Transcript Women-specific Illness

Women-specific
Illness
Vivien Tsu, PhD MPH
Determinants of Women’s Health
Biological:
Social:
• pregnancy/delivery
• poverty
• unwanted pregnancy
• lower status
• conditions aggravated
by pregnancy
• less education
• infections
• seclusion rules
• reproductive cancers
• gender roles
Deciding on Action
• Magnitude and seriousness of
problem, i.e. disease burden
• Affected groups
• Causes
• Feasible interventions
Burden of disease in women aged 1544 in developing countries
Injuries 12%
Cardiovascular
disease 6%
Other noncommun. dis.
14%
Malnutrition 6%
Depression/psy
chiatric 12%
Maternal
causes 18%
STDs & AIDS
16%
Tuberculosis
7%
Other commun.
Disease 9%
Source: Tinker, IJGO 70:149-58, 2000. (based on World Bank DALYs, 1993)
Cervical Cancer
Cervical Cancer Incidence, 2008
North America
12,491
Europe
54,517
Central and
South America
63,487
Asia
312,990
Africa
80,419
Numbers indicate cases per 100,000 population
Source: Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality
Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from:
http://globocan.iarc.fr
Another way to look at it
www.worldmapper.org (2002)
Why is the burden so high in
low-resource countries?
• ~490,000 cases; ~270,000 deaths each year
• >80% in developing countries
• Expected to increase to >775,000 new cases by 2030, with >99% of
deaths in developing countries
• No organized screening programs, despite many efforts
• “Competing” health problems
• Prevalence of high-risk HPV infection higher
• Limited awareness of cost-effective approaches to prevention
• Until recently, no vaccine available to prevent infection
HPV Infection & Cervical Cancer
• HPV is a necessary but insufficient cause of cervical
cancer
• 99.7% of cervix cancer cases associated with HPV
• Human papillomavirus (HPV) is a very common STI
(more than 50% of adults get it)
• Most HPV+ women do not develop cervical cancer
• Two HPV types—16 and 18—account for 70 percent of
cervical cancer cases (though regional variations exist)
• Progression from HPV infection to cancer usually takes
20–30 years
How cervical cancer develops
Long latent period allows
screening to detect precancer
Source: Wright, TC and Schiffman, M. Adding a Test for Human Papillomavirus DNA to Cervical-Cancer Screening.
The New England Journal of Medicine 2003;348:489-490.
Opportunities for Screening
• Visible pre-cancerous lesion
• Long development of pre-cancer
stage (10-15 years)
• Despite different rates, age pattern
is consistent - peak in pre-cancer in
30s and 40s
Why hasn’t cytologic screening (Pap
testing) worked for low-income areas?
• Low sensitivity and limited
reproducibility
• Requires frequent visits and
high coverage
• Requires quality controls and
regular training
• Global costs of programs are
very high
IARC MONOGRAPH: SCREENING FOR CERVICAL CANCER 2005
Potential cervical cancer screening
methods in low-resource settings
Visual inspection with
acetic acid (VIA)
Conventional pap
Visual inspection with
Lugol’s iodine (VILI)
careHPV (QIAGEN)
Hybrid Capture® 2 (hc2, QIAGEN)
Visual Inspection with Acetic Acid
(VIA)
• Cervix washed with vinegar (3-5% acetic acid) and
inspected with naked eye 1 minute later
• HPV-infected cells contain more proteins, which
vinegar coagulates and causes to appear more
opaque (acetowhite) than nearby normal tissues
• 5-day curriculum for nurses and midwives
• Equipment and supplies: speculum, cotton swabs,
vinegar, lamp or torch
• Immediate results
• ~31,000 women screened with VIA, ~30,000 in
control group
• Incidence of cervical cancer ~25% lower, and
mortality ~35% lower
• 38% reduction in incidence and 66% lower mortality
among women 30-39
(Lancet, 2007)
VIA and Low-resource Settings
• VIA is better than Pap smear for identifying
high-grade CIN - especially if testing is only
once in a lifetime
• VIA is simple to perform and provides an
immediate result without expensive equipment
• Possible to link confirmation/treatment to
screening visit
• Healthcare provider can be trained in one week
A new HPV DNA test for low-resource
settings
START project:
-Developed the new test.
hc2
-Validated it with specimens
from China and India.
QIAGEN:
-Set up production in
China.
The
careHPVTM
test
-Seeking regulatory approval
in China.
Cryotherapy:
Simple Treatment
• Metal probe applied to the
cervix to freeze (-50o C) the
abnormal area for total of 6 minutes
• Does not require electricity; uses low-cost CO2 or NO2
gas
• 80-90% effective in ablating even high-grade
precancerous lesions (CIN 2 or 3)
• Ideal for nurses to perform at district hospitals and
maybe even in health centers
• Appropriate for most lesions, except very large ones and
those involving the canal
Promising Preventive Option
• 2 new vaccines: Merck Gardasil; GSK Cervarix
• HPV vaccines are prepared from virus-like particles (VLPs)
using recombinant technology
• They are non-infectious
• Current HPV vaccines are designed to protect against HPV
16 and 18; one also protects against low-risk types 6 and 11
• The vaccines are highly effective and safe
• They provide protection for at least 6 years, likely much
longer
Current HPV VLP vaccines
Vaccine Type
Licensure status
Gardasil (Merck)
Cervarix (GSK)
HPV 6/11/16/18
HPV 16/18
Licensed in > 120 countries
Licensed in > 80 countries
Girls/Women age 9–26
Target groups
(age varies by country)
Girls/Women age 10–55
Boys 9–15 (Europe, Australia,
Mexico, others)
Clinical trials
Schedule
~21,000
~27,000
0-, 2-, 6-months
0-, 1-, 6-months
Getting ready in 4 countries
India
Uganda
Peru
Vietnam
Room for cautious optimism?
 Acceptance high in all 4 countries (75-95%)
 Positive support from parents, communities,
and leaders
 No serious adverse events
 High completion of 2nd and 3rd doses
 Peru has now joined 32 other countries
Challenges for the vaccine
• Financing
• GAVI funding on hold because of economic crisis
• But price has already dropped from $120/dose in US and
Europe to <$20-30 in Asia and Latin America
• Countries need to pay delivery costs while also introducing
other new vaccines
• New platforms for delivery (schools,
community outreach)
• Evaluating impact (time lag, technical
difficulties)
Breast cancer – on the rise
• 269,000 deaths in developing countries
• Women living longer
• Changing reproductive patterns
• Increasing obesity and smoking
• Again, inadequate services for detection and
treatment; fear and stigma
• Breast Health Global Initiative, developed resourcespecific guidelines http://www.fhcrc.org/science/phs/bhgi/
Indoor air pollution
Chimney woodstove in
Guatemala (SmithSivertsen et al, Am J Epid 2009)
• New stove vs. open fire among
rural Mayan women (n=504)
• After 18 months, significantly
fewer respiratory symptoms
(RR=0.42) and 61.6% less
carbon monoxide exposure
Anemia
Iron supplements and deworming in
Vietnam (Phuc et al, BMC Public Health, 2009)
• Women 15-45 received weekly iron-folic acid supplements
and periodic deworming
• Delivered by village health workers as part of regular care,
achieved 85% coverage (full or partial compliance)
• After 12 months, anemia dropped from 37.5% → 19.3%,
hookworm infection dropped from 76.2% → 23.0%
Emergency Contraceptive Pills
(ECPs)
ECPs:
Health Need
• 75 million women experience unintended
pregnancy annually
• 8 to 30 million women experience
contraceptive failure annually
• 36 million developing country women have an
abortion each year
• 20 million unsafe abortions occur annually --19
million in developing countries
What is Emergency Contraception?
• Emergency Contraceptive Pills (ECPs)
• Often referred to as “the morning-after pill”
• Birth control pill hormones taken in high dose within 3 days (72
hours) of unprotected sex
• IUD Insertion
• Within 5 days (120 hours) of unprotected sex
• Can also be a long-term contraceptive method
• Safe for women and for fetuses
ECP Mechanism of Action
• Clinical studies have shown that ECPs can inhibit
or delay ovulation
• Evidence regarding endometrial alterations
equivocal
- Not clear that changes observed would inhibit
implantation
• Biologic plausibility regarding inhibition of
fertilization
- Thickening of cervical mucous
- Alterations in tubal transport of sperm or egg
Source: Swahn et al., 1996, Ling et al., 1979, Rowlands et al., 1983,
Ling et al., 1983, Kubba et al., 1986, Taskin et al., 1994
Effectiveness: Single-Use
Progestin Only
100 women have unprotected sex in
the 2nd or 3rd week of their cycle
8 will become pregnant without
emergency contraception
1 will become pregnant using progestin ECPs
(89% reduction)
Source: Lancet, 1998.
Common EC Misperceptions
• ECPs are abortion pills Not true
•
Widespread ECP availability will
• encourage irresponsible behavior
Not true
• encourage adolescent sexual activity
Not true
• reduce men’s willingness to use condoms
• reduce reliance on other methods
Not true
Not true
Outreach Mechanisms
Client Materials
Women’s Health Websites
• www.rho.org (for info on cervical cancer and in the Archives tab
other RH issues, e.g. contraception, RTIs, gender violence)
• www.path.org/cervicalcancer
• http://www.path.org/files/RH_ec_toolkit.pdf (for EC toolkit)
• www.who.int/reproductive-health/
• www.reproline.jhu.edu/index.htm
• www.guttmacher.org
• www.who.int/gender/women_health_report/en/
Vivien Tsu, PhD, MPH
Associate Director,
Reproductive Health
[email protected]