaccination and cervical cancer incidence rates of women aged 20–29. (b) Time trends of full dose program coverage of HPV vaccination and cervical cancer incidence rates of women aged 20–29.

Discussion

In this review, we provide a comprehensive analysis of global HPV vaccination coverage data, supplemented by an analysis of countries that have not yet included HPV vaccines in their national immunization programs. The results show that HPV vaccination coverage rates vary widely across countries, and global coverage rate remains low. Methods to effectively increase HPV vaccination coverage need to be explored and implemented, especially in underdeveloped regions, to achieve the WHO target of 90% vaccination coverage by 2030 and to eliminate cervical cancer as a public health problem.

Since the introduction of the quadrivalent vaccine in 2006,¹⁹ HPV vaccines have been introduced in various countries, and as of February 2025, 148 WHO member States have included HPV vaccines nationwide or in part in their national immunization programs. In addition, 14 (54%) out of 26 low-income countries and 20 (37%) out of 54 lower middle-income countries still do not include HPV vaccines in national immunization programs. For countries that have not yet included HPV vaccines in their national immunization programs, many women also have the opportunity to be vaccinated through pilot/demonstration projects. Such as China, as of October 2024, eleven provinces as well as cities such as Zhengzhou, Ordos and Chengdu have included HPV vaccination in the vaccination program for the target population.20, 21, 22, 23 Papua New Guinea and Tunisia also plan to launch pilot/demonstration projects in 2025. The results of these projects will also provide important references for the early introduction of HPV vaccines in these countries.

Although the WHO recommended prioritizing HPV vaccination for girls aged 9–14, the global first-dose vaccination coverage rate for this age group in 2023 is only 27%. HPV vaccination implementation and HPV vaccination coverage rates vary widely among countries with different income levels. In 2023, upper-middle income countries presented the highest vaccination coverage for the first dose, low-income countries follow closely behind. Due to the high initial price of the HPV vaccine, high-income countries were the first to introduce it, and despite the early introduction in these countries, vaccination coverage rates in some of them are still low. Our findings suggest that some low-income (Rwanda, Uganda) and lower-middle income (Bhutan, Tanzania) countries have higher HPV vaccination coverage than high-income countries, which may be related to targeted women in low-income countries being vaccinated mainly through pilot/demonstration programs or HPV vaccination campaigns. This result is consistent with the findings of a previous related study.²⁴

In addition, HPV vaccination coverage among women of all age groups in different countries also varies to varying degrees. Our finding showed that for countries such as Australia, France, Switzerland, and Brazil, HPV vaccination coverage showed a significant downward trend with the increase of age groups, while in China and South Korea, vaccination coverage showed a trend of first increase and then decline, and the maximum coverage rate was concentrated in the 20–29 age group. This result may be due to the fact that China and South Korea had not included HPV vaccine in the national immunization program at that time, and people did not pay enough attention to the vaccination of low age groups, and most of the people who received HPV vaccines were adults with a certain economic ability.

The HPV vaccination coverage rates among different genders show significant disparities. Estimates from 2023 indicate that the global first-dose HPV vaccination rate for boys is lower than for girls. This discrepancy arises from the current focus on girls as the primary target group for HPV vaccination. However, studies have shown that the prevalence of HPV among males over the age of fifteen is substantial, and sexually active males serve as important reservoirs for genital HPV infections.²⁵ These findings underscore the importance of HPV vaccination for males. Adopting gender-neutral vaccination strategies in the future could help reduce the circulation of HPV vaccine-covered types within the population.

Given the current global HPV vaccination coverage situation, exploring effective strategies to improve vaccination rates is of paramount importance. Research has shown that implementing supportive national recommendations and policies, school-based HPV vaccination programs, increasing the supply of low-cost vaccines, and adopting single-dose vaccination schemes can significantly boost HPV vaccination rates.^26,27 In some resource-poor, low-income and lower middle-income countries, school-based strategies and vaccination delivery through mobile platforms have achieved high vaccination coverage rates (e.g., Rwanda reached 94% in 2019). However, many low-income and middle-income countries lack funding for school health programs, which makes HPV vaccination in schools often costly and difficult to sustain.

Demonstration or pilot projects in many countries have been carried out primarily with the support of Global Alliance for Vaccines and Immunization (Gavi).²⁸ However, Gavi eligibility is based on national income levels, with a primary focus on the world's poorest countries. Without additional support, countries not eligible for Gavi funding may face significant economic and other barriers when introducing HPV vaccination programs.

In the context of the current vaccine supply constraints, there is growing attention on the single-dose HPV vaccination strategy. Studies on the effectiveness of single-dose HPV vaccination in recent years have shown that it can provide comparable protection to two- or three-dose regimens.29, 30, 31, 32, 33 In 2022, the Strategic Advisory Group of Experts on Immunization (SAGE) recommended adopting a single-dose or two-dose HPV vaccination schedule.³⁴ In December of the same year, the WHO updated its position paper on HPV vaccines and recommended a single-dose vaccination for women aged 9–20 years (with priority given to the 9–14 age group). As of February 2025, 67 countries globally have announced the implementation of the single-dose HPV vaccination program.³⁵ Currently, Merck is planning clinical trials for the single-dose schedule of the nine-valent HPV vaccine to assess its efficacy and safety compared to the three-dose regimen.³⁶ In China, multi-center studies are underway to evaluate the effectiveness of the single-dose HPV vaccination strategy for Chinese women.³⁷ The adoption of the single-dose vaccination approach could play a crucial role in alleviating vaccine supply shortages and improving vaccine accessibility and cost-effectiveness in the future.

Additionally, time trend analysis demonstrated that in most assessed countries, HPV vaccination coverage is increasing or remaining stable, while cervical cancer incidence is showing a declining trend. However, the declining trend is not evident in some countries. This result can be explained by the fact that the HPV vaccination coverage data we used are estimates from the WHO/UNICEF, specifically for girls aged 9–14 in each country. However, the peak age for cervical cancer is between 30 and 50 years. Even in countries where HPV vaccination was first offered to girls aged 9–14 as early as 2006, the women vaccinated at that time are only 25–30 years old in 2022, and the protective effect of the HPV vaccine against cervical cancer may not yet be fully realized at this age. However, related modeling studies suggest that vaccinating only girls with the HPV vaccine (with a coverage rate of 90%) would reduce the median age-standardized incidence of cervical cancer in Low- and Middle-Income Countries from 19.8 to 2.1 per 100,000 women per year over the next century.³⁸ Therefore, the protective effect of the HPV vaccine against cervical cancer in the population requires a longer observation period.

This study has several strengths. First, it is the first to analyze global HPV vaccination coverage using data after 2020, which allows for a more comprehensive examination of changes in HPV vaccination rates following the release of the WHO's 2030 agenda. Moreover, in this study, we conducted a thorough data retrieval and analysis. In addition to the analysis based on WHO database, we performed an age-specific analysis of HPV vaccination coverage, integrating findings from the literature. Furthermore, we provide detailed information on HPV vaccination in countries that have not yet included the HPV vaccine in their national immunization programs.

However, there are some limitations. First, although we conducted a systematic literature search, data for most countries were sourced from WHO database, which lack detailed reports on study design, study population and related parameters, so quality assessment could not be conducted. Secondly, the unavailability of age-specific and sex-specific data restricted the ability to perform detailed subgroup analyses across all countries. Thirdly, due to data constraints, we did not conduct an analysis of the factors that affect vaccination rates. Additionally, we were unable conduct time-trend analyses for all countries due to the constraints of the available data. Finally, heterogeneity in vaccine brands and vaccination strategies across countries introduces challenges in the comparability of the data, which may affect the reliability of cross-country comparisons.

To sum up, globally, 148 WHO member states have incorporated the HPV vaccine into their national immunization programs, yet vaccination coverage remains highly variable and far below the WHO target of 90% coverage for girls by age 15. Economic barriers, particularly in non-Gavi-eligible countries, hinder vaccine introduction and scale-up, underscoring the need for increased international support. In the future, developing effective strategies to enhance HPV vaccination coverage and integrating these efforts with cervical cancer screening programs are critical to addressing this pressing public health challenge.

Contributors

JH contributed to the overall study design, data analysis, and manuscript preparation. JH, LZ and YC contributed equally. Concept and design: HC, Prof. Zhu, JH. Acquisition, analysis, or interpretation of data: JH, YC, LZ, YZ. Drafting of the manuscript: JH, LZ. Critical review of the manuscript for important intellectual content: YZ, ML, LW, RC, YD, LD. Statistical analysis: JH. Obtained funding: Prof. Zhu. Administrative, technical, or material support: HC, Prof. Zhu, YZ. Supervision: HC, Prof. Zhu. Other - Manuscript writing and revision: JH, LZ, YC. JH, LZ, HC and YC directly accessed and verified the underlying data. All authors read and approved the final version of the manuscript.

Data sharing statement

The study protocol, search strategy, inclusion and exclusion criteria, and detailed information on each included study in this systematic review can be found in the online supplement. All analyses were conducted using R statistical software (version 4.2.3). Inquiries regarding other data or materials from the study can be directed to the corresponding authors.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

Prof. Zhu reported grants from CAMS Innovation Fund for Medical Sciences, National High Level Hospital Clinical Research Funding, and Sanming Project of Medicine in Shenzhen during the conduct of the study. No other disclosures were reported.