Review Reports

Round 1

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

Estimated Authors,

I've read with interest the present narrative review dealing with an interesting topic, i.e. vaccination of HPV delivered to no cost (free) to high-risk subjects in PRC. Authors should be commended for summarizing a quite complicated topic, providing a summary of available policies in a highly diverse country such as PRC (whose internal heterogeneities are too often disregarded and overlooked by foreign researchers, at least from the point of view of the present reviewer, and therefore the present study would possibly fill a knowledge gap among international readers).

Well, all in all I think that some improvements may be useful.

First, provide some further context: (1) the size of the problem cervical cancer in PRC in the last decade; (2) the proportion of vaccinated subjects in both female AND male population; (3) stressing the provinces characterized by very high and very low rates of both vaccination and cervical cancer; I'm not asking the authors to provide a review within the present review, but some very basic information may radically improve the readability of the paper;

Second, provide a map of China pointing out the provinces involved in your analysis;

Third, in your study you did provide some information about a local manufacturer; it could be quite interesting providing a summary (either as a section within the main text or as a table) of which HPV vaccines are currently available in PRC, and which serotypes are currently covered by available formulates;

Fourth: tables are highly informative, but please increase their readability by increasing the size of the characters; the same for the figures;

Fifth, a rapid review of the English text (mostly appropriate) could improve its overall quality (e.g. sentence in row 177 starts with "2024"; it is clearly not a mistake but it could be improved by removing a number - even a calendar year, as the first word of the sentence; similar instances in subsequent blocks of text)

Finally, I would suggest to implement a summary table of the main web sites included into the analyses, with a short comment of the kind of data and information it could provide (e.g. take in consideration the following header: | WEB ADDRESS | COMPANY / GOVERMENTAL BODY | DATA PROVIDED BY THE WEBSITE | NOTES |.

 

Author Response

Reviewer 1

I've read with interest the present narrative review dealing with an interesting topic, i.e. vaccination of HPV delivered to no cost (free) to high-risk subjects in PRC. Authors should be commended for summarizing a quite complicated topic, providing a summary of available policies in a highly diverse country such as PRC (whose internal heterogeneities are too often disregarded and overlooked by foreign researchers, at least from the point of view of the present reviewer, and therefore the present study would possibly fill a knowledge gap among international readers). Well, all in all I think that some improvements may be useful.

1. First, provide some further context: (1) the size of the problem cervical cancer in PRC in the last decade; (2) the proportion of vaccinated subjects in both female AND male population; (3) stressing the provinces characterized by very high and very low rates of both vaccination and cervical cancer; I'm not asking the authors to provide a review within the present review, but some very basic information may radically improve the readability of the paper;

Authors’ response:

Following the three suggestions made by the reviewer, the authors added supplementary cervical cancer epidemiology and HPV vaccination coverage data in the 2^nd paragraph of the Background, indicating:

• incidence and related mortality of cervical cancer in China in the last decade;
• HPV vaccination coverage of the WHO recommended prioritized girls aged 9-14, females aged 9-45, and males;
• highlighted the areas with higher and lower incidence and related mortality of cervical cancer;
• highlighted the areas with higher and lower HPV vaccination coverage before 2020.

 

2. Second, provide a map of China pointing out the provinces involved in your analysis;

Authors’ response

The authors added Figure S1 in the Supplementary file with a map of China pointing out:

• 2 initial pilot cities;
• 18 provincial-level administrative divisions (PLADs) piloted free HPV vaccination before September 2025;
• 2 provinces where our field investigations and discussions were carried out.

 

3. Third, in your study you did provide some information about a local manufacturer; it could be quite interesting providing a summary (either as a section within the main text or as a table) of which HPV vaccines are currently available in PRC, and which serotypes are currently covered by available formulates;

Authors’ response

The authors added Table S2 in the Supplementary file, and listed HPV vaccines marketed in China by June 2026 with approved sub-types.

 

4. Fourth: tables are highly informative, but please increase their readability by increasing the size of the characters; the same for the figures;

Authors’ response

The authors revised all tables and figures with increased size of the characters.

 

5. Fifth, a rapid review of the English text (mostly appropriate) could improve its overall quality (e.g. sentence in row 177 starts with "2024"; it is clearly not a mistake but it could be improved by removing a number - even a calendar year, as the first word of the sentence; similar instances in subsequent blocks of text)

Authors’ response

The authors carefully reviewed the full manuscript, corrected the mistakes and polished the text.

 

6. Finally, I would suggest to implement a summary table of the main web sites included into the analyses, with a short comment of the kind of data and information it could provide (e.g. take in consideration the following header: | WEB ADDRESS | COMPANY / GOVERMENTAL BODY | DATA PROVIDED BY THE WEBSITE | NOTES |.

Authors’ response

The authors added Table S1 in the Supplementary file with a summary table of the main web sites included into the analyses.

 

Author Response File: Author Response.docx

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Thanks for the opportunity to review this article on evolution of HPV vaccination in China. I think it is very worthwhile to share the Chinese experience for other countries to understand.

Rather than present the article in a standard research format I would prefer it be reformatted to an analysis or opinion piece (such as Zhao in reference 15). As it currently stands the article is very repetitive (with similar material in the introduction, methods, results and discussion). I also did not form the impression that a recognised "systematic review" approach has been followed given the documentation available.

That is not necessarily a deficit, but recognising this is more an opinion piece/recount of experience rather than trying to represent it as a scientific approach would be beneficial. There is still a great deal of benefit in publishing the findings & analysis, particularly as most of the references are not readily accessible as they are in Chinese. Reformatting into an analysis or opinion piece could also remove a lot of the duplicated information.

Comments on the Quality of English Language

While the standard of English is quite good, there are subtle errors in English communication that should be reviewed.

Author Response

Reviewer 2

1. Thanks for the opportunity to review this article on evolution of HPV vaccination in China. I think it is very worthwhile to share the Chinese experience for other countries to understand. Rather than present the article in a standard research format I would prefer it be reformatted to an analysis or opinion piece (such as Zhao in reference 15). As it currently stands the article is very repetitive (with similar material in the introduction, methods, results and discussion). I also did not form the impression that a recognised "systematic review" approach has been followed given the documentation available.

That is not necessarily a deficit, but recognising this is more an opinion piece/recount of experience rather than trying to represent it as a scientific approach would be beneficial. There is still a great deal of benefit in publishing the findings & analysis, particularly as most of the references are not readily accessible as they are in Chinese. Reformatting into an analysis or opinion piece could also remove a lot of the duplicated information.

Authors’ response

1. The authors appreciated very much the point raised by the reviewer that, “recount of country experience rather than trying to represent it as a scientific approach would be beneficial”. Therefore, the authors followed the suggestion made by the reviewer and the framework of the recommended Ref. (Zhao, F.; Lang, J.; Qiao, Y.; Zhu, L. How can China achieve WHO's 2030 targets for eliminating cervical cancer?. BMJ 2024,386,e078641.). The following revisions were made:

• Changed the abstract into un-structured;
• Integrated the original section of Method into the current section of Background, and removed duplicated contents
• Removed section titles of “Method and materials”, “Results” and “Discussion”, replaced with “Evolution of the policy”, “Impact of the pilots”, “Implications for NIP expansion”.

 

 

2. Comments on the Quality of English Language: While the standard of English is quite good, there are subtle errors in English communication that should be reviewed.

Authors’ response

The authors carefully reviewed the full manuscript, corrected the mistakes and polished the text.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Thanks to the authors for taking on board my suggestions to revise the paper.

I think the manuscript is now sufficiently improved to warrant publication.

In the revised version provided Table 1 is not fully rendering - Table 1 was fine in the original version, so I expect this can be readily corrected.

 

Comments on the Quality of English Language

Respectfully, there remain a few examples of English language and syntax that would benefit from editorial review.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript addresses a highly relevant policy question and provides a clear narrative of how China moved from local pilots to a national free HPV vaccination policy, using the Multiple Streams Framework as the organizing lens.

Please tighten the study design description. You describe this as a review that follows “systematic review” principles, but most inputs appear to be policy documents, government websites, grey literature, key informant interviews, and field investigations. Please state explicitly what type of review this is, how sources were identified, and what steps were taken to reduce selection bias.

Please add a transparent and reproducible approach for document retrieval. For example, list the government and agency websites searched, the search terms used, the time window covered, and inclusion and exclusion criteria for selecting policy documents and reports. At minimum, readers should be able to reproduce your source compilation process.

The “key informant” component needs more methodological detail. Please specify the number and roles of informants, sampling strategy, interview guide development, whether interviews were recorded and transcribed, how responses were coded, and how you ensured reliability of interpretation. Without this, it is difficult to assess rigor and potential bias.

Please revisit ethics and governance for the interview and field investigation components. Even if your institution determined that formal IRB review was not required, the manuscript should describe consent procedures, confidentiality protections, and how informant data were handled.

The manuscript would benefit from clearer triangulation. You draw several causal inferences, for example that pilots drove uptake, shaped the market, and created economies of scale leading to price reductions. Please indicate which claims are supported by quantitative data versus stakeholder opinion, and where possible provide direct metrics to support the pathway.

Please provide more concrete outcome data from pilots and early implementation. For instance, report vaccination coverage among eligible girls by pilot site and year, doses delivered, completion rates, equity patterns, and program costs. If these data are not available, please state that clearly and soften conclusions accordingly.

The financing discussion is promising but needs sharper differentiation of mechanisms. You mention welfare projects, public health insurance, medical savings accounts, and social resources. Please define each mechanism clearly and specify which were actually used to fund vaccine purchase versus delivery costs, and what portion of total costs they covered.

The price reduction narrative needs more detail and context. Please clarify procurement modality, negotiated versus tender pricing, whether the cited low price applies nationally or only within a province, and whether it reflects vaccine only or vaccine plus delivery. Also discuss sustainability and supply constraints if demand increases nationally.

Please strengthen the use of the Multiple Streams Framework. Currently, the framework is presented, but parts of the Results read as a chronological narrative. Consider mapping each key milestone explicitly to problem, policy, and politics streams with concrete indicators, and clarifying what evidence supports convergence and the opening of a policy window.

Please discuss generalizability more carefully. China’s governance structure, fiscal capacity, domestic manufacturing base, procurement leverage, and media environment are distinctive, so I recommend adding a short section that clearly separates lessons that are likely transferable from those that are context dependent.

Also, please incorporate and discuss DOI: 10.1111/ajco.13513, which summarizes common barriers to HPV vaccine program implementation in low and middle income Asia Pacific settings. Using this framework will help you position China’s pilot first approach and cross sector coordination against regional challenges such as financing, delivery infrastructure, procurement and supply, demand generation and misinformation, and equity gaps.

Please ensure the manuscript distinguishes policy adoption from implementation effectiveness. A national policy announcement is an important milestone, but the success of the program will depend on coverage, completion, equity, and delivery quality. Consider reframing some statements to avoid implying effectiveness without supporting data.

Please improve clarity around key definitions and targets. Specify the eligible age groups for routine and catch up vaccination, the dosing schedule, and whether eligibility is defined by school grade or age, since this affects implementation and comparability across provinces.

Minor presentation issues to address before acceptance. Please double check grammar and consistency in terminology, and ensure tables and figures are fully interpretable on their own, including complete captions and definitions of abbreviations.