Title: Exploring the Role of Cervicovaginal Microbiota as Risk Factor for Cervical Cancer in
Sub-Saharan Africa: A Systematic Review and Meta-analysis
Version: 1 Date: 11 Feb 2025
Reviewer:  Simon Manga
Reviewer's report:
Reviewer’s Comments
1. This is a very interesting and important topic the authors are working on. Congratulations to
the authors for initiating such a study.
2. The introduction is very weak. The first 2 paragraphs of the introduction are out of topic.
The first paragraph talks about cancer and the second paragraph talks about cervical cancer.
Meanwhile, your work is on “Role of Cervicovaginal Microbiota as Risk Factor for Cervical
Cancer”. So, rather than introducing cancer, introduce your title. Your first paragraph in an
introduction has to be very strong in such a way that the reader should immediately see the
importance and relevance of your title. In fact, the first paragraph should carry the statement
of the problem.
3. In your second paragraph, you say “In the aetiology of cervical cancer, HPV is undeniable,
but not sufficient”. This is not true. Current evidence has demonstrated that HPV is a sufficient
cause of cervical cancer. To back up your point, you went and cited a 1999 article. Please, cite
current literature.
4. Your exclusion criteria are not correct. They are the exact opposite of your inclusion criteria.
For example, if you have studies done in SSA as your inclusion criteria, by default, studies done
out of SSA are automatically out of your search. Your exclusion criteria are supposed to be a
subset of your inclusion criteria. That is, among the studies that meet your inclusion criteria,
some of them are going to be dropped because of 1 or 2 reasons. This is what makes up your
exclusion criteria.
5. Results: the first 2 paragraphs under results are part of your methods and they should be
transferred to the methods section.  Your results should begin with “Risk factors associated with
cervical cancer”.
6. Why did you limit your search to SSA? This study would have been richer if you included
studies from all over the world. That would have also enriched your discussion because you
would have been able to compare the phenomenon between different regions.
7. In your work, you did a lot of elaboration on lifestyle risk factors for cervical cancer. This is
beyond and above the scope of this study. Please, your work is on cervicovaginal microbiota as
risk factor ... You are supposed to be dealing with just one risk factor and not all the lifestyle risk
factors like smoking, etc. Lifestyle that is associated with the risk of cervicovaginal microbiota
can be acceptable. The inclusion of lifestyle factors has diluted the quality of your work.
8. There are 3 terms that you have used interchangeably and this is creating confusion in your
work; vaginal microbiota, cervical microbiota, and cervicovaginal microbiota. Please, it’s better
to stick to one term and use it throughout the manuscript. The term “cervicovaginal microbiota”
which is in your title is preferable.
9. In discussion, you say “The injudicious use of antibiotics among these women leads to
destruction of the normal vaginal flora and reduction in host immunity thereby increasing the
risk of microbial diversity”. Please, this has to be referenced
10. Still in discussion, “The pooled prevalence of HPV at 40% in this study was quite high when
compared with the global prevalence at 10%.” This is not plausible. How can global prevalence
be only 10%? Again, you cited very old articles of 2006 and 2007 to back your point. This is
unacceptable. Please, review the current literature.
11. Your conclusion is overstated, “Community-based intervention and education is highly
recommended to address cultural taboos, misconceptions and stigma surrounding cervical
cancer which deter women from seeking preventive services, in order to improve women's
reproductive health thereby reducing the burden of cervical cancer.” This has no relationship
with your work.
12. There seems to be an error in your PRISMA. The last 2 arrows are confusing. The arrow
on the right comes in with 15 articles and the arrow from the left comes in with 5 articles. If
these add up, the total should be 20 articles. So, that particular arrow was supposed to come
but from the last box.