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

February 14, 2024

Information

Speaker: Leith León-Maldonado, DPH & Leticia Torres-Ibarra, DSc

Wednesday, December 1, 2021

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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>