News and views of interest to our community
An impressive collection of over 370 letters, articles, editorials and video messages demonstrating widespread interest and support to eliminate cervical cancer recently was presented to the WHO SAGE committee and the GAVI Alliance. Cervical Cancer Action, PATH, and the International Union Against Cancer (UICC) produced the dossier to graphically illustrate global support for cervical cancer prevention. The dossier includes letters and op-eds authored by presidents, members of parliament, ministers of health, and national and international professional associations, among others. Africa is particularly well represented.
In addition to the documents, the dossier includes the names of over 1,200 CCA members, representing nearly 700 organizations, who signed an online “Global Call to Stop Cervical Cancer” in 2007 and 2008. Please download the dossier to share with policymakers and stakeholders in your community!
The 2nd Stop Cervical Cancer in Africa conference, held in Kampala, Uganda, and organized by Nigerian cancer advocate Princess Nikky Onyeri, was opened on July 21, 2008 under the auspices of the First Lady of Uganda, the Honorable Janet K. Museveni. Distinguished participants included ministers of health from Uganda, Kenya and Nigeria, members of the Ugandan Parliament, representatives from African first ladies, and nearly 500 others from Africa, the USA and Europe.
The conference communiqué called for funding and implementation of national screening programs, training of health providers in screening and treatment for precancer, and high-level advocacy for more affordable and accessible HPV vaccines.
During the meeting, UICC and CCA presented an overview of global cervical cancer advocacy. They encouraged partnerships among African groups advocating for donor investment; affordable pricing and adequate supplies of vaccines and screening tools; and a greater awareness about cervical cancer among policymakers and the public. Participants of the meeting contributed over 200 letters of support to the CCA dossier (see related story above).
The First Lady of Uganda closed the conference by pledging to support all efforts to fight cervical cancer and calling for effective cervical cancer prevention services, including education, screening, and vaccination.
The 3rd Stop Cervical Cancer in Africa meeting will be held July 20–22 2009 in Cape Town, South Africa.
Health systems and communities must be well prepared to adopt a new health technology or intervention. This is particularly true for new vaccines that prevent infection with HPV, the primary cause of cervical cancer, because HPV vaccines are administered to a preadolescent population that is not reached by traditional immunization programs.
As governments consider whether to introduce HPV vaccines, they face important questions about the programmatic and financial implications of vaccine introduction and use. PATH is working with ministries of health (MOHs) and other partners to pilot HPV vaccine introduction in four countries—India, Peru, Uganda, and Vietnam—and generate data to help policymakers and planners make informed decisions. Formative research is the first step in this process.
A spotlight on Peru
Cervical cancer kills more than a quarter million women each year, and at least 33,000 of these deaths occur in Latin America and the Caribbean. Because of this high regional burden, PATH selected Peru as one of the countries for pilot introduction of the HPV vaccine.
In late 2006 and early 2007, the Peruvian MOH, PATH and other partners conducted formative research in four regions (coast, mountain, jungle and the capital), focusing on community attitudes, current health systems and government policies that will affect HPV vaccine introduction.
The researchers used multiple techniques to elicit input from diverse participant groups including:
The studies in Peru demonstrated that many individuals are interested in and supportive of HPV vaccination and other interventions that combat cervical cancer. For example, once participants were given basic information about the HPV vaccine, they generally felt positively about it—as long as they understood that the vaccine is not experimental and that they would be counseled on how to manage minor side effects. The findings also revealed that certain questions and obstacles, including improved coordination between several groups involved in immunization in Peru, must be resolved for vaccine introduction to progress smoothly.
The project team used these findings to shape the strategies that are now being implemented in the Peru demonstration project. Highlights include:
Translating strategy into action
On May 9, 2008 the first girl was vaccinated as part of the Peru demonstration project. Peru’s Minister of Health attended the project launch, signaling engagement at the highest levels of Peru’s public health system. As of this writing, girls enrolled in the demonstration project have received the first two doses of the three-dose vaccine series. Emerging data already show high levels of vaccine coverage and acceptance. And dropout between first and second doses is very low—preliminary data show that more than 99 percent of girls received their second dose and those who missed it had either moved houses or transferred schools.
The findings from all four countries in which PATH is piloting vaccine introduction are expected in 2010 and should help provide an evidence base for governments considering when and how to incorporate HPV vaccination into a comprehensive cervical cancer prevention program. Combined with prevention strategies that include cervical cancer screening and precancer treatment, evidence-based HPV vaccination programs could reduce rates of cervical cancer deaths in the developing world to the low levels already observed in many industrialized countries.
For more information about PATH cervical cancer prevention work: www.path.org/cervicalcancer
This article was adapted from PATH’s Directions in Global Health newsletter.
In an effort to encourage the rapid introduction of HPV vaccines, Merck pledged to make three million doses of GARDASIL® HPV vaccine available to governments, organizations and institutions in GAVI eligible countries. The program was announced at the Clinton Global Initiative in September 2007, and recently approved its first round of donations.
Recipient organizations will be launching pilot programs in Bolivia, Cambodia, Ghana, Haiti, India, Lesotho, Nepal and Nicaragua. Over 190,000 doses of HPV vaccines were awarded to the eight organizations.
In this issue
From the news wires
WHO Strategic Advisory Group of Experts (SAGE) committee recommends that girls be vaccinated against HPV
In early November 2008, a World Health Organization (WHO) advisory group of experts recommended that the agency support the uptake of human papillomavirus (HPV) vaccines in developing countries. This recommendation was made after a lengthy review of the potential impact of HPV vaccines, the safety of current vaccines and the viability of vaccine introduction in developing countries as demonstrated in current initiatives. This WHO position sends an important signal to policymakers and donors that cervical cancer is a public health priority and that HPV vaccination programs merit financial and political support from the international community.
The Strategic Advisory Group of Experts (SAGE) recommendation states that HPV should be included in immunization programs provided that:
Based on the SAGE committee recommendation, WHO will issue a position paper on HPV vaccination, setting forth their justification of support, recommendations for use and strategy for uptake. Such position papers heavily influence the strategies and urgency with which the WHO promotes global access for a vaccine. The position paper on HPV vaccines is expected to be published in the WHO World Epidemiology Report in April 2009.
For more information on WHO processes or pricing of new vaccines, the International AIDS Vaccine Initiative has recently published two briefs that provide useful information.
The first brief, WHO’s Key Normative Processes and Institutions for Vaccines: A Primer, describes the steps by which the WHO develops recommendations on the use of new vaccines and prequalifies manufacturers.
The second brief, Procurement and Pricing of New Vaccines for Developing Countries, explains how vaccines are procured and explores how their prices are set for the public sector in developing countries.
Cervical cancer was featured at the latest UICC World Cancer Congress held in Geneva August 27–31. Nobel Prize winner, Professor Harald zur Hausen opened the first congress plenary by reviewing the nearly century-long history of the discovery of human papillomaviruses and the application of that knowledge for human health. Zur Hausen called for a comprehensive approach to preventing the disease—including screening and vaccination. He also described the many challenges of HPV elimination: high vaccine prices and lack of political support for mass vaccination campaigns—heightened by the decades of lag time in observable health impact.
The subsequent panel sessions, presentations, and press conference covered a wide variety of topics. CCA, PATH, and UICC organized a panel entitled “Uniting for advocacy and positive change.” The panel addressed the urgent need for public information, awareness and advocacy to position cervical cancer prevention on the global agenda.
The World Cancer Declaration, launched by UICC and endorsed by delegates of the 2008 UICC World Cancer Congress, echoed the call for universal vaccination programs in areas most affected by HPV.
Ministers of health from throughout the Americas endorse new Regional Strategy to prevent cervical cancer using new technologies
During the discussions, country representatives provided comments in support of a comprehensive approach to cervical cancer prevention and control. They emphasized the need for increased action to strengthen programs through an integrated package of services: health information and education; screening and precancer treatment; invasive cervical cancer treatment and palliative care; and evidence-based policy decisions on whether and how to introduce HPV vaccines.
The countries commited to work toward undertaking a seven-point plan of action which involves:
The endorsement of a Regional Strategy and adoption of a resolution on cervical cancer prevention and control has the potential to significantly stimulate and accelerate the introduction of new screening technology and HPV vaccines into programmes throughout Latin America and the Caribbean.
Findings published in the October issue of The Lancet Oncology demonstrate that a new, rapid HPV DNA test was 90 percent accurate in detecting precancerous cervical disease. You-lin Qiao, professor of the Chinese Academy of Medical Sciences and his colleagues conducted the research in rural Shanxi province of China. Cytology screening and testing with visual inspection with acetic acid (VIA) were used as a comparison with the molecular test. QIAGEN, the company producing and field-testing the assay, said that results can be made available in low resource settings after a wait time of about 2.5 hours.
The new HPV screening test is designed to support the “single visit approach” to cervical cancer screening and treatment in low-resource settings. The product has been developed through a public-private partnership between QIAGEN and PATH. PATH currently is managing a five-year research project in India, Nicaragua and Uganda to compare the new test to cytology and VIA. The resulting data will support evidenced-based policymaking on cervical cancer screening choices.
An updated version of the Institut Català d'Oncologia (ICO) HPV Information Centre Monograph Series on HPV and Cervical Cancer, published this summer in Vaccine was unveiled at the UICC World Cancer Congress in Geneva in August. The monograph series presents the first broad analysis of the cost-effectiveness of introducing HPV vaccination and new screening methods into the hardest hit regions of the world. The benefits varied, depending on the size and makeup of the population and the burden of cervical cancer in each country. An independent collaboration of more than 180 leading experts, the report provides analyses of primary and secondary prevention methods in Asia-Pacific, Latin America and Caribbean regions including in-depth discussions of the challenges and limitations that have been met in pilot programs within these regions. The next edition, expected in 2010, will focus on Africa, the Middle East, and Eastern Europe.
To obtain a copy of the new monograph:
From the news wires
PANAMA CITY, Panama, 28 October 2008 – Panama is the first country in Latin America and the Caribbean to provide the human papillomavirus (HPV) vaccine to young adolescent girls, free of charge.
As part of a collaboration between UNICEF and the Panamanian Ministry of Health, among other partners, public health centres will offer the preventive vaccine to all girls aged 10 and 11.
HPV is the leading cause of cervical cancer. In Latin America and the Caribbean, more than 86,000 cases of the disease are detected yearly, and 33,000 women die from it – on average, one every four hours.
This year, a Nobel Prize was awarded to Harald zur Hausen for his research on cancer of the cervix, which uncovered the role of papillomaviruses. The vaccine developed on the basis of this research protects against two types of cervical cancer.
Panama to lead the way
With this initiative, Panama may be in a position to encourage other countries in the region to take the same step.
“Other countries have yet to do so, primarily due to the cost of the vaccine regimen. But when one analyzes the longer-term cervical cancer treatment costs, this seems to be a very prudent and smart move,” said UNICEF Representative in Panama Mark Connolly.
“Panama is demonstrating that it is not too expensive to prevent the number-one cause of cervical cancer, and thus is involved in a public health intervention focused on young female adolescents that will have an important short- and long-term impact on Panamanian youth,” he added.
At the programme’s launch, where more than 100 adolescents were vaccinated, the President of the Republic of Panama, Martin Torrijos, told gathered dignitaries that no Panamanian should have to die because of cervical cancer.
September 30, 2008
New Zealand introduced HPV vaccine in June 2008, bringing the total number of Pacific countries that have done so to six (Australia and four Pacific Island countries). HPV immunization was added to the immunization schedule for girls in school Year 8 (or at age 12 if not delivered in a school-based program). A phased catch-up program will be available for girls born on or after 1 January 1990.
Fiji also is planning to introduce HPV vaccine in late 2008 for 9-12 year-old girls with the help of 110,000 doses of vaccine donated by Merck. The implementation will be supported by the AusAID funded Health Sector Improvement Plan.
Mexican government announces innovative program to provide HPV vaccines, HPV testing, and Pap smears for Mexico’s neediest
On November 9, 2008, the Mexican Ministry of Health unveiled a new national strategy to fight cervical cancer in their country. The new national “Estrategia de Prevención Integral de Cáncer Cérvico Uterino” will be piloted in the 125 most disadvantaged municipalities in the states of Chiapas, Durango, Guerrero Nayarit, Oaxaca, Puebla and Veracruz.
The pilot program will offer vaccine to girls from 12–16 years of age, Pap tests to women 25–34 years of age and HPV testing to women 35–64 years of age.
The first phase of the program is expected to reach nearly 300,000 women and girls—with over 86,000 girls receiving the HPV vaccine and nearly 205,000 women receiving HPV testing for the first time. The pilot program uses campaign style outreach to communities. Women with abnormal test results will be followed up with the appropriate diagnostic tests and treatment.
Mexico’s strategy of bringing the most advanced health technologies to the most disadvantaged communities is novel for the region and has brought together a diverse group of national agencies, nongovernmental organizations, and other stakeholders.
Lance Armstrong and John Seffrin
Preventing, treating and defeating cancer are among the greatest scientific challenges and personal triumphs of our time. And right now, we have the power to save our mothers, sisters and daughters from a type of cancer that claims a life every two minutes globally.
Cervical cancer progresses over decades, attacking women who might never know they are sick until it is too late. It often hits women in their prime, when they're raising children, working hard and fully engaged in family, community and economic life, making these unnecessary deaths especially tragic.
Cervical cancer is unique among cancers because we know one of the main causes for it: certain strains of the human papillomavirus (HPV). We also know how to prevent it. There are now vaccines available that, when given to girls before they become sexually active, will later protect them from the potentially deadly strains of HPV.
In the United States and other wealthy countries, HPV vaccines, along with screening and early detection technologies, have become the standard. Yet cervical cancer remains the number one cause of cancer death among women in the developing world, because they do not have access to these technologies.
It's hard to stop all HPV strains from spreading, but we can stop certain ones from killing.
Today in Geneva, the Board of the GAVI Alliance, which includes a U.S. representative, will decide whether to commit to making HPV vaccines available to girls in the 72 poorest countries. GAVI is an international alliance of governments, international agencies and nongovernmental organizations that helps bring needed vaccines to countries that can't otherwise afford them. Once GAVI commits to a vaccine, it works with leaders in the public and private sectors to deliver its promise. But without a GAVI commitment, this lifesaving vaccine will remain the privilege of the few, rather than being deployed on the front lines of this terrible disease.
We have the data to prove that providing HPV vaccines to the poorest regions of the world is feasible, affordable and necessary. GAVI calculates that the cost of HPV vaccine at $10 per dose is possible, and in all likelihood, far less. The purchase price for GAVI-eligible countries will be $.30 per dose, which even the poorest of countries can pay. The difference will be covered through international financing and dramatic discounts from the pharmaceutical companies that make the vaccine. This combination of need, and a simple, affordable solution, makes the path forward clear.
To be sure, no new innovation or technology is without some controversy, and the HPV vaccine is no exception. Some concerns have been raised over the impact the vaccine may have on sexual behavior; however, there is no evidence that the introduction of this or any other effective vaccine leads to changes in human behavior, including sexual activity.
At the same time, we recognize that HPV vaccine alone is not enough to eradicate cervical cancer in the coming decades. We need to bring simple new screening technologies to women for whom the vaccine is not appropriate. Vaccines are most effective when they are given to girls before they become sexually active and contract the virus. For all other women, screening tools, as well as treatments for both precancerous cervical abnormalities and cancer itself, must be made more widely available. In places where screening and treatment may always be out of reach, vaccination is paramount.
Indeed, it is one of the miracles of our young century that cervical cancer prevention now comes in a vial. The HPV vaccine is built on Nobel-recognized science. It is effective. It is safe. It is affordable. And it is needed most in the places where it is hardest to get it.
The United States has another opportunity to show our belief and leadership in the powers of innovation and technology, by this commitment to improve lives of families, communities and nations. We urge our delegation to GAVI to vote "yes" on the commitment today in Geneva.
Dorothy Shaw and Jane Schaller
As Canadian women, mothers, physicians, and global-health advocates, we would like to draw attention to a great opportunity for the advancement of health in our time: the global elimination of cervical cancer.
Every two minutes of every day, a woman somewhere dies of cervical cancer. The vast majority of these women who die — hundreds of thousands of them every year — are poor women from poor countries who have limited or no access to screening and treatment facilities. These women suffer untold agony as their cancer progresses, and ultimately die untreated and without relief.
Cervical cancer is a disease that mirrors the disparities of the world today; 85 per cent of the deaths and most of the devastation of this terrible disease occur in Africa, Asia and Latin America.
Here in Canada, among women who fortunately have routine access to screening procedures, each year significant numbers will be newly diagnosed as having cervical cancer, with an estimated 1,300 new cases in 2008. Their disease is usually cured by early intervention, although in 2007, the deaths of 390 women in Canada were related to cervical cancer. The threat of cervical cancer hangs heavy over the heads of all women.
We now stand at a very special moment in health history. Based on science that merited the Nobel Prize for medicine this year, new vaccines are available to prevent infection with the virus that is the basic cause of cervical cancer, human papilloma virus (HPV). The virus is extraordinarily common in both women and men, and can lead to a variety of cancers, most commonly cervical cancer among women who are not screened and treated early on.
Now, for the first time, this potentially fatal infection can be prevented by immunization with the new powerful HPV vaccines. Indeed, the HPV vaccines might be considered to be the first effective vaccines against a form of cancer. The devastation and fear of cervical cancer have inspired many of us to work personally and professionally to see the end of this dreaded condition.
In 2007, the Canadian government adopted the policy that access to HPV vaccines is "critical" for Canadian girls. A countrywide scheme was devised to provide the vaccine to girls through schools of every province. Over the past year, further research and experience indicate the HPV vaccines are extraordinarily safe and do not encourage high-risk or early sexual behaviour among girls.
As with most new vaccines, the need for possible future booster doses has not been resolved yet, but this will become apparent and can be dealt with as years of experience accumulate.
Thinking beyond our borders, we encourage Canadians, our government and all citizens to play a role in ensuring global access to these new lifesaving technologies. Women and children throughout the world should have the means of prevention of infection with the HPV virus and cervical cancer, just as the women and children of Canada do.
Significant policy discussions during the coming weeks at key international institutions — the World Health Organization and the GAVI Alliance — will influence whether HPV vaccine will become widely available for women and girls in the world's poorest countries.
The ultimate price per dose will be critical in making the HPV vaccine affordable, cost-effective, and a feasible addition to existing immunization programs. Noting that our government invests to protect our own women and children with this new technology, we ask that women and girls around the world are given access to this vaccine that will prevent death and untold suffering.
Dr. Dorothy Shaw is president of the International Federation of Gynecology and Obstetrics; Dr. Jane Schaller is executive director of the International Pediatric Association.
Where lives are cheap: As the UK and US dither over the cervical cancer vaccine, thousands die in places it's needed most
November 19, 2008
Thousands of 12- and 13-year-old girls will be lining up outside their school medical offices this term, some of them shivering, stomachs lurching, waiting for a jab in the arm that it is hoped will prevent them suffering cervical cancer - a particularly unpleasant form of the disease which kills more than 900 women a year in the UK.
There is every sign that takeup of the vaccine will not be universal. In a pilot study, 20% of parents did not give permission for their daughter to have the jab - whether from apathy or anxiety. Girls are being told that if they feel strongly, they can go to their GP and get vaccinated anyway, but that will surely be rare. And takeup will certainly slump for the boosters, months later.
In spite of a health service information campaign and assiduous marketing by the two firms who vied for the NHS contract - the British company GlaxoSmithKline (the winner) and Merck - many people seem to know little about the vaccine, and the usual worries have already surfaced. Is it safe? Does it have side-effects? The legacy of MMR will run for many years.
In the US, websites have started up and the anti-vaccine rumour machine has been grinding away for a while now. Some of the doubts are reasonable - we cannot know what the long-term effect of the jab will be, because it has been tested for less than seven years so far, though the chief worry is that the protection will wear off. Others, such as alarming side-effects, are not well substantiated.
But while Britain and the US are dithering and doubting, there is an urgent need for the vaccine. The real damage done by this horrible disease is in the developing world. There are about 500,000 cases worldwide every year, and more than half the women die. About 80% of the deaths are in poor countries.
These countries don't have screening programmes. They don't have the surgery and radiotherapy to treat cervical cancer, either. The women who die are often mothers and breadwinners, leaving struggling families. A simple vaccine - two or three injections for every girl - could transform their prospects.
But Merck charges $360 for the three-dose vaccine course, presumably needing to recoup the $100m it is said to have spent on marketing in the US on top of development costs. GlaxoSmithKline will have struck a deal at a lower price in Britain to win the NHS contract, but this is still out of reach for countries in Africa and Asia. Merck is not insensitive to this potentially damaging issue and has committed itself to giving away enough vaccine to immunise a million women in the developing world. But the anticipated demand, should an affordable vaccine become available, is for the immunisation of 58 million girls in 60 countries by 2020.
Enormous hopes were building right up until the end of last month. The GAVI Alliance - set up with the help of Bill and Melinda Gates - was expected to support global rollout of the cervical cancer vaccine. It didn't happen. In the face of global financial meltdown, there were nerves about the chances of raising enough money for a programme that will have to begin in schools - it can't just be added to the infant immunisation schedule.
GAVI will return to the issue. It has negotiated a cost in principle from the drug companies of less than $10 a head, of which governments would pay just 30 cents. A big new funding campaign among donor countries would still be needed, even at this price. But when we are spending so much vaccinating girls whose risk of cancer is really pretty low, surely offering the same chance to girls whose lives could genuinely be saved is a no-brainer?