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African Health Monitor
Issue #19
March 2015
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Editorial

News and Events

Articles

News and Events

 

African countries, the World Health Organization and partners hold consultations on various aspects of cervical cancer prevention and control

Pool of consultants prepared for introduction of inactivated poliovirus vaccine into routine immunization in the African Region

Peer workshops organized to facilitate introduction of inactivated poliovirus vaccine into routine immunization in the African Region


African countries, the World Health Organization and partners hold consultations on various aspects of cervical cancer prevention and control ±

The WHO Regional Office for Africa, in collaboration with partners, organized a series of consultations on a comprehensive approach to cervical cancer prevention and control between May 2012 and March 2014. Pretoria, South Africa, was the venue for the first consultative meeting held in May 2012, followed by the second, from 19 and 22 February 2013 in Ouagadougou, Burkina Faso.

Participants at the regional consultation forum on human papilloma virus prevention and control in Yaoundé, CameroonGhana, 28 April–1 May 2014

Both meetings brought together participants from 15 countries from WHO subregions and partners including BMGF, PATH, IARC, PRRR, GAVI and JHPIEGO. In the light of interest shown in these meetings and the decision by Global Alliance for Vaccines and Immunization (GAVI) to support more countries to introduce human papilloma virus (HPV) vaccine, WHO-AFRO organized a further regional consultation from 24 to 26 March 2014 in Yaoundé, Cameroon. The main objective of the Yaoundé consultation was to assist countries in making informed decisions on the prevention of cervical cancer.

Experts presented their views and perspectives on the epidemiology of cervical cancer and HPV approaches to screening and treatment and how cervical cancer prevention programmes are operating at the country level. Lessons learned in implementing cervical cancer prevention programmes were shared with representatives from other countries and action steps for strengthening programmes were discussed.

The meeting generated enthusiasm about the potential of HPV vaccines to combat cervical cancer especially among countries planning to introduce them. However, participants realized, from experiences shared by country teams on implementing cancer/cervical cancer control plans, that challenges for the successful and sustainable implementation efficacy of prevention programmes must be resolved before HPV vaccine can be introduced in their countries and that in order to have a successful control programme, interdisciplinary stakeholders need to be involved and solid in-country coordination is required by the ministries of health in the African Region. Some of the key implementation challenges and questions to be tackled include:

  • • What are the optimal and sustainable delivery strategies?
  • • Who is the target population?
  • • How large is the target population?
  • • How can the target population best be accessed?
  • • Are there adolescent health service infrastructures or partners for creating health system synergies with HPV vaccination?
  • • What are the communication challenges and solutions?
  • • How much does a national HPV vaccination programme cost and how can it be resourced?

In conclusion, country teams observed that they were better prepared to work with key decision-makers and other stakeholders in their respective countries, and to identify priorities and work on implementing some of the proposed actions leading towards a comprehensive national approach to preventing cervical cancer. This may be achieved with support from WHO, international donors, and other agencies that provide technical assistance.

Cervical cancer remains a leading cause of cancer mortality among women in Africa. With 528 000 new cases every year, cervical cancer is the fourth most common cancer affecting women worldwide, after breast, colorectal and lung cancers; it is most notable in the lower-resource countries of sub-Saharan Africa. It is also the fourth most common cause of cancer death (266 000 deaths in 2012) in women worldwide.

More than 99% of cervical cancer cases are related to genital tract infection HPV. In Africa, HPV infection prevalence is estimated at 24.9%, with significant subregional variations (35.8% in East Africa, 21.0% in West Africa and 21.0% in Southern Africa). The infection is acquired mostly through sex and peak age of infection is during adolescence. Most HPV infections do not result in cancer. However, major risk factors for cervical cancer mortality include tobacco use and lack of screening and adequate treatment of precancerous lesions. In addition, HPV and human immunodeficiency virus (HIV) co-infection accelerates progression towards cancer. Various efforts are been made to prevent and control the condition in the African Region.

More than 80% of global cervical cancer deaths occur in less developed regions where it accounts for almost 12% of all female cancers. In sub-Saharan Africa, 34.8 new cases of cervical cancer are diagnosed per 100 000 women annually and 22.5 per 100 000 die from the disease. These figures compare with 6.6 diagnosed and 2.5 deaths per 100 000 women in North America. The drastic difference in the burden and mortality between sub-Saharan Africa and North America can be explained by lack of access to effective screening and to services that facilitate early detection and treatment in sub-Saharan Africa. Cervical cancer can have devastating effects with a very high human, social and economic cost, affecting women in their prime. However, the disease should not be a death sentence, even in poor countries. Low-tech and inexpensive screening tools exist and could significantly reduce the burden of cervical cancer deaths in Africa.

These realities flag the need to implement the tools already available for cervical cancer, notably HPV vaccination combined with well-organized national programmes for screening and treatment into sharp focus. In order to prevent cervical cancer, which has been shown to exert significant socioeconomic psychosocial impacts on African populations, two approaches have been recommended: primary prevention through immunization and screening for pre-cancerous lesions, and provision of early treatment to prevent progression of precancerous lesions to cancer.

Two HPV vaccines – Cervarix® (bivalent) and Gardasil®/Silgard® (quadrivalent) – are currently available, widely licensed and in use in about 100 countries and are WHO prequalified: both vaccines are highly efficacious in preventing infection with virus types 16 and 18, which are together responsible for approximately 70% of cervical cancer cases globally. They are also highly efficacious in preventing precancerous cervical lesions caused by these virus types. One of the vaccines, Gardasil®/Silgard® (quadrivalent), is also efficacious for prevention of anal and genital warts. The primary target group in most of the countries recommending HPV vaccination is young adolescent girls.


Pool of consultants prepared for introduction of inactivated poliovirus vaccine into routine immunization in the African Region ±

On 26 May 2012, the World Health Assembly (WHA) declared the completion of poliovirus eradication as a programmatic emergency and requested WHO Director-General to undertake the development of a comprehensive polio eradication and endgame strategy (WHA65.5). The Polio Eradication and Endgame Strategic Plan 2013–2018 was drawn up in response to this declaration. Among other things, the endgame plan calls on countries to introduce at least one dose of inactivated poliovirus vaccine (IPV) into routine immunization schedules, strengthen routine immunization, and withdraw oral polio vaccine (OPV).

Workshop on IPV introduction in English-speaking countries of the WHO African Region, Brazzaville, 3–4 April 2014

Workshop on IPV introduction in French-speaking countries of the WHO African Region, Brazzaville, 14–15 April 2014

In furtherance of this goal, the WHO Regional Office for Africa, in collaboration with the United Nations Children’s Fund (UNICEF), organized two workshops in April 2014 for participants drawn from the English- and French-speaking countries. Each workshop lasted for two days. The overall objectives of the workshops were to equip participants with key technical information and up-to-date references to guide the interaction with decision-makers and programme managers; and to train a critical mass of consultants who will be available to support country planning activities and training sessions for the introduction of IPV. Specifically, the workshops aimed at providing the participants with a basic understanding of poliovirus disease, eradication efforts, existing and expected vaccines as well as the various polioviruses and the endgame strategy. Participants were also taken through a review of logistical, operational, regulatory and communication issues relevant to IPV. Furthermore, the workshop provided a platform for taking the participants through an overview of routine immunization as one of the three interventions in the fight to eradicate poliovirus disease in the African Region. Participants were taken through routine immunization system strengthening and trained on how to leverage polio infrastructure and resources to strengthen routine immunization systems for a sustainable fight against polio and other vaccine-preventable diseases. They were also oriented on the policies and operational procedures of GAVI as well as the process of making applications to GAVI for the introduction of IPV into the routine immunization systems of countries.

In his opening address, the Director of the Immunization, Vaccines and Emergencies Cluster of WHO-AFRO, Dr Deo Nshimirimana, thanked the participants for responding to the invitation to attend the workshops and reflected on the importance attached to them. He reminded participants of the crucial role they have been invited to play in the fight against polio in Africa. He reiterated the major goals of the Global Polio Eradication Initiative (GPEI); the significance of the WHA decision to declare the completion of poliovirus eradication as a programmatic emergency and the development of the Polio Eradication and Endgame Strategic Plan 2013–2018 – the final phase of the fight against the disease worldwide.

Dr Nshimirimana also spoke of the need for all countries to introduce IPV into their vaccination programme before the end of 2015, and the importance of strengthening the pool of trained staff to enable them to support their own countries and other African countries, as required. This would strengthen the technical capacity of countries in the Region in the implementation of the introduction of IPV, Dr Nshimirimana said.

At the end of the workshops, participants felt equipped to face the task ahead. Both participants and facilitators expressed satisfaction with the training methodology, with participants declaring their willingness to support countries in their drive to introduce IPV into their routine immunization systems and be on course with global best practices.


Peer workshops organized to facilitate introduction of inactivated poliovirus vaccine into routine immunization in the African Region ±

As part of the polio endgame strategic plan, countries in the African Region plan to introduce the injectable inactivated polio vaccine, and replace the trivalent oral polio vaccine (tOPV) with bivalent oral polio vaccine (bOPV) in 2016. Also in the plan is the eventual removal of the bOPV between 2019 and 2020 leaving only injectable (IPV) as recommended by the Strategic Advisory Group of Experts (SAGE) on immunization. This will foster the eradication of the wild polioviruses (WPVs) and circulating vaccine-derived polioviruses (cVDPVs) and reinforce immunity against the three types of wild poliovirus in the African Region.

To facilitate the introduction of the IPV vaccine in the African subregions WHO, in collaboration with UNICEF, organized three peer review workshops for countries planning to submit applications to the GAVI for funding support in September 2014. Each peer review workshop brought together countries within each of the four subregions.

Participants at the peer review workshop in Ouagadougou, Burkina Faso, 18–20 August 2014

Participants at the peer review workshop in N’Djamena, Chad, 26–28 August 2014

Although the workshops targeted GAVI-eligible countries, some countries in this category with plans to submit applications to GAVI could not attend the peer review workshops. For instance, Sierra Leone, a GAVI-eligible country with plans for GAVI support, did not make it because of the Ebola situation in the West African subregion. Other countries, together with some GAVI non-eligible countries like Algeria, participated and took advantage of the platform in preparing their applications, which they submitted to other funders.

Broadly, the objective of the workshops was to improve the technical quality of the documents for submission to GAVI through peer evaluation. Specifically, the workshops provided opportunities to analyse country documents on the introduction of IPV for compliance with GAVI requirements. Issues like GAVI policy, application guidelines and forms, decision letter among others, were reviewed. Suggestions to improve the documents for submission were given; strengths and weaknesses of the documents and writing processes were highlighted; and steps for submitting the application before the GAVI deadline discussed.

The adult learning technique was adopted as the workshop methodology. Each country reviewed and presented another country’s proposed plans or application on IPV introduction to be submitted to GAVI in September. The presentations were reviewed at plenary and comments made to improve the quality of the applications submitted. Group work sessions were used for the improvement of applications. This methodology was very useful as it afforded countries the opportunity to learn from the documentation of countries other than theirs.

The aims of the workshops were achieved and all participating countries went back with a reasonable level of completion of their IPV introduction plan application document.

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