3. 3 |
Life course approach to cervical cancer prevention and control
Girls 9-14 years
• HPV vaccination
Girls and boys, as appropriate
•Health information and warnings about
tobacco use
•Sexuality education tailored to age & culture
•Condom promotion/provision for those
engaged in sexual activity
•Male circumcision
Women > 30 years of age
“Screen and treat” – single visit approach
• Point-of-care rapid HPV testing for high risk
HPV types
• Followed by immediate treatment
• On site treatment
All women as needed
Treatment of invasive cancer at any age and
palliative care
•Ablative surgery
•Radiotherapy
•Chemotherapy
•Palliative Care
Primary Prevention Secondary Prevention Tertiary Prevention
Global guidelines Global Indicators Global Cost-effectiveness recommendations
4. 4 |
May 2018: WHO Director General’s Call to Action to eliminate
cervical cancer as a public health problem
5. 5 |
Definitions on Control, Elimination and Eradication
The Dahlem Workshop in March 1997 discussed the hierarchy of
possible public health intervention with infectious diseases
(Dowdle 1998).
Dowdle WR. The principles of disease elimination and eradication.
Bull World Health Organ 1998;76 Suppl 2:23-5.
http://www.who.int/bulletin/volumes/84/2/editorial10206html
/en/
6. 6 |
Elimination
of disease: reduction to zero of the incidence of a specific
disease in a defined geographical area as a result of deliberated
efforts, continued intervention measures required (Example:
Measles in the Americas).
of infection: reduction to zero of the incidence of infection
caused by a specific agent in a defined geographical area as a
result of deliberated efforts, continued intervention measures
required (Example: Chagas).
as a public health problem: this term should only be used if
clear target definitions are commonly agreed - continued
intervention measures required (Example: Target definitions for Leprosy).
7. 7 |
Key questions that must be addressed
What will the cervical cancer threshold to achieve
elimination as a public health problem be (4 or
10/100000)?
What combination of screening and vaccination strategies
can lead to elimination (for different thresholds)?
When could elimination be reached, for different
strategies and countries?
What is the most efficient/cost-effective strategy to reach
elimination?
8. 8 |
Overview Model Comparison Work
Step 1
Use 4 models fit to few
countries
Use simplified screening
vaccination scenarios
Examine:
Consistency in model
predictions
Understand potential for
elimination
Step 2
Use 4 models fit to wider
range of countries
Use realistic screening and
vaccination scenarios
Examine:
Strategies that lead to
elimination
Time to elimination
Added benefit of strategies
Intermediate goals on the
pathway to elimination
Step 3
Use small set of
screening & Vaccination
scenarios
Global predictions:
Elimination & Pathway to
elimination
Selected countries:
Costing & Cost-
effectiveness of
elimination
9. 9 |
OVERALL CONCEPTUAL FRAMEWORK
2030 2120
2020
Elimination
Cervical
cancer
cases/100,000
Current vaccination and screening
Intensive vaccination
Very intensive screening and vaccination
2060
10. 10 |
Example of definition and 2030 targets
The 2030 targets and elimination threshold are subject to revision depending on the outcomes of the
modeling and the WHO approval process
Vision: A world without cervical cancer
Goal: below 4 cases of cervical cancer per 100,000 woman-years
90%
of girls fully vaccinated
with HPV vaccine by 15
years of age
70%
of women screened with
an HPV test at 35 and 45
years of age and all
managed appropriately
30%
reduction in mortality
from cervical cancer
2030
TARGETS
11. 11 |
Reported HPV vaccine coverage
Various ages, 2014-2016
Source: Brotherton & Bloem, 2017
%
AFR AMR EUR SEAR WPR
0
10
20
30
40
50
60
70
80
90
100
Bot
Mau
Rwa
Sey
SA
Ug
Arg
Bar
Bel
Bra
Can
Chi
Col
Ecu
Hon
Mex
Pan
Par
Per
Sur
USA
Uru
Aut
Bel
Den
Fin
Fra
Ger
Hun
Ice
Ire
Ita
Lat
Mac
Mal
Net
Nor
Por
Slo
Spa
Swe
Swi
UK
Bhu
Aus
Bru
Coo
Fij
Mal
Nzl
Pal
12. Cervical cancer screening:
proportion of women between 30 – 49 screened for cervical cancer at least once
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
Benin (2015)
Pakistan (2013)
Timor-Leste (2014)
Egypt (2017)
Sudan (2016)
Ethiopia (2015)
Myanmar (2014)
Burkina Faso (2013)
Iraq (2015)
Uganda (2014)
Senegal (2015)
Azerbaijan (2017)
Tajikistan (2016)
Morocco (2017)
Uzbekistan (2014)
Solomon Islands (2015)
Algeria (2016)
Kenya (2015)
Malawi (2017)
Kuwait (2014)
Lebanon (2017)
Zambia (2017)
Swaziland (2014)
Georgia (2016)
Tuvalu (2015)
Jordan (2007)
Viet Nam (2015)
Armenia (2016)
Kyrgyzstan (2013)
Turkey (2017)
Trinidad and Tobago (2012)
Mongolia (2013)
Thailand (2007)
Nauru (2016)
Turkmenistan (2014)
Bhutan (2014)
Dominica (2008)
Brunei Darussalam (2015)
Republic of Moldova (2014)
Anguilla (2016)
Tokelau (2014)
Bermuda (2014)
Saint Kitts and Nevis (2008)
Saint Lucia (2012)
Belarus (2016)
Bahamas (2013)
% of women aged 30-49
Source: WHO STEPS
14. 14 |
Strategy towards the elimination of cervical cancer as a
global public health problem: key outputs
Guiding principles: life course and public health approach, social justice and
equity, integrated people-centered health services
Increased
coverage of HPV
vaccination
Increased
coverage of
screening &
treatment of pre-
cancer lesions
Increased
coverage of
diagnosis &
treatment for
invasive cancer
and palliative care
Accelerators
1
2
3
KEY OUTPUTS
15. 15 |
KEY OUTPUT 1: Increased Coverage of HPV Vaccination
WHO recommendations
• 2 doses to girls 9-14 , minimum 6 months apart
• Introduce to multi-age cohort, 9-14 yrs ( 15-18 if feasible) in first year
• 3 doses for: girls 15 y and older; and for immuno-compromised individuals
Challenges
• Limited supply of the HPV vaccine
• Vaccine not affordable and high delivery cost
• After introduction vaccination coverage low in many countries due to factors like choice of
delivery strategy, insufficient communication and hesitancy related factors
Accelerators
Sufficient, affordable supply of HPV vaccine
• Concerted effort between partners and private sector to overcome vaccine supply constraints
Introduction of HPV vaccine
• Coordinated initiative to identify and leverage sustainable resources from countries and from
donors/financing agencies to introduce vaccines in more countries
Increased quality and coverage of service delivery
• Develop and implement high quality, multi-sectoral introduction plans
• Use or develop sustainable and equitable delivery platforms
• Develop high quality and sustained communication and mobilization approaches
16. 16 |
KEY OUTPUT 2: Increased coverage of screening & treatment
of pre-cancer lesions
WHO recommendations
• Women aged 30-49 be screeened at least once in their lifetime for cervical cancer, and
rescreened every 5 years.
• HIV positive women should be screened every 3 years
• Immediate treatment where possible
Challenges
• Expensive and complex screen and treat technologies complicate scaling-up
• New or optimized service delivery methods required for LMIC contexts
Accelerators
• Sufficient, affordable supply of screen and treat technologies & products
• Prompt certification of new products
• Price reductions
• National scale-up of screen & treat
• Simple algorithms need to be introduced for different settings
• Increased quality and coverage of service delivery
• Countries detailed implementation plans to introduce and scale-up products and delivery
models
• Strengthen patient retention and linkage to treatment
17. 17 |
KEY OUTPUT 3: Increased coverage of diagnosis, treatment
and palliative care for invasive cancer
WHO recommendations
• Women diagnosed with early invasive cervical cancer can be cured with effective quality treatment
• Cervical cancer diagnosis must be confirmed by histopathological examination
• Cancer surgery and radiotherapy are major primary treatment modalities
• Palliative care is an essential element of cervical cancer control
• Reducing delays in access to diagnosis and treatment can improve survival of women with cervical cancer
Challenges
• About 80% of cervical cancer in LMICs is detected in late stages
• Quality pathology and treatment is often not accessible
• Treatment is often associated with catastrophic health expenditure
• Access to palliative care is almost non-existent
Accelerators
• Access to quality pathology, cancer surgery and radiotherapy
• Reducing cost of equipment and cancer medicines
• Sufficiently trained health workforce
• Implemented protocols and care pathways
• Timely diagnosis, staging, treatment, and referral of patients
• Increased access to palliative care
• Ensured financial access to treatment
• Integrated into UHC or other social support programs
20. 20 |
Why are these events important?
Building political support for elimination
– WCC 2018; IPVS 2018; FIGO 2018 – signals support of the expert communities
– Civil society support critical to engage Member States
– Civil society support critical to motivating WHO leadership to be aspirational
– Head of State champions critical to raise the profile on the global stage
– Head of State commitments foster cross party and pan-government support
How can you help?
– Share the developments with your governments and convey the sense of a
growing coalition of civil society in support of the elimination agenda – across
health fields; geographies from community to global organisations
– Build your own regional or national coalitions to advocate collectively in 2019
– Press for similar Head of State support
– Press for a national commitment to elimination of cervical cancer
21. 21 |
Continuing country work
Missions of the Joint Global Programme
– Uzbekistan: 23-25 October 2018; Mongolia: 13-15 November 2018
– Tanzania: 3-7 December 2018; Morocco: 17-19 December 2018
– Bolivia; Ghana; Guinea; Kenya; Madagascar; Malawi; Myanmar; Nigeria; Senegal;
Sierra Leone; Zambia; Zimbabwe : early 2019
Developing cervical cancer strategies in JGP countries
– Costing of those plans advanced in 10 AFRO countries
– Investment case in development, critical for the engagement on UHC in 2019
Growing support for scale up of screening and treatment of pre-cancers
– PEPFAR supporting 8 AFRO countries; new call for country proposals eg
Mozambique
– Coming soon in Q1 2019 – announcement of Unitaid awards
Editor's Notes
528,000 new cases
266,000 death
90 % of the deaths in LMIC
Cervical cancer is an unacceptable disease and the burden is still far too high in many countries, principally in middle and low income countries,
reflecting the many inequities across the world in terms of access to services.
High income countries have addressed the burden with organized screening programmes and now the low cx ca incidence can be maintained by the introduction of vaccines
The strategic direction 2, highlights the 3 key WHO recommendations to be implemented at scale in countries based on a life course approach, as represented on this figure:
- HPV vaccination;
- Screening and treatment;
- Treatment of cancer and access to palliative care.
For vaccination, the vaccine group in WHO is currently looking at new evidence available to update the recommendation if needed, and to present findings to the next SAGE meeting
For screening and treatment: new recommendations are going to be published on thermal ablation and screening amog HIV positive women. The strategy will focus on the extensive implementation of one of the recommended algorithm: HPV testing followed by immediate treatment for women tested positive in a single visit approach
As more cancer will be identified in the context of an intensive screening campain, strengthen access to reatment and palliative care is essential
So the call to action made on 19 May by the WHO Director-General is critical to define a path forward and engage with partners and member states, to overcome the challenges and scale-up cost-effective interventions.
Coordinated action globally is needed to eliminate cervical cancer.
Already many partners have endorsed this call to action, as per the many logo you can see on this slide, but we are also reaching out to more partners to join forces.
As many partners are already working towards contributing to this goal, the key message of the call to action was that this should be done in a more coordinated manner in order to accelerate progress.
The WHO DG Recognized that several countries and UN agencies have already moved forward under the UN Global Joint Programme on Cervical Cancer Prevention and Control, however, he insisted that to succeed, we need everyone on board, and that we must expand our partnership to include anyone and everyone who can help us reach our goal.
Question: What will different models tell us when and how global cervical cancer elimination can be reached under the most optimistic and aspirational assumptions?
Work is on going presently to define the goal for elimination; and the core impact indicator to measure elimination will be cervical cancer incidence.
We are also working on the targets to be reached at different points in time for two core process indicators:
- HPV vaccination coverage,
- and screening coverage w HPV tests, assuming that 90% of women screened positive will be managed appropriately;
In addition the impact on mortality from cervical cancer will be measured
The indicators and targets on this slide are the one that appear in some of the WHO document and these are presently being revised to the light of elimination context
What the Flagship will achieve by 2023
• Deliver on the GPW target of a 50% coverage of HPV vaccine (also an SDG indicators).
• Contribute to the following GPW targets:
• (i) a 20% relative reduction in premature mortality from NCDs including cancer through prevention and treatment;
• (ii) an increase in the availability of oral morphine in facilities caring for patients in need of this treatment for palliative care at all levels from 25% to 50%.
• The Flagship will also contribute to:
• (i) the Global STI Strategy target of 70% of countries having introduced HPV by 2020; and
• (ii) the NCD Global Action Plan target of 25% reduction of premature mortality from NCDs including cancer by 2025 as well as the SDG target of one-third reduction by 2030.
Achievement of the above targets will also make a significant contribution to scaling up UHC, and to achieve the SDG targets on universal access to SRHR and gender equality and empowerment.
