The monthly meeting for ECHO Latin America ELA Project: Monthly teleconferences about cervical cancer prevention and control programs took place on Friday, September 2020 , covering the topic about strategies to reach WHO HPV vaccination coverage.
During the meeting, ECHO ELA Project collaborators Silvana Luciani (PAHO), Melissa Lopez Varon, MD Anderson Cancer Center (MDACC), Sandra L. San Miguel, National Cancer Institute (NCI), and faculty members, Dr. Silvina Arrossi (Argentina), Dr. Maria Tereza da Costa (PAHO/WDC/Brazil), Dr. Mauricio Maza (El Salvador), and Dr. Mila Salcedo (MDACC/Brazil) welcomed 91 participants, including leaders for national cervical cancer and immunization programs from the Ministries of Health in Latin America, NGO representatives and other professionals working on related projects; Focal Points from each of the PAHO offices in Latin America, PAHO representatives from Washington, D.C., WHO in Geneva, MD Anderson Cancer Center University of Texas, the U.S. National Cancer Institute, and collaborators working on this topic.
Summary from the previous monthly session – August 28, 2020
Dr. Maria Tereza da Costa (PAHO/WDC)
Dr. da Costa provided a summary of the previous meeting, including her own conference about the didactic topic, 'ESAVI and the HPV vaccine.'' Dr. da Costa presented data on the safety of the HPV vaccine and events allegedly attributed to HPV vaccination, reaffirmed the safety of the vaccine based on scientific evidence, mentioned the most common myths related to HPV vaccination, and emphasized the importance of a rapid response to prevent a crisis because it could result in a rejection of the vaccine by the population resulting in a negative impact on coverage. Dr. Ana Goretti Kalume Maranhao from Brazil presented the case illustrating the topic on the 'Adverse Events Allegedly Attributed to the HPV Vaccine: Outbreak in the State of Acre, Brazil.' The events referred to adolescents who had seizures and mobilized public health and the population with national repercussions. The Brazilian Ministry of Health made an agreement with the Institute of Psychiatry of the University of Sao Paulo to evaluate twelve adolescents with seizures. Dr. Renato Marquetti, Psychiatrist at the University of Sao Paulo, explained, that all cases happened in the capital of Acre and that adolescents belonged to low SES families with social vulnerabilities. Most adolescents have suffered shortages and belong to dysfunctional families, parental unemployment and their financial situation depends on maternal finances. The children were hospitalized for two weeks, were monitored by continuous video encephalogram, 10 of them presented non epileptic psychogenic crisis and two cases presented generalized epilepsy (in two brothers with that genetic condition). After conducting countless evaluations, all other possible clinical complications were ruled out. The conclusion of the study is that there is no biological association with the HPV vaccine. Dr. Goretti mentioned that the thorough evaluation was necessary to clarify the clinical situation of adolescents, to given them the necessary treatment and to reverse the situation of mistrust of the vaccine, not only in Acre, but also for other states in Brazil. We hope this experience will serve as a lesson learned for other countries. This work was published in the scientific journal 'Vaccine'.
Visit the website for additional information: https://mediaplayer.mdanderson.org/video-full/95ABA76A-4B10-4164-A01A-C2289368ECFD
Didactic Theme
The didactic theme, 'Vaccine Coverage and Strategies to Reach the 2030 Goal’ was presented by Paul Bloem, WHO.
Dr. Mauricio Maza, Executive Director, Basic Health International, El Salvador presented the case 'Lessons Learned from Cervical Cancer Prevention During the Pandemic.’. Participants should be reminded that the ECHO® project is based on multilateral knowledge exchange using cases at the epicenter of the discussion.
Dr. Ana Goretti – Congratulations to Paul on his lecture, especially for sharing the campaign slides of the Brazilian Cancer Institute. Vaccination coverage rates remain in decline due to the closure of schools and the pandemic and this situation is very concerning to us. We will start a public health advertising campaign about vaccination of children and adolescents up to the age of 15 in October. The campaign is aimed not only at parents, but also at doctors as they play a very important role in vaccinating teens. We hope that this campaign can improve vaccination coverage.
Paul Bloem – Thank you for the comment, it is important to consider a multi-vaccine campaign. It is also important to increase the age to access the vaccine, usually in Brazil it is up to 14 years, but if you have missed a year due to the pandemic, you could increase the age to 15 years.
Dr. Aulo Ortigoza Gonzalez - We belong to the Secretary of Health of a state of 5 million inhabitants and are projecting a pilot plan to present it to the National Oncology Division of Venezuela. We have not implemented any vaccination programs in Venezuela, although the vaccine has been introduced privately without being sure about its follow-up. We have chosen two municipalities, an industrial area near the city of Maracaibo where we have approximately 23,000 children between the ages of 10 and 14 years and another indigenous border municipality, where we have 13,000 adolescent children and we feel the support from the indigenous community who trust us. If you were to start a program from scratch, would you start a pilot program in the indigenous area or in the industrial area?
Paul Bloem – I could respond in two manners; one is what happened in GAVI countries. Countries tested in one or two districts and the introduction was delayed at the national level and we wasted time. There are many challenges when vaccination is only introduced on a small level and there are always critics that say that we are 'experimenting' in an area and if an isolated area is used it even seems that we are not only experimenting but also hiding. In a way, it is easier to introduce vaccination at the national level. We may also think that many countries started small and then switched to larger and more successful levels. If we must choose between two zones, we have noticed that the most difficult area, the one that is further away, suffers a lot since when problems arise it is difficult to access that area. If one wants to demonstrate feasibility it is better to choose a nearby area, if one thinks about equity it is important to consider a distant or indigenous area which has less access to screening. If conditions are difficult, it is easier to go to an area where there is greater access for the results to be successful.
Dr. Maribel Almonte – I have two questions, one about the dose of the vaccine. We know that there are several studies that are trying to evaluate the possibility of applying a single dose hoping that the protection will be the same. If this is possible, if it is confirmed that only a single dose is needed, have you estimated the overall impact that only one dose would have in both Latin America and globally? The second question relates to the pandemic, we know that all health services have been affected by the pandemic, thinking about the innovation one should consider in one or two years, when we have a COVID-19 vaccine, could we take advantage of the use that we will vaccinate against COVID-19 to also vaccinate against HPV? I mean, could we do an integrated program to deliver both vaccines?
Paul Bloem – For the elimination strategy a global study was carried out in terms of impact, assuming 90% coverage with complete protection. If it turns out that a dose is sufficient for complete protection, it would not change the curve and the impact would be the same, but 1) would be achieved with half the resources (single dose) and would be achieved with the first dose which will change the curve of the overall coverage since in many countries the coverage of the first dose is much better than the second dose. It would have an epidemiological impact. Regarding your second question, we need to integrate the efforts with the new COVID-19 vaccine because the resources are going to be smaller. The new vaccine could have its own challenges and if it is not yet well accepted, how would it affect other vaccines? The most important thing is that many countries are not going to have a lot of resources and we're going to have to keep optimizing resources.
Dr. Lina Trujillo - Congratulations to Paul for his excellent lecture. In Colombia, we do not yet have such high coverage (90%) HPV vaccination, I will now send you the latest data from the Ministry of Health. From WHO, do you come up with a strategy to integrate 90-70-90 or do we continue to act separately, the vaccination group, the screening group and the treatment group?
Paul Bloem - Thank you for providing this data. At WHO/UNICEF we make our own projections based on the data provided from each country (through PAHO using THE JRF). We may have different ways to calculate coverage, but we continue to calibrate data and estimates with countries. Regarding the integration, it is a challenge and the most important thing is that everyone must consider that all three axes are important. It is essential to integrate the three, if the cancer programs that previously promoted and provided screening and treatment are now also making prevention with vaccination. That's not to say that we're necessarily going to put vaccination together with service-level screening, but we must coordinate services/axes and integrate communication.
Dr. Renato Kfouri – I would like to know a little more about integration with other adolescent health programs, such as education programs to prevent youth pregnancy and drug use.
Paul Bloem – There are many missed opportunities in many countries, and we have a lot of work to do to programmatically combine HPV vaccination with other interventions. We conducted an opportunity analysis identifying 8 or 9 easy interventions that could be combined, such as deworming, sexual education, etc. However, integrating these interventions into practice has been very difficult. We've seen very little of this. There is a paucity of school health programs in many countries to introduce the vaccine and strengthen the relationship with adolescents in order to address other issues. There's that work to be done and we must propose it again.
Dr. Lúcia Helena de Oliveira – Congratulations to Paul for supporting our Region. Adding a commentary on vaccine integration, as in Brazil and Panama, they are already planning how to recover these lost doses. In the Region, we have a 15-17% decrease in vaccine coverage and the HPV vaccination coverage is probably lower. The issue of combining COVID-19 vaccines with the HPV vaccine would be a bit complicated since when COVID-19 vaccines arrive, there will not be enough supplies and in addition, adolescents will not be prioritized for the COVID-19 vaccine.
Silvana Luciani – From the beginning of the ECHO ELA series, we are proposing that countries form a multidisciplinary group – with experts from all three axes – and representatives from the government and civil society sector to put together a comprehensive plan and work comprehensively; therefore, the integration Paul presented can be expressed through a multidisciplinary committee and a national plan for the elimination of cervical cancer in an integral way.
Dr. Dalys Pinto: Panama is also scheduled for a vaccination campaign to promote HPV and Tdap next October.
Dr. Itamar Bento: Is it possible to estimate when we will have the response on the vaccine at a single dose?
Paul Bloem: There are a number of worthwhile studies (both RCTs and ecological) that are being carried out all over the world including in Guanacaste, Costa Rica (ESCUDO, CVT). They all provide evidence for different aspects and will produce their intermediate and final data between 2021 and 2025. Clearly the situation of COVID could affect these dates. The year 2022 is probably the first "window (of time)" for an analysis of the available data and a possible policy change - depending on the strength of the evidence.
Dr. Itamar Bento Pinto: Would it be possible to have a version of this PAHO video with audio in Portuguese?
https://basichealth.org/CervicalCancer/Videos
Spanish:
https://www.youtube.com/watch?v=SSYfDgCrl0A
Portuguese:
https://www.youtube.com/watch?v=bbf7Q5QoZy4
English:
https://www.youtube.com/watch?v=cejwvdpQxbg
French:
Please follow the link to access the meeting recording and feel free to share with other colleagues: https://mediaplayer.mdanderson.org/video-full/A34270B2-56C0-4E1C-AABF-A243B639A385
The next meeting will be held on Friday, October 30, 12:00PM-1:30PM EST, Washington, D.C.
Didactic THEME: 'Why is the introduction of the HPV test recommended in screening programs? – by Dr. Maribel Almonte, IARC; a case will also be presented.