Experiences and Challenges in Implementing the Cervical Cancer Prevention Program in Mexico

Transcript

• 00:00<v ->Jam-packed with both quantitative</v>
• 00:03and qualitative information.
• 00:06So first, I would like to welcome each and all of you
• 00:10to this wonderful opportunity to listen
• 00:14from Dr. Leith Leon and Leti Torres
• 00:19about their very important mixed methods research work
• 00:25focusing on the Cervical Cancer Prevention Program
• 00:29in Mexico.
• 00:31Before I do that, I do want to mention
• 00:34that this is the inaugural seminar for our newly-minted
• 00:39CMIPS Maternal-Child Health Promotion Program,
• 00:44and we very intentionally highlight the word promotion
• 00:48because we think there is already a lot of knowledge
• 00:52about risk factors for many, many major serious conditions
• 00:58affecting women and young children,
• 01:01and that it is really time to focus more on solutions
• 01:07and on how to co-design effective programs,
• 01:12how to evaluate them, how to scale up these programs.
• 01:17And I am very pleased that today's seminar
• 01:23is co-sponsored by the Yale Scholars
• 01:26in Implementation Science Career Development Program
• 01:30from the Yale School of Medicine,
• 01:32the Global Health Concentration
• 01:33from the Yale School of Public Health
• 01:36and the Global Oncology Program at the Yale Cancer Center.
• 01:42And all of us who represent those programs
• 01:45as well are very grateful to CMIPS for the opportunity
• 01:50to join them in the organization
• 01:53of this wonderful, wonderful seminar.
• 01:57Just a little advertisement, if I may,
• 02:03the Maternal-Child Health Promotion Program
• 02:08has really been launched with a lot of enthusiasm.
• 02:13And under the leadership of Dr. Amber Hromi-Fiedler,
• 02:18we now have a formally approved
• 02:21Maternal-Child Health Promotion track
• 02:24for the MPH students in our school.
• 02:28And we also are working very diligently
• 02:33under the leadership of Amber on the development
• 02:36of Maternal-Child Health Promotion pathways
• 02:40for PhD students across departments in the school.
• 02:46We are also very engaged in advancing
• 02:50Maternal-Child Health Promotion research within Yale,
• 02:56across institutions, both in the US and globally.
• 03:01And I feel especially proud about today's webinar
• 03:04because the reason we found out about the wonderful work,
• 03:08or I found out,
• 03:10Donna already knew about it,
• 03:11but that I found out about the wonderful work
• 03:13from Leith and Leti
• 03:16was because they both gave an amazing lecture
• 03:20as part of the summer implementation science course
• 03:25that we did in partnership
• 03:27with the National Institute of Public Health in Mexico,
• 03:30which is the institutions where both of them work.
• 03:35So Leith Leon-Maldonado is a doctor in public health,
• 03:42who is working as a researcher
• 03:44in the Department of Cardiovascular Diseases,
• 03:47Diabetes Mellitus, and Cancer
• 03:49at the Center for Population Health Research or CISP,
• 03:54and is also a faculty member
• 03:56of the School of Public Health
• 03:59at the National Institute of Public Health in Mexico.
• 04:02And that is the School of Public Health in Mexico
• 04:06and is accredited by CISP
• 04:09as well as the same way that ours is.
• 04:13She worked on zoonosis programs
• 04:16at the Michoacan Health Services,
• 04:19Michoacan is a beautiful state in Mexico,
• 04:22and has helped coordinate
• 04:23the FRIDA and FASTER-Tlalpan studies
• 04:26on cervical cancer screening.
• 04:30Her principal areas of interest
• 04:32are alternatives for the prevention
• 04:35and control of cervical cancer and HPV infections
• 04:39and associated cancers.
• 04:42Leti Torres-Ibarra is a doctor in science,
• 04:46who is also a researcher and faculty member
• 04:51in the same department at INSP as Leith is.
• 04:56Her translational research has consistently...
• 05:02I'm sorry, I got lost here.
• 05:04Has consistently aimed at reducing HPV cancer burden.
• 05:08She has been working to carry out a process
• 05:11of technological assimilation for cervical cancer prevention
• 05:15and control within the Mexican healthcare system,
• 05:19and has contributed to the design
• 05:21and execution of large studies
• 05:24aimed at evaluating cervical cancer screenings.
• 05:28The results of her quantitative evaluation
• 05:31of alternative HPV vaccination schedules for girls
• 05:35has become a cornerstone of the World Health Organization
• 05:39updated recommendations for HPV immunization.
• 05:44And I also know that Leti happened to be,
• 05:48I think, a predoc/postdoc scholar at Harvard
• 05:53under the mentorship of Dr. Donna Spiegelman.
• 05:58So please join me in welcoming Leith and Leticia
• 06:05by clapping with your symbols if you can.
• 06:07and I want to give them the floor
• 06:11so that they can start illuminating us with their talks.
• 06:15Welcome. (speaks in foreign language)
• 06:18<v ->Thank you very much.</v>
• 06:20Thank you for the invitation, thanks.
• 06:22<v ->Thank you, Rafael, for this wonderful presentation.</v>
• 06:26And I really would like to thank all of you for having us.
• 06:34And I really very excited to share with you
• 06:38the experience and challenge in implementing
• 06:40the Cervical Cancer Prevention Program in Mexico.
• 06:45So let me share my screen.
• 06:57Can you see my screen now?
• 06:59<v Rafael>Yes.</v> <v ->Yeah, we can see it.</v>
• 07:01<v ->Okay.</v>
• 07:04So...
• 07:11Okay.
• 07:18So in this talk, we are going to talk about cervical cancer.
• 07:23Why?
• 07:24Because this is a public health program
• 07:28that caused premature death,
• 07:30and this is a preventable disease
• 07:34that cause hundreds of thousands of women deaths every year.
• 07:40And cervical cancer now,
• 07:42it's an example of a preventable disease.
• 07:46As we can see later,
• 07:47mortality due to this disease
• 07:49is a manifestation of health inequity.
• 07:53Unfortunately, where women lives,
• 07:56her socioeconomic ethnocultural or immigration status
• 08:00mean the difference between life and death
• 08:03from this common cancer, which already...
• 08:11This cancer, worldwide, in the 2020,
• 08:15caused more than 600,000 incident cases
• 08:21and more than 300,000 deaths.
• 08:26As I mentioned, as you can see in these two maps,
• 08:33the top map represent the incident cases
• 08:37and the bottom one represent the mortality rates.
• 08:42And you can see that more than 85% of the cases
• 08:47are diagnosis in less developed countries,
• 08:51where cervical cancer rocking second only
• 08:55after breast cancer.
• 08:58In regions with the scarce resource,
• 09:01fragile or fragmented health services,
• 09:04this cancer contributes to the cycle of poverty.
• 09:10This, despite we have proven cost effective interventions
• 09:15available for this cancer,
• 09:18as you can see in these maps,
• 09:20we can observe substantial variations
• 09:23between regional and geographic countries.
• 09:27For example, in this map,
• 09:31and that represent the...
• 09:32The mortality rates were white.
• 09:34We can see that the more intense orange
• 09:40are the countries with the highest mortality rates.
• 09:48What happened in Mexico about the incidents?
• 09:52This cancer
• 09:53is the second most commonly diagnosed cancer among women.
• 09:56And according to IARC in 2020,
• 10:029,000 new cases of cervical cancer occur in Mexico.
• 10:07Here is important.
• 10:09I would like to mention that, for many years,
• 10:13we didn't have a population-based cancer register.
• 10:17But the good news is that in the last five years,
• 10:24the field record has been created in a city,
• 10:28in desert of Mexico, in the peninsula of Mexico.
• 10:32And we are very excited
• 10:34because probably at short term, we can have data too,
• 10:40a more accurate data about this disease.
• 10:46And cervical cancer is a second leading cause of death,
• 10:50also in Mexico among women, among Mexican women.
• 10:54Annually, more than 4,000 women death by this disease.
• 11:02A similar disparity exists within our country.
• 11:07And in this map, you can see the 32 states of Mexico
• 11:11and the states located at the south of Mexico
• 11:19are the states with the highest social deprivation
• 11:22and also are the states with the higher mortality rates
• 11:27than the rest.
• 11:30You can see in this map,
• 11:31the mortality rates is twice the...
• 11:38The mortality rates...
• 11:38Sorry, the mortality rates in this area
• 11:42is twice the mortality rate of Mexico City.
• 11:48And this is an example that this cancer
• 11:55is influenced by determinants of access to health.
• 12:02And this situation, these early situations happen
• 12:05now in a era where we have options available
• 12:11for primary and secondary preventions,
• 12:14which offer an excellent opportunity
• 12:16to intervene more effectively against this cancer.
• 12:20So now, we can see that women
• 12:23shouldn't have to die from this disease.
• 12:29Actually,
• 12:31in 2018,
• 12:34the WHO Director Dr. Tedros,
• 12:39made a global call for action
• 12:42towards elimination of cervical cancer because, as we know,
• 12:50we now have the tools to eliminate the disease
• 12:57through the vaccination and through the screening.
• 13:04In this slide,
• 13:06I would like to show how the prevention program
• 13:08in Mexico is made up.
• 13:10We have the body strategies,
• 13:14primary prevention through vaccination
• 13:18and secondary prevention through screening.
• 13:21The vaccination is focused as a public health program.
• 13:28It's free, and it's focused in girls
• 13:30to 9 to 11 years old.
• 13:34And then secondary prevention through this training
• 13:38and depends of the age,
• 13:41the women below 35 years old are screening with Pap smear,
• 13:50and women from 35 to 64 years old
• 13:56are screening using HPV as primary screening test.
• 14:08Just a summary.
• 14:11As you probably know,
• 14:13HPV vaccines
• 14:21have an excellent safety efficacy against the HPV infection
• 14:27and against cervical cancer and another HPV-related disease.
• 14:32There are three licensed HPV vaccines,
• 14:37quadrivalent, bivalent, and nonavalent.
• 14:40In this year,
• 14:42we celebrate the 15 years
• 14:44since the first HPV vaccine was FDA register.
• 14:50The first two vaccines available
• 14:53that were quadrivalent, bivalent vaccines
• 14:57include protections against HPV 16 and 18,
• 15:02that are the main HPV types that contributes
• 15:07to 70% of cervical cancer cases.
• 15:15The inclusion of the other seven high-risk HPV types
• 15:20that are the HPV 31, 33, 45, 52, and 58
• 15:25will increase the protection to almost 90% of the infection
• 15:29responsible for cervical cancer prevention.
• 15:32So these are great news.
• 15:37By December in 2019,
• 15:43100 countries had introduced HPV vaccine
• 15:45in their national immunization programs for girls,
• 15:49mainly in high-income countries.
• 15:52At present, 70% of current cervical cancer cases
• 15:57occur in countries that have not yet introduced HPV vaccine.
• 16:01And that is why continuous screening is still required,
• 16:05but the scaling up and sustaining programs
• 16:07in routine health service in that countries is challenging.
• 16:12I would like to know that Mexico along with Panama
• 16:17were the fierce middle income countries
• 16:22that introduce HPV vaccination
• 16:24in the National Immunization Programs in 2008.
• 16:33Mexico has a universal HPV immunization program since 2012.
• 16:42This photo shows our former Mexican president,
• 16:47our former Ministry of Health
• 16:56in a public event,
• 16:57launched the immunization program.
• 17:00The HPV vaccine is to all girls
• 17:03in fifth grade of primary school
• 17:06or to those girls of 11 years old since 2012.
• 17:13We have an school-based vaccination program,
• 17:17and we use a two-dose schedule.
• 17:21The first dose is administered at month zero,
• 17:26and then at six months later.
• 17:36Here, I will like to mention
• 17:41that Mexico was a pioneer
• 17:43to implement alternative vaccination skills,
• 17:46again, HPV since 2009.
• 17:51Probably your question,
• 17:53why reduced the number of doses?
• 17:56The standard dose schedule
• 17:58was three doses at month zero, two, and six.
• 18:03But since the beginning,
• 18:05Mexico proposed an alternative vaccination schedule
• 18:09against HPV because of cost saving
• 18:12and programmatic advantage
• 18:13that may facilitate high coverage.
• 18:16So at the beginning,
• 18:22Mexico proposed an alternative vaccination schedule
• 18:25of month zero, six, and at that month,
• 18:29and five years later.
• 18:32But after provide evidence
• 18:38that a booster five years later is no longer need,
• 18:44we have now an alternative dose schedule
• 18:47at month zero and month six.
• 18:51Why this?
• 18:53Because this is called saving.
• 18:58Reducing one dose have an impact
• 19:04and an easier administration.
• 19:06We have one visit less to the primary schools.
• 19:12This strategy allow us to increase the coverage,
• 19:15saving dozen of doses of vaccine to reach more girls.
• 19:23According to many studies,
• 19:25it has been proof that this is a cost effective
• 19:30if a vaccine coverage reach more than 70%.
• 19:37We can increase adoption
• 19:39of the immunization programing population
• 19:40with limited healthcare access.
• 19:45Another reason to change this dose regimen
• 19:51is that if we adopt this to dose schedule,
• 19:57we can reduce the loss to follow up in this population.
• 20:04And as I mentioned, I would like to share.
• 20:09These are our results of a non-randomized clinical trial
• 20:16that our group conduct since 2009.
• 20:23This trial was established in Mexico.
• 20:27We enrolled more than 1,000 healthy girls,
• 20:33almost 500 women to test if alternative dose schedule
• 20:42were not inferior to the standard dose schedule.
• 20:48Our results show that after five years,
• 20:53the immunogenicity of the bivalent HPV vaccine
• 21:00in Mexican women is safe and produced
• 21:03and travels immune response with antibody levels
• 21:07that remain stable over five years
• 21:09after primary immunizations.
• 21:12In this green line, you can see the GMTs,
• 21:18the geometric mean titers of the HPV vaccine
• 21:24with a standard dose schedule.
• 21:27And in this wine bar,
• 21:30we can see the immunogenicity levels
• 21:33of the two dose schedule.
• 21:36And we can see that this immune response
• 21:42is above the natural infection.
• 21:44And we found that this antibody response
• 21:49was not inferior to the response observed in girls
• 21:53of the same age.
• 21:56These results,
• 21:57along with another results of other studies,
• 22:02contribute to the recommendation of the WHO
• 22:08about the HPV vaccination
• 22:10that now says that two-dose schedule
• 22:13in years aged 9 to 14 years is support.
• 22:21In Mexico, I can say that the acceptability of all vaccines,
• 22:27it's very, very high.
• 22:31These are the results of a study conduct in Mexico City
• 22:39where in this study,
• 22:42the investigators asked to mothers of girls
• 22:46about the acceptability of HPV vaccine,
• 22:49and there is a high acceptability of almost 90%.
• 22:54The reasons for not acceptance among these mother
• 22:57were not knowing enough about HPV
• 23:01because (indistinct) is not a risk for HPV infection
• 23:05or because they think that the HP vaccine
• 23:10is a new vaccine or they are unaware of the side effects.
• 23:16In adults,
• 23:18our group also have conduct an study
• 23:23to evaluate acceptability among adults.
• 23:26We can observe that the acceptability of the HPV vaccine,
• 23:31it's also very high.
• 23:35Now, we have a new challenge in HPV vaccination in Mexico.
• 23:40First, we have a shortage of vaccine since 2019.
• 23:47The bivalent vaccine company exits the market.
• 23:51So we have now a monopoly of HPV vaccine.
• 23:57In 2016, GSK made a decision to stop supplying Cervarix.
• 24:05Now, we have to...
• 24:08Probably, we'll have to buy the other vaccines
• 24:13but are more expensive.
• 24:15And the situation worsen with the SARS-CoV-2 pandemic.
• 24:21As you know, in Mexico,
• 24:22the schools were closed until two months ago.
• 24:28And so we need catch-up programs to reach that girls.
• 24:34And briefly, I would like to share the experience
• 24:38about cervical cancer screening.
• 24:41And just to remember,
• 24:42the goal of the cervical cancer screening
• 24:45is reduce the burden of cervical cancer
• 24:47by the early detection of cervical precancers
• 24:51that can be timely treated
• 24:52to prevent progression to invasive cancer.
• 24:55Unfortunately, the impact of the program
• 24:59has been insufficient in Mexico,
• 25:01despite the resource allocated
• 25:03in the Mexican Cervical Cancer Screening Program
• 25:06has been allocated since 1974.
• 25:10Most of the cervical cancer cases in Mexico
• 25:13are detected at advanced stage of the disease,
• 25:18explaining the high mortality.
• 25:20In this graph, you can see the bars are the deaths.
• 25:29This gray line is the standardized mortality rate.
• 25:35Unfortunately, the call reducing the mortality rate
• 25:38to less than 11 in 2012 was not met.
• 25:49The reasons why these efforts
• 25:52are harboring insufficient,
• 25:54why that we have a healthcare system that is fragmented,
• 26:05that is enabled to provide infrastructure resource
• 26:09and quality control required in each of the stage
• 26:12from the screening to appropriate management
• 26:14of diagnosed cases.
• 26:17For many years, we have used the publish screening test
• 26:20that has a low sensitivity to detect cervical precancer
• 26:27at the beginning of the '90s.
• 26:31And evaluation of the quality of cervical cytology specimens
• 26:35in Mexico report that more than 60% of the samples
• 26:40were inadequate.
• 26:41In addition, some of the cervical cytology screening centers
• 26:46report more than 50% of false negative results.
• 26:52We have an opportunistic program with low coverage,
• 26:56and also we have a lack of tracking system
• 27:02for abnormal cervical cancer screening follow-up.
• 27:06That's why the WHO now recommends that high risk HPV
• 27:13will be the primary screening test for cervical cancer
• 27:17in countries and regions that don't have
• 27:19an effective Pap program.
• 27:21And Mexico introduced the HPV test
• 27:24as the primary screening test
• 27:30in the National Cervical Cancer Screening Program in 2009.
• 27:40Our research group has a lot of experience
• 27:46evaluate the usefulness of the HPV DNA
• 27:50in more than 250,000 of Mexican women
• 27:58through four demonstrative projects.
• 28:01And the results of these large projects
• 28:06show that HPV is more sensitive than Pap smear,
• 28:12that a single HPV test is more sensitive
• 28:15that even two Pap tests in a one-year period,
• 28:20that HPV test by vaginal self-collection
• 28:23detects more than four times more invasive tumors
• 28:27when compared to cervical cytology.
• 28:31but also we learn that if we refer
• 28:34all HPV positive women colposcopy,
• 28:36we can cause a large burden to the system,
• 28:39so triage test is required.
• 28:45This is our HPV-based Cervical Cancer Screening Program
• 28:50that was launched in 2008.
• 28:53First, women should attend the primary health center
• 29:02where the cervical sample collection is made up.
• 29:07The high risk HPV test is offered.
• 29:13When the program was launched,
• 29:17the implementation of this program launch new challenge
• 29:24because the modification of the program
• 29:26have an extra medical visit to obtain a new cervical sample
• 29:32for cytology triage.
• 29:35So in this program,
• 29:39the women have to return to receive the result of HPV.
• 29:47And if they have an HPV positive result,
• 29:52a second cervical sample should be collected.
• 30:01Then depends on the results of the triage with cytology,
• 30:08the women have to return for a third visit
• 30:13to diagnosis confirmation.
• 30:15Unfortunately, there was an increase
• 30:18in the loss of follow-up among high risk HPV positive women
• 30:22as a consequence of these multiple visits
• 30:26to acquire an adequate sample for cytology
• 30:29and because of the lack of tracking systems.
• 30:33And these problems add to the limited clinical accuracy
• 30:36of cytology which offer, as you remember,
• 30:39only a sensitivity of 40%
• 30:43to the test cervical intraepithelial neoplasia.
• 30:47So now we have modified this program,
• 30:55one visit was removed.
• 30:56Now, the women go to the primary health center
• 31:03for the cervical sampling.
• 31:08And then she has to come back only
• 31:14for the results of the HPV, and the cytology has triage.
• 31:20Unfortunately, after these modifications,
• 31:26we remains some challenges.
• 31:28We now have a very low follow-up
• 31:34to colposcopy of Pap positive women.
• 31:40We only have 43% of women with abnormal Pap smears
• 31:46that are successfully follow up to diagnosis confirmation.
• 31:51And the women who are...
• 31:59The women who are attending in colposcopy
• 32:03have a low proportion of biopsy collect
• 32:06to confirm that the diagnosis.
• 32:10So this...
• 32:15In this slide, I only want to say
• 32:21that HPV test is effective for cervical cancer detection,
• 32:26but it's not enough.
• 32:29In Mexico,
• 32:30according to the National Health and Nutrition Survey
• 32:33in 2012, the self-report Pap smear or HPV
• 32:37in the last 12 months, it's only 50%.
• 32:43So we have many barriers
• 32:45to meet the screening coverage of more than 70%.
• 32:51We have barriers like access
• 32:54in marginalized or remote places.
• 32:57We still having some logistical issues of transportation,
• 33:01inadequate facilities.
• 33:04And overall, we have many barriers,
• 33:08cultural barriers like fear, shame about this.
• 33:14Probably the biggest advantage of HPV testing
• 33:17is that we can use vaginal samples, self-collected by women.
• 33:21And this is an example of the flyer
• 33:24that we use as part of our FRIDA project in Mexico,
• 33:29where we explain to the women
• 33:31how they can collect by themselves a vaginal self-sample.
• 33:40And now, recently the last year, indeed,
• 33:46we publish results of our pilot test
• 33:51because we are HPV testing subsample urine
• 33:56as an alternative primary screening method.
• 34:00These blood options, vaginal or urine subsample
• 34:07can be excellent strategies to reach more women
• 34:12and to overcome the challenge of coverage.
• 34:20And in summary, I think that these are our challenge
• 34:23in the Mexican Cervical Cancer Screening Program.
• 34:26We have to increase the coverage.
• 34:28We have to improve the participation,
• 34:31and probably we have to incorporate these alternatives
• 34:35to pelvic examination.
• 34:37We have to improve the efficiency of screening
• 34:40to detect women in the highest cancer risk
• 34:42using a more efficient triage strategies.
• 34:46We have to install a cancer information system.
• 34:51That this cancer information system
• 34:55can facilitate the follow-up to another stage
• 35:02like the follow up to colposcopy.
• 35:06But also we have to talk about this implementation
• 35:10of some strategies like the Pap smear
• 35:15as primary screening test in some institutions in Mexico.
• 35:19But we have to talk about what will be the role
• 35:22of the cytotechnologist that work in Mexico.
• 35:29So as you know, we have now effective interventions,
• 35:35but we have an effective cervical cancer prevention program
• 35:39in Mexico.
• 35:41And finally, I would like to thank
• 35:46to our two senior investigators.
• 35:50The evidence in Mexico has been possible
• 35:53thanks to the leadership of Dr. Eduardo Lazcano
• 35:56and Dr. Jorge Salmeron, who are our mentors.
• 36:00And thank you so much.
• 36:14<v Rafael>So I think the speakers</v>
• 36:18have requested for all questions to be answered
• 36:21until both presentations are completed,
• 36:24if that is okay with you,
• 36:26so that we can Leith now go on to make her presentation.
• 36:40<v ->Can you see it?</v> <v Rafael>Not yet.</v>
• 37:05<v ->Can you see it now?</v> <v Rafael>Yes.</v>
• 37:08<v ->Thank you.</v>
• 37:10Again, hello, everyone.
• 37:12My name is Leith Leon-Maldonado.
• 37:15I work for the National Institute of Public Health
• 37:18in Mexico, INSP, as a researcher and faculty member.
• 37:23Thank you, Donna and Dr. Rafael Perez-Escamilla
• 37:25for the invitation.
• 37:26Amber, thank you.
• 37:28It is an honor.
• 37:30As Dr. Leti Torres comment, in this second part,
• 37:34I will address implementation
• 37:36of cervical cancer prevention strategies
• 37:39based in two studies conducted in Mexico.
• 37:44The experiences and lessons that we have learned.
• 37:50That Dr. Escamilla said,
• 37:52I will answer the question at the end of my presentation.
• 37:58In the first part, Leti told you why cervical cancer
• 38:02continue to be a public health in Mexico.
• 38:08This has led to search for alternatives
• 38:11to face the border of cervical cancer in our country.
• 38:16In a scenario where around 4,000 women die per year
• 38:21for a preventable disease,
• 38:23Mexico has the advantage of having introduced
• 38:27early prevention strategies such vaccination
• 38:31against HPV and HPV test as a strategies
• 38:35to face the disease.
• 38:37That is decision making has narrowed the gap
• 38:40between evidence and action.
• 38:43However, to have implemented novel strategies wasn't enough.
• 38:48We faced challenges.
• 38:50Why?
• 38:51Mainly because the program continues
• 38:54having difficulties in increasing coverage
• 38:56and achieving a decrease in mortality.
• 39:00We can ask ourselves why.
• 39:02What's happening in the program?
• 39:05Why don't women get screened?
• 39:08And even when we have a more effective screening tool,
• 39:12that is the HPV test, why don't return to the follow-up?
• 39:17Did we have problems
• 39:19during the implementation of the HPV test,
• 39:22or could it be the strategies?
• 39:26But Leti said the evidence suggests that they are affected.
• 39:31Could it be the implementation of the strategies?
• 39:34Surely the answer is not unique,
• 39:37and it's not simple in a complex program.
• 39:40Let's talk about what we have learned.
• 39:45Within the line of research on HPV and cancer in INSP,
• 39:50studies have been carried out that show the difficulties
• 39:54on the Cervical Cancer Prevention Program.
• 39:57Today, I tell you about two studies.
• 40:00One conducted in Michoacan State
• 40:02in the center of the country in 2011
• 40:05and another in Mexico City carried out in 2018.
• 40:12And what we learned from the evidence?
• 40:16The study in Michoacan aimed to identify
• 40:19information and counseling needs
• 40:22when HPV test was used
• 40:24amongst Cervical Cancer Prevention Program users.
• 40:28The study took place in Chilchota, Michoacan
• 40:31in an Indigenous community
• 40:33and a marginally sized area of Morelia City.
• 40:37Complex scenarios were vulnerable
• 40:40and disadvantaged women reside
• 40:42and have greater risk of cervical cancer.
• 40:46The analysis presented is part of a large study
• 40:50that we included interviews with women
• 40:52in different types of screening.
• 40:55The findings of the group of women
• 40:57who have received their HPV results are presented today.
• 41:04What is counseling?
• 41:05We can understand counseling as a directive, dynamic,
• 41:10flexible process in a environment of trust and empathy
• 41:15between users and health professionals.
• 41:18It is a process of communication, advice,
• 41:22listening and solving to facilitate decision making.
• 41:27In the context of the Cervical Cancer Prevention Program,
• 41:31it is intended that women are informed
• 41:34about HPV screening test,
• 41:37clear their doubts about different topics.
• 41:41They express their concerns about HPV infection,
• 41:46the vaccine, cervical cancer,
• 41:48and make assertive decision for prevention by using counsel.
• 41:56The study approach was qualitative.
• 41:59It was approved by IRB,
• 42:01an informed consent was obtained in all the cases.
• 42:05Women who recently received their HPV results
• 42:09were interviewed in two settings,
• 42:12urban area and an Indigenous communities
• 42:15with different level of marginalization.
• 42:20During the interviews,
• 42:21beliefs, perceptions and experiences about HPV,
• 42:26cervical cancer and screening were explored.
• 42:31The participants were between 33 and 66 years old.
• 42:3646% of the Chilchota women spoke Purepecha
• 42:42and 75 were beneficiaries of Oportunidades Program.
• 42:46The education level was six years or less in 75%
• 42:51and 73 didn't have paid jobs.
• 42:55Oportunidades was a program to support families
• 42:59living in poverty to improve the capacities for nutrition,
• 43:03health, and education,
• 43:05providing financial resources and services.
• 43:11In this study, briefly,
• 43:13I present some of the resource on information
• 43:16and counseling needs.
• 43:18The findings are topics of HPV,
• 43:21including doubts about the transmission of the virus,
• 43:25the severity of the infection.
• 43:26For example, a woman from Morelia said
• 43:30that she would have like to ask if HPV is transmitted
• 43:35by having several partners.
• 43:37And a woman from Chilchota had doubts
• 43:40about what HPV is and how it is transmitted.
• 43:46Another topic of interest was about the screening test,
• 43:50the usefulness of the test, the procedures,
• 43:53the meaning of the results, HPV results,
• 43:57HPV test results and public results.
• 44:00Why the test results are are different?
• 44:02A woman from Chilchota felt sad
• 44:07when she doubt about the having HPV result
• 44:10and another words confused about the meaning
• 44:13of the words positive and negative.
• 44:16Another issue was the stigma about HPV,
• 44:19including doubts about infidelity,
• 44:23an issue that greater concern
• 44:25when understand that an HPV results
• 44:29is the same as a partner infidelity.
• 44:34The recommendation of these study
• 44:37are to straighten information about counseling,
• 44:40about HPV and cervical cancer to mitigate sadness
• 44:45and anxiety and stigma
• 44:47and inaccurate beliefs about HPV infection.
• 44:51Since it generates negative attitudes
• 44:54about the screening process,
• 44:59you have studied a black box concept, right?
• 45:02Let's think about it.
• 45:05The input of the Cervical Cancer Prevention Program
• 45:08was the implementation of the HPV test.
• 45:11The Pap was already part of the program.
• 45:15In the output after implementation,
• 45:18unnecessary emotional impact was identified,
• 45:21such as stigma, fear, and uncertainty.
• 45:25Doubts about testing, including the Pap smear,
• 45:29despite being using Mexico for over 50 years.
• 45:34What happened inside of the black box?
• 45:37We can't explain the input and the output,
• 45:40but we can explain the results,
• 45:43what procedures were implemented
• 45:45and how were implemented in the practice.
• 45:51Were the procedures different in urban areas
• 45:55than in a foreign or indigenous context?
• 45:59We need to block the black box,
• 46:01open it, and study how behavior, culture,
• 46:05knowledge influence.
• 46:07We don't know.
• 46:09By observing the results from the implementation,
• 46:12we can ask ourselves.
• 46:14What happening to the intervention?
• 46:18What was the problem?
• 46:19The effectiveness of the intervention
• 46:21of each implementation.
• 46:27Next, I'm going to share our experiences
• 46:30and what we learned from the FASTER-Tlalpan study.
• 46:34FASTER is an strategy aimed
• 46:38that proposed to combine of the HPV vaccine
• 46:42and the screening based in the HPV test in adult women
• 46:48between 25 and 45 years old.
• 46:53FASTER was conducted in real conditions.
• 46:56Vaccination and screening were introduced,
• 46:59combined as Cervical Cancer Prevention Program.
• 47:03FASTER is a randomized clinical trial,
• 47:06was implemented in eight healthcare centers in Mexico City.
• 47:11It was approved by IRB.
• 47:16Once FASTER study was carried out in healthcare centers,
• 47:21we aim to evaluate the results of the implementation
• 47:24of a strategy like FASTER from the accessibility
• 47:28and feasibility components.
• 47:31The question is if a strategy like this were introduced
• 47:35in Cervical Cancer Prevention Program,
• 47:37would it be acceptable?
• 47:39Would it be feasible?
• 47:41The innovation was the vaccine since the HPV test
• 47:45was already an standard procedure in Mexico.
• 47:49Therefore, acceptability vaccine
• 47:52among the participant women was evaluated
• 47:55using our open questionnaire.
• 47:59We also evaluate the acceptability.
• 48:03We use an interview guide with doctors and nurses
• 48:05based on the study objective, the literature,
• 48:10and the theoretical framework.
• 48:13The feasibility was evaluated using a checklist
• 48:17to identify the minimum infrastructure
• 48:21needed for vaccination and screening.
• 48:26There are the tools we use to evaluate these components.
• 48:30And number one, we used to ask about the reason
• 48:34for accepting or rejecting the vaccine.
• 48:38Number two, we used to evaluate acceptability
• 48:41from the perspective of the health professionals.
• 48:44And number three, we use to evaluate the feasibility.
• 48:49We can identify the minimum infrastructure
• 48:52necessary for vaccine and screening.
• 48:57Here are some of the results
• 48:59about the reasons to accept the vaccine.
• 49:0293% of women accept HPV vaccine.
• 49:06Some of the reason for accepting
• 49:08were prevention and healthcare motivated
• 49:11by sexual behavior, medical history, fear,
• 49:15and benefits of the vaccine.
• 49:17The susceptibility of HPV vaccine among adult women
• 49:23allow us to understand their responses,
• 49:26their response to a vaccination if a strategy like this
• 49:30were implemented in health services.
• 49:34However, some comments suggest that it is necessary
• 49:39to refer the counseling and training
• 49:42or help professionals who provide counseling.
• 49:47While the rejection of the vaccine was less than 10%,
• 49:51the reason for rejection could represent the barriers
• 49:56to the implementation of the vaccine
• 49:58at the population level.
• 50:00For example,
• 50:02the perception about the vaccine not being safe,
• 50:05lack of confidence and information about the benefits,
• 50:09health education, counseling
• 50:12and dissemination of the information.
• 50:14Good health increase awareness and promote
• 50:18positive attitudes toward vaccination.
• 50:22The findings from health professionals
• 50:25suggest a positive attitude towards vaccination
• 50:28and the combined strategy.
• 50:31Among the vaccination benefits are decreased incidents
• 50:35and cervical cancer mortality,
• 50:39prevention over treatment.
• 50:42To implement the strategy at population level,
• 50:46approximately 25% of the participants
• 50:51believe they were no obstacles at all.
• 50:54There is the perception that women
• 50:57would accept the HPV vaccine
• 50:59and the great challenge to decision making
• 51:02at institutional level.
• 51:05They identify deficiencies in infrastructure, supplies,
• 51:10medical personnel, as well as health information.
• 51:14The barriers are machismo, myths, and mistrust.
• 51:22Regarding the feasibility in terms of minimum infrastructure
• 51:27necessary to implement the vaccine on the screening,
• 51:31it was observed that eight healthcare centers
• 51:35had a fridge to store the vaccines
• 51:39and 75% had a generator
• 51:42and 88 had at least one portable cooler.
• 51:47As for the screening,
• 51:48no healthcare center had a specific space.
• 51:5250% performed cervical examination
• 51:56in shared doctor's offices.
• 51:58And the other 50% didn't have a space for the screening.
• 52:0663% had a examination table and a lamp
• 52:10and not had a private space
• 52:13for delivering results and counseling.
• 52:15It is important to remember that the screening
• 52:18had been part of the prevention program
• 52:21established in Mexico since the '70s,
• 52:24and that infrastructure should be in place
• 52:27in healthcare centers.
• 52:31The findings suggest that it is feasible
• 52:35to implement a combined strategy.
• 52:37However, if it's advisable to address
• 52:41weaknesses of the program
• 52:45by improving screening infrastructure,
• 52:48having the supplies and improving attention to users,
• 52:52informing them of the procedures
• 52:54and benefits of these tools, screening and vaccination.
• 52:59Even when the vaccines is acceptable,
• 53:03we must not forget the reason for rejection.
• 53:09In order to avoid implementation barriers,
• 53:12implementing the combined strategy
• 53:15not only means having the vaccine
• 53:17at the same time as a screening,
• 53:20but also strengthened the program operation.
• 53:26Finally, returning to the idea of the black box,
• 53:30the input of the Cervical Cancer Prevention Program
• 53:32is implementation of the HPV vaccine.
• 53:36The HPV test was already part of the program.
• 53:41The results suggest that it could be feasible
• 53:46to implement the vaccine and screening
• 53:49and the vaccines have high acceptability among women
• 53:53and health professionals.
• 53:55But what happened inside of the black box again?
• 53:59What did we do to achieve high vaccination acceptability
• 54:03and how we did it?
• 54:05We need to block the black box, open it,
• 54:08and study how to achieve acceptability
• 54:13and how we can reproduce the intervention
• 54:15at population level.
• 54:17How can we replicate it and be sustainable?
• 54:21That is the challenge.
• 54:25Thank you very much for your attention.
• 54:27It's a pleasure to share our experience with you.
• 54:30Thank you very much.
• 54:32<v ->Thank you.</v>
• 54:33Thank you very much, Leith and Leti.
• 54:36Very, very complimentary talks.
• 54:39I know we're right on time now.
• 54:42We are scheduled to continue meeting
• 54:45with Leith and Leticia for the next hour
• 54:50together with the CMIPS team,
• 54:52but I'm sure if any of you want to stay on
• 54:56you could stay to ask questions.
• 54:59Are we staying in this Zoom, William, or-
• 55:01<v ->No, I think there's a different one, Rafael,</v>
• 55:03but maybe we could take, you know,
• 55:05just a few minutes to take a question or two.
• 55:07I know at least one person had a question.
• 55:10<v ->Yeah, Vinita had her hand raised</v>
• 55:13right after Leti finished her talk.
• 55:16<v ->Yeah.</v>
• 55:16<v Vinita>Yeah, hi.</v>
• 55:17My name is Vinita Parkash, I'm a pathologist.
• 55:20And so I guess my question to you was,
• 55:23why does your cytology sort of...
• 55:28I think you said that the performance
• 55:30had a very high false negative rate.
• 55:33What type of Pap smear are you doing?
• 55:36Is this liquid-based cytology?
• 55:38And the second question is,
• 55:40what is the training for cytotechs in Mexico?
• 55:45I've run programs in India,
• 55:47so we've been able to bring up the performance
• 55:53of our cytotechs, and we've actually come up
• 55:56with a very different program
• 55:56from the one that is used in the US.
• 56:04<v ->Thank you.</v>
• 56:06For many years, we have used the standard Pap smear.
• 56:12That's why we have a lot of inadequate samples
• 56:16because there is a lack of training
• 56:20about how to collect the samples among the nurses.
• 56:25And also because there are a lot of mucus
• 56:30and blood in the cervical samples and the training...
• 56:41I think that the main issue is the lack of quality control
• 56:45among our cytotechnicians and our cytopathologists
• 56:50because, for many years,
• 56:54we have not implement quality control mechanisms
• 57:00to ensure that these professional have the ability
• 57:06to read and to interpret these slides.
• 57:12And recently, we have incorporated a liquid-based cytology
• 57:18and this is a great opportunity to do the HPV test
• 57:23and the liquid-based cytology using the same sample.
• 57:28I think this can improve our screening program.
• 57:35But yes, you're right.
• 57:36We have a large percentage of false negative samples.
• 57:50<v Vinita>Sorry, thank you.</v>
• 57:52<v ->Okay, are there any other questions?</v>
• 57:56Okay, if not, I know Leith
• 58:00that you will be meeting with Beth
• 58:04as well after the meeting with CMIPS.
• 58:07And I will be there at that meeting, Beth,
• 58:09so that you know, okay?
• 58:11So thank you all very much,
• 58:13and I guess we all at CMIPS need to move
• 58:18to another Zoom link to continue our conversations
• 58:22with Leti and Leith.
• 58:24Thank you very much.
• 58:25<v Leti>Thank you.</v>
• 58:27<v Vinita>Bye, everybody.</v> (overlapping chatter)
• 58:28<v ->Thank you. (overlapping chatter)</v>