ECHO ELA PROJECT: THIRD SESSION - 31 JULY 2020

Tema Didáctico – Dra. De Oliveira - Preguntas y Comentarios

Dra. Suyapa Bejarano: In reference to the herd immunity, in our countries we introduce the vaccine without knowing the actual HPV prevalence among our population, what could be expected from our region as a result from the actual vaccine?

Dra. De Oliveira: There are various studies that have demonstrated the herd immunity and even though there are no data about HPV prevalence at the population level in Latin America, we can base ourselves on the current data from the literature regarding herd immunity.

Dr. Rafael Aguirre: When vaccine coverage is mentioned, how many doses are you referring to?

Dra. De Oliveira: Two doses

Dra. Ileana Quirós:  In Costa Rica we have the ESCUDO study to determine the effectiveness of only one dose.

Dr. Renato Kfouri:  I have various comments, in relation to the number of doses, I believe we have to encourage for studies to validate the efficacy of only one dose to reach vaccine coverage and we also have to consider increasing the Interval between the first and the second doses in Latin America. My third comment pertains to the vaccination of both genders, there are some countries that also include vaccination of boys and this incentivizes the vaccination among girls as there’s no gender bias.

Dra. De Oliveira:  Administering only one dose would be ideal, we would not need so much vaccines and it would be more economical, and we would increase coverage. Although we are close to establishing a one dose only, SAGE still does not recommend it as there isn’t enough evidence yet. SAGE does have a longer span of dose administration when there are problems with the quantity of vaccines available. The problem with the longer span is being able to reach the same individuals to administer their second dose. There are countries such as Chile that vaccinates girls in school annually and ensure to get the same cohort vaccinated twice. Regarding the topic about boys and girls, in our region, there are no data that substantiates that vaccinating boys increases vaccine coverage among girls. The recommendation from the technical group from PAHO and SAGE is to prioritize HPV vaccination among girls.

Dra. Claudia Camel: I’d like to know if during this pandemic, will there be more projected problems or delays in delivering vaccines acquired through the Revolving Fund from PAHO/WHO?

Dra. De Oliveira: This is not happening yet, the countries are receiving the vaccines within a reasonable amount of time, this was one of our concerns initially but not anymore. There were problems with an airport that was closed, and the vaccine could not be delivered; however, that problem has been fixed. We’ve learned to manage the prompt delivery of vaccines during the pandemic and we don’t expect any additional problems.

Dr. Aulo Ortigoza:  For Venezuela, this is a novel program and I have a few questions, what would you recommend for a country that is just starting this program? Secondly, would it preferred to target a specific age range, such as tweens of 11 years old or kids/tweens between 9 and 11 years old? Which one is preferred? Our strategy is to use vaccination centers from small towns and vulnerable communities where indigenous populations reside, we could target women, moms, girls older than 12 years old and the elderly. I’m wondering if someone from Latin America has had a similar experience and has implemented vaginal citoly o another new method to increase screening.

Dra. De Oliveira:  PAHO is elated to hear that Venezuela is implementing this program. The recommendations from SAGE and WHO regarding HPV vaccination is to focus on vaccinating girls as that is our main goal to eliminate cervical cancer. It is important to initiate vaccinating one cohort to learn how to implement the vaccination process well prior to extending it to other cohorts, and there’s various countries that are participating in ECHO ELA that have the experience and can share with Venezuela. The idea to integrate the HPV vaccination with the screening is excellent, not just to prevent cervical cancer but also to integrate other medical services.

Dra. Ana Goretti:  An observation, the greatest coverage among girls in Brazil is 48% and approximately 20 something percent among boys. In order to make the decision to include boys in the HPV vaccination protocols, we had to have a very broad discussion with multiple conversations with experts and stakeholders. I’m in agreement with Renato that the inclusion of boys is an important factor to increase coverage among girls. We’re starting a related study. I must mention that the coverage among boys is lower as we started vaccinating them later. The vaccination among girls began in 2014 and the vaccination among boys began four years later in 2018. This is a matter of gender equity.

Dra. De Oliveira: The presented data comes from the Joint Report Form ‘JRF.’ I’ll review the data from Brazil to make sure it’s accurate. I believe it’s best to focus on vaccinating one group, such as girls, to increase coverage. However, the final decision belongs to each country.

Dr. Itamar Bento Claro: Are the two vaccine doses different or the same?

Dra. De Oliveira:  They are the same vaccines, which are currently licensed and there are possible vaccines that could be implemented in the future that are in the pipeline.

Dra. Margaret Dumitru: How have you managed the anti-vaccine sentiment and the language barrier in indigenous and por communities that are also afraid of the vaccine relating it to infertility?

Dra. De Oliveira: We support our countries with the development of a New Vaccine Introduction Plan, which includes an essential component dedicated to language and communication barriers. These sort of situations or cultural beliefs that you mention, among others, should be identified by each country prior to the vaccine introduction in order to have specific strategies to address each situation in different countries. It is important to be ready for these situations before they take place along with learned lessons, which could also warn us of what we could potentially be dealing with. In order to address these issues, we implemented communication workshops at the regional level in Latin America and the Caribbean. These workshops were replicated in multiple countries. In relation to what you describe, one of the best approaches is to work with community leaders prior to introducing the vaccination.

Dr. César Miranda: According to the map that was presented, the only country in Latin America without a vaccine program is Venezuela. Does this project offer coverage now to this country?

Dra. De Oliveira: All the countries can and should participate in the cervical cancer elimination plan. If they have not started vaccinating, there are screening and treatment components that should be strengthened in the country. We recommend working in parallel with national authorities to advocate for the introduction of the vaccine.

Dra. Margaret Dumitru: What about Venezuela, Nicaragua, Cuba and Haití?

Dra. De Oliveira:  Please refer to answer above.

Dr. Itamar Bento Claro: Have all the countries in Latin America re-initiated doing cervical cancer screening?

Silvana Luciani: Most countries in Latin America report having a disruption in primary care services, including cervical cancer screening. A summary of the results, and a report, from a survey regarding the interruption of services during COVID-19 may be found in the PAHO website:  https://www.paho.org/en/news/17-6-2020-covid-19-has-impacted-operation-health-services-noncommunicable-diseases-americas 

 Case from El Salvador – Dr. Mario Morales 

El Dr. Mario Morales Médico Ginecólogo y Máster en Medicina Social, Unidad de Enfermedades No Transmisibles Priorizadas, MINSAL presento el segundo caso titulado ‘La Vacunación contra VPH – El Salvador.’

Presentación

 

 

 

 

 

Questions and Comments

Dr. Morales asked the experts and the participants, how can we prioritize the continuity of vaccination, screening and treatment services considering the elimination goals, but also considering the priorities that are in conflict?

The ECHO ELA Faculty had the opportunity to address this question as follows:

Dr. da Costa stated that El Salvador already has its Vaccine Introduction Plan ready and was scheduled to be implemented in 2020; however, due to COVID-19, this was not possible. Moreover, the schools where the girls were going to be vaccinated are now closed. Dr. da Costa also stated that the recommendation from PAHO is for the countries to continue vaccinating, the only thing that is not recommended is the conglomeration of too many individuals.

Dr. Maza, from El Salvador stated that COVID-19 has presented multiple challenges due to its contagious nature. He also stated that he is collaborating with the Ministry of Health in a study providing follow up to women who had their screening over 5 years ago and is concerned as these women need follow up screening. We have not been able to re-initiate the study and we’re developing protocols to provide follow up to these women.

Dr. Arrossi stated the pandemic impact is not uniform across each country. For example, in Argentina, there are certain areas where COVID-19 is well controlled. It is important to think about protocols that can be adapted to the pandemic situation in different zones/areas of a country. Screening should be re-established wherever is possible with strict security protocols to protect patients, which should be our top priority. At the same time, we should differentiate between the women who should be screened and the women who already have a lesion diagnosis. In this case, these are two completely different situations, and we should try to guarantee the access to treatment being guided by security protocols to women who already have a high grade lesion diagnosis and evaluate the conditions to reestablish the screening that is urgent under the guidance of the cervical cancer elimination plan but could be placed on a temporary hold in comparison to a woman who already has the diagnosis of a lesion and requires treatment.

Dr. Salcedo stated that she agreed with her colleagues. She reiterated that each country is different, and it is very difficult to have only one protocol for all the countries. Moreover, she emphasized that the vaccination and screening should be carried out with appropriate protocols safeguarding the safety of the patients. 

Dra. Ileana Quirós: Dr. Morales: what are you referring to when you mention 13-14% positive: HPV of high risk or diagnosed lesions? Do you conduct biopsies to confirm the type of lesion?

Dr. Morales: I’m referring to women with HPV tests with a positive result who later require visual evaluation by a doctor and if they meet the eligibility criteria to conduct a cryotherapy, this is conducted. If they do not meet the criteria for cryotherapy, they are referred to a hospital for a colposcopy for their treatment. 

Dr. Aurelio Cruz:  We need to know the resilience of a health system. We need to assess the impact of COVID-19 in countries with relation to resources and infrastructure to detect and follow up women who are positive.

Dr. Itamar Bento Claro: Due to the heterogenous impact of the pandemic in Brazil, it is not possible to adopt only one recommendation across the board. As a rule, it is recommended to consider the return to cervical cancer detection activities and for health officials to consider the local indicators in reference to COVID-19 incidence.

Case from Argentina- Dr Nathalia Katz

Dr. Nathalia Katz,  infectologist and HPV vaccination reference - Medical Area of the Directorate of Control of Immunopreventable Diseases of the Ministry of Health of Argentina presented a case on "Vaccination against HPV - Argentina."

Presentación

 

 

 

 

Dra. Montealegre (ECHO ELA Faculty): In reference to the school vaccination programs, are these synchronized with other programs for younger children for other vaccines?

Dr. Katz: No, for those younger than 2 years old, it’s complex and vaccines need to be implemented by specialists, we’re working on that at another level. The Ministry of Education is involved solely in ensuring that kids enrolling in school are vaccinated at 11 years old.

The recorded session (fully conducted in Spanish with some Portuguese) may be found by clicking on the following link, please feel free to distribute among your colleagues:

https://mediaplayer.mdanderson.org/video-full/22973114-EA13-4BD3-90E4-2FB9EF2F55CA

The next meeting will be held on Friday, August 28 at 12:00 PM-1:30PM EDT, Washington, D.C.

Didactic TOPIC: 'ESAVI and the HPV vaccine' - speaker, Dr. Maria Tereza da Costa, PAHO / WDC.

The case will be presented by Dr. Ana Goretti from the Brazilian Ministry of Health.