The monthly meeting for ECHO Latin America ELA Project: Monthly teleconferences about cervical cancer prevention and control programs took place on Friday, August 28, 2020 covering the topic about HPV vaccination safety.
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 120 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 – July 31, 2020:
Melissa Lopez Varon presented a summary of the previous meeting. Dr. de Oliveira presented on the HPV vaccination progress in the Americas. The topic of vaccination was presented in the context of the cervical cancer elimination strategy. Dr. de Oliveira mentioned the vaccines that are available in the region and the coverages highlighting that there is a lot of variability among the different countries. A total of 43 countries and territories are implementing the HPV vaccine in the Latin American region. Recommendations to increase coverage in the Region were discussed. During the first country case, Dr. Morales from El Salvador asked a very specific question about how vaccination, screening and treatment services can be prioritized during and after the pandemic. ECHO ELA Faculty emphasized the importance of multisectoral collaborations and the need to increase funds rather than reduce them. Dr. Katz from Argentina presented the second country case and talked about the HPV vaccination strategy in Argentina. Dr. Katz provided a comprehensive summary of coverage between 2011-2019 and gave examples of the 8 strategies for prioritizing HPV vaccination in Argentina during and after COVID-19.
Visit the website for additional information: https://www.paho.org/en/topics/cervical-cancer/echo-ela-project-third-session-31-july-2020
Didactic Topic:
The Didactic Topic, 'ESAVI and the HPV Vaccine'' was presented by Dr. Maria Tereza da Costa, PAHO/WDC, who presented on the safety of the HPV vaccine, HPV vaccine myths, events allegedly attributable to vaccination or immunization (ESAVI), and response to a crisis by ESAVI. Dr. Ana Goretti Kalume Maranhao presented the case 'Adverse Events Allegedly Attributed to the HPV Vaccine: Outbreak in the State of Acre, Brazil'. Participants should be reminded that the ECHO® project is based on multilateral knowledge exchange of knowledge using cases at the epicenter of the discussion.
Dr. Renato Kfouri – In Brazil there is a delay in diagnosis and intervention. School vaccination must be implemented. What happened in Acre is a phenomenon that we could have again, and we must have more timely answers. Lessons learned include early care and proper treatment of children.
Dra. Jane Montealegre (Faculty – ECHO ELA) – Is there a mechanism to monitor what types of HPV vaccination conversations are taking place on social media in Brazil?
Dra. Ana Goretti – Brazil’s Ministry of Health has a team dedicated to social communication that seeks and identifies daily news about health and vaccines. There is even a WhatsApp specifically dedicated to informing our population if a specific news item is factual or not. The HPV vaccine, among all the other vaccines, is the most relevant topic that emerges, especially among antivaccine groups and “fake news.” In reference to the news media support, the incident among the teenagers from Acre was well reported by the national news media, even though the local news media gave the story a lot of negative coverage blaming the HPV vaccine for the problems experienced by the teenagers. After the evaluation was conducted by the IPQ, during the submission of the results to the Acre government, an emphasis was placed on developing a communications plan about the outbreak in Acre to educate the population and health care providers. However, the communication plan had to be suspended due to COVID-19 and is currently on hold to be released as it is very important to communicate and educate the population.
Dr. Silvio Tatti- Dr. Goretti, is the psychogenic profile found in the DSMV classification of psychiatric diseases?
Dra. Ana Goretti – Yes, it is described as a stress triggered in response to the vaccination, by WHO as well as by the International Classification of Diseases (ICD) as non-epileptic convulsion crisis.
Dra. Margaret Dumitru- Dr. da Costa, can you expand on the 4 steps to dealing with situations of credibility?
Dra. Da Costa (Faculty – ECHO ELA) – Mainly one has to meet with one’s team and co-workers and know exactly what is happening and have all the data at hand and immediately gather the decision-makers to review the analysis of the situation and identify the measures to be taken. The local press must also be involved to disseminate what is happening and the measures being taken in response to the problem in question, the faster the response the better. We must respond to the population and explain what happened and how the situation is being remedied. It is essential to identify a responsible spokesman to collaborate with the media.
Dr. Juan Saavedra – Given this experience where there was social impact from the side effects with seizure, which was misinterpreted socially, it would be interesting as a strategy to avoid the negative impact, to make a social media communication campaign before starting vaccination in any region. Possibly if we inform the population in advance about what the vaccine is, what we expect from it, and what the benefits are, the negative impacts are likely to be less. I wonder if it would have a positive benefit to avoid the negative social impact through a vaccination campaign.
Dra. Ana Goretti – It is important to clarify that Brazil's Ministry of Health had two annual media campaigns, one in March for the first dose and the other in September for the second dose. Communication with the population has been very important, we want our doctors to talk more about the importance of vaccination and possible adverse effects. Communication is a key point for vaccination acceptance; however, the media campaigns had to be interrupted by the COVID-19 pandemic in the country.
Dr. Aulo Ortigoza: was there any correlation among the events that were presented with/social stratum/school type/family environment religion/family contact with anti-vaccine groups?
Dra. Ana Goretti – Yes, there was a correlation. I’ll defer to Dr. Renato Marchetti from the Psychiatry Institute at the University of Sao Paolo, psychiatrist who has coordinated the assessment of the teenagers from Acre.
Dr. Renato Marchetti – Indeed, we observed certain characteristics among the group affected by this outbreak, all those affected were of low social class, most of them had suffered from childhood deficiencies, most belong to dysfunctional families and all of them belong to the Pentecostal Evangelical religion. There were many cases of unemployment and the financial situation was dependent on maternal finances.
Dra. Lely Guzmán - Es muy importante el énfasis mencionado por la Dra. Goretti sobre los factores de riesgo en cuanto a la demora para el diagnóstico, perjudica las vacunas y es importante hacer las capacitaciones y sensibilizaciones al aproximarnos a la planeación de la vacunación incluyendo a los padres, a los profesores, a los cuidadores y vacunados. También es importante hacer esas articulaciones con las sociedades y los médicos para que ellos también vean la importancia y no hagan asociaciones rápidas sobre las vacunas y este tipo de desastres.
Dr. Jorge Hoegl– In Venezuela there are drawbacks to achieving mass HPV vaccination even though the vaccine has been approved by government entities since 2015. I have had the experience of administering the tetravalent vaccine in 89 patients, among adolescents and patients between the age of 28 and 34, none of my patients have had any side effects and it has not been easy to convince patients that the effects are minimal and the benefits of the vaccine outweigh the risks. A tangible reality in Latin America includes teenage pregnancies and invasive lesions are seen among patients under 25 years of age. I agree that the education of our society, including doctors, is very important. Scientific evidence on the effectiveness of vaccination is strong and robust. There is no doubt that social networks can help us expand education within our countries.
Dr. Renato Kfouri – It is important to note that in Brazil we have also had to deal with the intervention of politicians in the situation in Acre. Some politicians communicated directly with mothers and some health professionals who did display very ethical behavior, and this is another complex aspect that we had to deal with.
Dr. Raul Montesano- Can you comment on the temporary association of vaccination with the onset of neurological tables, some toxic factors were ruled out in the area and is there a geographical distribution of cases?
Dr. Renato Marchetti – All cases occurred in the city of Rio Branco in the state of Acre. Responses related to immunization stress are of three types: acute stress reaction, which occurs before or within a few minutes after immunization and neurological effects take place later, either a few days or weeks later. Most cases had acute reactions and then had neurological reactions with psychogenic non-epileptic seizures among others. All other possible clinical complications were ruled out. There were two cases of a biological nature with two patients who were carriers of generalized epilepsy, the two of them were siblings with a genetic condition, a type of epilepsy that begins at the age at which vaccines are administered. It could be a coincidence or possibly the immunization may have caused a biological trigger.
Dra. de Oliveira – It has been proven that the best strategy consists of vaccinations in schools. Lessons learned have taught us that countries with the best coverage use the school strategy. The challenge with the pandemic is that schools are closed. It was recommended that vaccination campaigns should be suspended. At PAHO, we are monitoring and comparing monthly child vaccine coverage with last year's figures, what we have identified is that the vaccination coverage has decreased by 14 percent. We don't have the HPV comparison number, but it will surely be a significant percentage since vaccinations in schools have been suspended. It's important to be prepared for countless of problems prior to next year when we try to recover vaccine coverage.
Dra. da Costa – A commentary on the political impact, during the delivery of the results, the Ministry of Health together with Dr. Renato Marchetti and his team had to explain the whole situation to political entities and then to the governor of Acre. Dr. da Costa congratulated Dr. Marchetti on the explanation and his tactfulness and diplomacy in dealing with the political entities, a delicate process which Dr. Marchetti performed in an impeccable manner. PAHO is preparing for the negative impact on HPV coverage. We're already thinking about strategies to make up for lost time. What happened in Brazil, and in Colombia, regarding social vulnerability is a very important factor that we must keep in mind.
Dra. Salcedo (Faculty – ECHO ELA) – I congratulate the speakers and would like to highlight that the learned lesson is that it is very easy to find the wrong information on social networks 'Fake News'. But we must be guided by truth based on scientific evidence. An event like the one that took place in Acre can have a negative impact on an entire country, and we must work together to prevent this from happening again.
Dra. Arrossi (Faculty – ECHO ELA) – I also congratulate the speakers for illustrating the cases, recounting the sad events and reality of the story, but also offering information and evidence. I applaud the speakers and the Brazilian team for the analysis of the cases and conclusions. This is a call to action about the importance of social media and the education of our communities. For example, before the COVID-19 vaccine even comes out, there are already stories circulating and rumors are spreading on social media and this presents a challenge since it is how our communities are informed. The scientific community needs a lot of support from the media to work together and educate our communities. Dr. Arrossi stressed that she has many ideas about possible strategies to counteract a situation like the one that happened in Acre.
Dr. Maza (Faculty – ECHO ELA) - I also congratulate the speakers, El Salvador is one of the few countries that has failed to introduce the vaccine, which we had hoped to start this year and due to the pandemic, there has been a delay. It is of the utmost importance to learn what is happening in other countries. Following up on Dr. Arrossi's comments on COVID-19 vaccine discussions in our communities, if there is a vaccine that is more than 10 years old and there is a lot of evidence that it is safe and effective, and now we will receive a new vaccine we should have the mindset that vaccines are safe. Dr. Maza stressed that the current situation presents an opportunity for all professionals in the public health area to educate our countries that vaccines are safe.
Dra. Lina Trujillo- The Colombian experience could be a good reference of education for the rest of the countries because of the magnitude of the number of girls and by the complex outcome of this event in relation to problems of regaining the community’s trust. Coverage levels have not been recovered, there are many lessons that we can share with everyone (especially what should not be done) and that we continue to learn from and suffer the consequences from.
Dra. Claudia Garcia: I think it is necessary to have a global strategy from PAHO - WHO in collaboration with the leaders of each country. Conducting a communication strategy for the community presenting the safety and importance of vaccination.
Silvana Luciani, PAHO-NCDs: PAHO-WHO has a guide on communication strategies for the HPV vaccine that can serve as reference: https://www.paho.org/hq/index.php?option=com_content&view=article&id=14299:fin-cancer-cervical&Itemid=72265&lang=en
Dra. Ida Molina - Is there annual information available regarding ESAVI's severe HPV-associated side effects reported by countries available at the PAHO/WHO level?
WHO is monitoring the safety of vaccines, including the HPV vaccine through the Global Advisory Committee on Vaccine Safety:” https://www.who.int/vaccine_safety/committee/topics/hpv/en/
Dra. Margaret Dumitru- I think it is important to involve medical guilds, nursing graduates and health commissions operating in local governments, municipal councils and regional and regional councils ... it would be to work with communities and their leadership and decision-makers.
Dra. Lina Trujillo. Dr. Hoegl - since when do you have it in Venezuela? How do you access it? Through the private market? Is it part of the public program?
Dr. Jorge Hoegl - Through the private market, but it is also approved by the public program since 2015, oncohoegl@gmail.com – here is my mail if you need more information.
Dra. Ileana Quirós- Exactly, I think the mix of information that is being shared through social networks regarding the management of COVID, the COVID vaccine and other vaccines is concerning. I've noticed a new ‘outbreak’ of poor messaging in social media platforms.
Dra. Marcela Celis Amórtegui- : I congratulate the speakers on their presentations. We must work on strengthening confidence in the vaccine. In our country we continue to work on this issue, as coverage remains low.
Dra. Andrea Matos - In Peru, vaccination coverages have been growing, but we still have difficulties with the second dose. Vaccination in communal spaces has been successfully reactivated through the pandemic
Dra. Suyapa Bejarano - La estrategia de vacunar en escuelas ha sido muy apropiada, sin embargo, solicitar consentimiento de los padres no ha sido fácil.
Dra. Claudia Garcia- The strategy of vaccinating in schools has been very appropriate, however, requesting parental consent has not been easy.
Dra. Margaret Dumitru- Thank you very much for the Invitation. This is a very important topic, appreciate being invited to participate in these dialogue spaces.
Dra. Ermelinda Zavala- Excellent presentations today; they prepare us for our own implementation of the HPV vaccine. Thank you ECHO ELA.
Dr. Aulo Ortigoza-: Good meeting/clear strategies to follow.
Dr. Juan Carlos Umaña Velásquez- Congratulations to the speakers, we acquire important information, which we will apply in Latin America.
Dra. Ana Goretti – Once again, I’d like to thank and congratulate the Psychiatry Institute from the University of Sao Paolo, led by Dr. Renato Marchetti for his excellent work. I also take this opportunity to reiterate that this meticulous psychiatric assessment was needed to elucidate the diagnosis to revert the unfavorable situation from the vaccine, not just in Acre, but also in other states, and hope that the outcomes can support not only Brazil but also other countries that are experiencing a similar situation. I’d like to take this opportunity to also inform you that the outcomes from this work is being published this month by the renowned scientific journal – ‘Vaccine.’
The recorded session (fully conducted in Spanish with some Portuguese) may be found by clicking on the following button, please feel free to distribute among your colleagues:
The theme of the fifth monthly session of the ECHO ELA program will be "Vaccine coverage and vaccination strategies against HPV to reach the goal of 2030," speaker, Dr. Paul Bloem, WHO.
The case will be presented by Dr. Roberto Arroba Tijerino, MSc Immunization Coordinator, Technical Secretary of the National Commission of Vaccination and Epidemiology, Ministry of Health, Costa Rica.
- DAY: Friday, September 25, 2020
- TIME: 12:00 - 1:30 PM (EDT) [You can check here the time in your area]