Zimbabwe Where Are We By MN Munyoro WHO NPOEPI Presentation to The Health Cluster 121113 ID: 927857
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Slide1
HPV Vaccine Introduction Demo Project in Zimbabwe Where Are We?
By
M.N Munyoro, WHO/ NPO/EPI
Presentation to The Health Cluster
12/11/13
Slide2Presentation OutlineLeading Causes of Cancer Morbidity and Mortality in the RegionCervical Cancer Disease BurdenBackground to HPV ApplicationAdvocacy Social Mobilization and Communication
Prevention
Proposed Vaccination Strategy in Zimbabwe
HPV Vaccines
Lessons Learnt from Other countries and Way Forward
Slide3The vast majority of cervical cancers are caused by:Infection with the Human Papilloma Virus (HPV)Risk factors include:SmokingImmunosuppression, e.g. HIV infectionUnhealthy diet (low in fruits/vegetables)
Long term oral contraceptives use
Multiple full term pregnancies
Multiple partners
Cancer of the Cervix is
an abnormal growth in the lower, narrow part of the womb
Slide4Natural History of HPV infection
Susceptible
Acute
infection
Chronic
infection
Precancerous lesion
1°Intervention:
HPV Vaccination
Immune
Cervical
cancer
Timeframe following acute infection:
5-15 years
20+ years
2 years
2°Intervention:
Screening/Treatment
2° and 3° Intervention: Screening/ Treatment
Most HPV infections are asymptomatic
>90% of new infections (including those with high risk types) clear or become undetectable within 2 years
But persistent infection with high risk types leads to cervical cancer
Slide5The leading cause of cancer morbidity and mortality in this Region
World-wide estimated 530,000 new cases of cervical cancer in 2008
14% of these occurred in Africa
Of all cancers,
cervical cancer
is the most common in Africa, followed by breast cancer
The death ratio in Africa is 67%, while it is 52% globally
Globocan 2008: Factsheets
Slide6Annual number of deaths from Caner of Cervix
by age group,
Globocan
2008
Slide7High Cervical Cancer Disease Burden-Justification for HPV ApplicationIn Zimbabwe Cervical Cancer remains the leading cause of morbidity among all the cancers.In 2009 cervical cancers contributed to 19% (669 cases) of all new cancers and 13 % (134) of all cancer deaths.(Cancer Registry 2009)
Slide8Cancer Incidence Zimbabwe,2010 Source: ZNCR
Slide9Slide10Burden of Cervical Cancer ZimbabweHow many cases are diagnosed each year?
-
Approx 1000 new cases / year (32% all cancers)
What is the incidence of disease?
-ASR 47/100 000
Which age groups are most affected?-40 to 49 yearsWhat are the annual death rates from cervical cancer? -
33 / 100 000
Slide11Cervical Cancer in Zimbabwe
Slide12Background Information National Cancer Registry established in 1985HPV Vaccine Advocacy Group was formed in 2008.
Zimbabwe-specific HPV vaccine guidelines
formulated at the stakeholders workshop on 16th April
2009
Guidelines
based on the model HPV vaccine recommendations for sub-Saharan Africa by the sub-Saharan Africa cervical cancer working group expert panel year
2008
Slide13Background ContdHPV Vaccine Advocacy workshop with stakeholders was held in June 2009
During the workshop,
MoHCW
re-affirmed its
commitment
to introduce HPV
vaccine as part of the overall fight against cancer
of the cervixHPV Vaccine introduction officially approved with HPV Vaccine Launch in October 2009. GSK paid for Vaccine Registration Dec 2009Vaccine registration 8 August 2012
Cervarix launch, 31 October 2012
Slide14Events leading to HPV applicationMarch 2012 communication from GAVI advising interested countries to applyICC meeting convened to support the need to apply Ministry
officials (NCD, CH, Reproductive Health) attended
WHO supported regional
meeting in SA on HPV Demo projects
implementation- May 2012
Application
process started with EPI team in the lead. (Team included CAH, RH,EPI
MoHCW staff including HPO, EPI partners ,WHO,MCHIP, UNICEF,NCD officer). Ministry of Education was extensively consulted.
Slide15Events contdGAVI HPV vaccine demo application June 2012October 2012 Zimbabwe submitted its first application which was not successful-GAVI requested for some clarifications
GAVI response required some clarifications centered on :
- Need to involve Civic Organization Groups
Need to detail how to reach the HPV vaccine target group bearing in mind that this group is outside the usual EPI target group
Slide16Events contdClarifications submitted and HPV application approvedGAVI
HPV vaccine demo approval
-June
2013
MOHCC Strategic Advisory Group on HPV vaccine introduction was recently
appointed
by
PSFirst SAG meeting on HPV Vaccine introduction convened.
Slide17Advocacy Social Mobilization and communicationACS to be carried out among key community opinion leaders for acceptance of the new vaccine. The
sero
-prevalence of HIV/AIDS is high in Zimbabwe
, among which 60% are women. Cervical cancer is more prevalent in
immuno
suppressed HIV positive women and progresses faster in these women
Slide18Advocacy Social Mobilization and communication:Questions likely to arise from the community in relation to the HPV vaccination :-Why
give HPV vaccine to 10 year olds only?
-Why
not give HPV to Boys?
-Why
not give HPV to Women
-Why
in two Districts only
Slide19The core of Cervical Cancer “
Primary Prevention
” is immunization of girls against HPV infection
Cape
Verde
Mauritius
Seychelles
Comoros
Nationwide introduction
Not yet in country EPI
Not AFR
Demonstration project in 2013
2 Countries wide introduction : Rwanda and Lesotho
HPV vaccination:
Girls age 9 – 13 years
Priority given to areas with low access to cervical cancer screening
So far Rwanda and Lesotho included it in national programs
About 8 other countries in demo phase
Other interventions:
Health information and warnings about tobacco use
Sexuality education tailored to age and culture
Condom promotion/provision for those sexually active
Male circumcision
Slide20Secondary prevention Entails screening & early diagnosisCurrently the best chance of saving lives.Traditionally
cervical cytology (Pap smear) is known to have reduced incidence in developed countries.
Visual
inspection with acetic acid or iodine is better alternative in this region followed by
cryotherapy
.
Slide21Secondary Prevention contdHPV testing for high risk HPV type (e.g. HPV 16; 18 and others) is available in the Region. 15% of countries in the Region have capacity to conduct Acetic acid visualization whilst 25% have capacity to carry out Cervical cytology
Slide22WHO Position Paper on HPV Vaccine - 2009HPV vaccination should be introduced into national immunization programmes where prevention of cervical cancer and other HPV-related diseases is a public health priority and where vaccine introduction is programmatically feasible and financially sustainable.
Countries should prioritize achieving high coverage in the primary target population of 9 to 13 year old girls.
Slide23WHO Position Paper on HPV Vaccine (2009)Other considerations for HPV vaccination:Introduce as part of a coordinated strategy to prevent cervical cancer and other HPV-related disease.Prioritize populations who are likely to have less access to cervical cancer screening later in life.Seek
opportunities to link
vaccine delivery to other health services and programmes targeting young people.
Do not divert resources from effective cervical cancer screening programmes.
Slide24Proposed Vaccination Strategy in ZimbabweIn view of the age of girls in and out of school in Zimbabwe, a mixed strategy (school-based, health facility-based and outreach) approach.A
total of 4 441
10
year old girls,
is
targeted.
GAVI
will support the purchase of the HPV vaccine and injection materials at a total cost of $159 500 for two years and GOZ and partners will meet the remaining costs.
Slide25Vaccination strategy ContdEach child will be expected to receive 3 doses for full protection; -First dose to be given in April 2014 then ---second
dose in May 2014
-
3
rd
dose in October 2014.
Demonstration project will be followed up with a national roll out of HPV
Slide26Vaccination Strategy ContdCervical Cancer screening services are currently in the urban setting in both private and public health sector which marginalizes the rural women.
Plans
are in place to roll-out cervical cancer screening and treatment services to provincial and district hospitals which to a larger extent are made up of rural populations
.
Slide27HPV VaccinesTwo vaccines currently available, widely licensed, and WHO prequalified: Cervarix® (bivalent): Prevents precancerous lesions from HPV types
16
and
18
Gardasil®/
Silgard
® (
quadrivalent): Prevents precancerous lesions from HPV types 16 and 18 and anogenital warts from HPV types 6 and
11 Up to 30% of all cervical cancer cases caused by HPV types other than 16 and 18, so these vaccines do not eliminate -need for future cervical cancer screeningBoth vaccines require 3 doses administered over 6 months
Both vaccines have excellent safety profiles
Slide28HPV Vaccines (continued)Both vaccines demonstrate best efficacy in individuals HPV-naïve to the vaccine types so best to vaccinate girls prior to initiation of sexual activity (
target is 9-13 year old girls
)
For both vaccines, younger girls have higher immune responses than 15 to 26 year old females
There is no evidence of waning protection over time for either vaccine (post-vaccination follow-up period exists up to 9 years)
Small studies in HIV-infected persons show that HPV vaccine is safe and immunogenic but duration of protection is unknown
Slide29Some lessons from countries who have introduced HPV(Tanzania)Adequate sensitisation, to inform the public and to dispel rumours. Improved and timely school record keeping.
Adequate training and resources for
health workers
(including vaccine cold storage).
Slide30Way Forward Preparations for HPV introduction have started and to be intensified as from 4th quarter 13Two demonstration project districts have been identified-
Marondera
and
Beitbridge
Need for TA (HQ,AFRO,IST) support in
planning, implementation, monitoring and evaluation cannot be overemphasized
Slide31Conclusion Smooth implementation of the demonstration project will create a good environment for the national roll outInvolvement of the community based organisations will also enhance community ownership of the projectPartner collaboration in the process is of Paramount importanceAdvocacy and communication and social mobilisation activities also need to be emphasised before and during implementation
Slide32THANK YOU , TATENDA, SIYABONGA