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It has taken 18 years for India to produce its own affordable version to tackle the countrys second-biggest cause of cancer deaths among women
Tue 12 Mar 2024 05.00 EDT
It is a Wednesday morning and Sneha Neurgaonkar sits on a gurney in a private hospital in Pune, India. The 14-year-old is at the Lalwani mother and child care hospital to receive the first Indian-made human papillomavirus (HPV) vaccine, which prevents cervical cancer.
Unlike the 10-year-old girl who was given the vaccine before her, Sneha knows what cervical cancer is and the damage it is doing to women in her country.
I researched cervical cancer on Google and its bad, she says. Protection is very important because females are the leaders of the future generation and without them, there is no world.
Cervical cancer is the second biggest cause of cancer deaths among women in India, killing an estimated 70,000 a year a quarter of the global burden of the disease. According to the World Health Organization (WHO), cervical cancer is the fourth most common cancer in women worldwide, with about 90% of deaths from the disease occuring in low- and middle-income countries.
Nearly all cervical cancers are caused by an infection from certain types of HPV. It takes 15 to 20 years for the disease to develop.
The HPV vaccine has been shown to significantly reduce cases, but access to the vaccine in India has been extremely limited because the existing doses, sold by foreign pharmaceutical companies Merck and GSK, are expensive.
Developed as a joint initiative between the Indian government and the Serum Institute of India (SII) the worlds largest vaccine manufacturer by dose Cervavac is the first vaccine manufactured in the country to receive approval from its drugs controller general.
Last month, the government announced it would include the vaccine in the countrys immunisation programme, meaning it will be distributed for free to girls between nine and 14.
Until this month it was only available in private healthcare settings at a cost of 2,000 rupees (19) for three doses. From March 8 it was offered at the hospital at the price of 1,500 rupees to those who had registered in advance. Adar Poonawalla, SIIs chief executive, says the vaccine will be available by December to the government at a cost of 300-400 rupees a dose.
The SII, based in Pune, can currently manufacture 70m doses of the vaccine annually, but aims to at least double that by 2026. About 25 million children are born in India every year.
Once demand in India has been satisfied, Poonawalla wants to export the vaccine. Well start with African countries, the Indian subcontinent, maybe South America, he says. Europe and the US probably wont be seeing this vaccine because theyre used to the 9-valent [vaccine]. Maybe in five or six years, well make the 9-valent and go to these countries.
Umesh Shaligram, an executive director at SII, says the new HPV vaccine will have a huge impact.
I always had a feeling that women in low- and middle-income countries are not well treated, he says. Its a mother who gives you energy and power. In Indian spirituality we have prayers, we have goddesses everywhere. If you ask me whether we pass on that respect, probably not. I always felt that lack. I was very happy we could do something for that particular aspect of life.
This vaccine comes almost two decades after the first HPV vaccine was developed in 2006. Shaligram blames Covid for the delay in production, but some have criticised the delay.
At some point it has to stop being an achievement when we get a low-cost indigenous vaccine that we can afford 18 years after one in the west, says Achal Prabhala, coordinator of the AccessIBSA project, which campaigns for access to medicines in India, Brazil and South Africa. Why cant SII challenge the environment to produce vaccines simultaneously to those in the west?
Back at Lalwani, Sneha and her mother, Sonia, are happy she has been vaccinated with an Indian-made vaccine. If it is made in India, we have more trust, says Sonia.
Sneha says she has been telling her friends about the vaccine. She doesnt think many of them know about cervical cancer. Currently theres not much awareness, she says. We have not been taught about it in school. Period awareness is now being implemented, but before it was considered taboo.
Her doctor, Sunita Lalwani, a consultant gynaecologist and obstetrician, agrees: I dont think the government or families used to spend money on womens health. It was only in [childbirth] or if the lady really fell ill where women were taken care of. Vaccination was never considered. Womens health was very taboo.
Despite the WHOs recommendation that all women over 30 attend a cervical cancer screening every five to 10 years, less than 2% of women in India aged 30 to 49 years have been screened.
Lalwani faces problems in convincing women to attend appointments for cervical smears, a procedure in which a small brush is used to gently remove cells from the surface of the cervix and the area around it so they can be checked for cancer.
Pap smears have always been available but where are the takers? I have to ring up my patients and send them SMS. Let me tell you, many dont turn up.
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Neil Young is back on Spotify after boycotting the platform over two years ago, he said in a new blog post. The Canadian singer ditched the platform over vaccine misinformation on the Joe Rogan podcast, later saying he was fed up with Spotifys "shitty" sound quality anyway.
Young returned because Rogan's podcast is no longer exclusive on Spotify. "My decision comes as music services Apple and Amazon have started serving the same disinformation podcast features I had opposed at Spotify," he said, without specifically mentioning the Joe Rogan Experience.
There's no way he could also pull his catalog from Apple Music and Amazon as well, he added, "because my music would have very little streaming outlet to music lovers at all" if he did. Young also expressed hope that Spotify would improve its sound quality, while shouting out Quobuz and Tidal for presenting his songs in high-res.
"Spotify, you can do it! Really be #1 in all ways. You have the music and listeners!!!! Start with a limited Hi res tier and build from there!" he wrote. (Spotify did announce that it would launch a HiFi tier way back in early 2021, but it has yet to actually do so.)
Fellow Canadian Joni Mitchell joined Young in the boycott, and her music is still missing from the platform. Both had reason to be incensed about the vaccine misinformation on Rogan's show as both were victims of polio a disease that was wiped out in North America thanks to vaccines.
It's hard to say how Young's boycott affected Spotify, but it certainly impacted his finances. Last year, Billboard estimated that pulling his songs from Spotify cost him roughly $300,000 in lost recorded music and publishing royalties.
While HPV vaccine is cost effective, affordability can still be a challenge, especially for middle-income countries that are no longer eligible for subsidized pricing via Gavi, the Vaccine Alliance. For instance, Kenya may soon transition away from Gavi support and see its vaccination program costs increaseexceeding US$10 million per year for HPV, the study demonstrated. Moreover, countries face competing health needs and may sometimes need to prioritize one intervention over anothermeaning, even a cost-effective vaccination program may get skipped due to affordability limitations.
It's important to reassess cost-effectiveness as the HPV vaccine landscape and country circumstances change. Gavi transitions can impact affordability and vaccine pricing can change. New vaccines can enter the global market; for instance, Cecolin, a lower priced HPV vaccine, received WHO prequalification in 202111 years after the first HPV vaccines were prequalified. And vaccination recommendations can evolve; in 2022 the WHOs Strategic Advisory Group of Experts on Immunization endorsed a single-dose HPV vaccination schedule as an alternative to the two-dose schedule, which impacts how much vaccine a country needs to procure to protect girls and women. HPV vaccination programs in Kenya and the Philippines, for instance, predate Cecolins approval and the single-dose endorsementand our research shows that a product or schedule switch could be more cost effective or even cost saving in these countries.
Product choice in particular influences the degree of cost effectiveness. Pricing is of course a concernGARDASIL 9, for instance, which at the time of study cost more than other vaccine options and isnt supported by Gavi, generally wasnt cost effective for the countries studied. But in addition to price variations, the virus types the vaccine protects against matter. The currently available vaccines directly protect against the two major virus types that cause cancer, and some potentially offer cross-protection against additional virus types not included in the vaccine. Type of protection offered impacts health outcomes, which in turn impacts cost effectiveness.
For instance, our research showed that in Mongolia, Cervarix may offer better value for money than GARDASIL even though Cervarix was priced higher at the time of study. This is because Cervarix has shown cross protection against some virus types not included in the vaccine but that were prevalent in a notable percentage of cervical cancer cases in Mongolia. Similarly, the study in Kenya showed that Cecolin provides better value for money when cross-protection is not considered, whereas Cervarix is the most cost-effective choice when it is considered.
Vaccines are one of the best buys in public health but that doesnt mean countries should say yes to every new vaccine or schedule change that comes along, said Clint Pecenka, PhD, Director of Health Economics at PATH. HPV vaccination saves lives and improves healthand health economic assessments like cost-effectiveness analyses can help ensure it makes good financial sense, too. In the case of HPV vaccination, research shows that vaccination is often a wise economic choice for countries.
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'Turning back the clock': Kanawha health officer speaks out against vaccine exemption bill
{p}Kanawha Countys leading health official released a statement Monday expressing his concern after state lawmakers passed legislation over the weekend that would allow for vaccine exemptions in schools. (WCHS){/p}
KANAWHA COUNTY, W.Va. (WCHS)
Kanawha Countys leading health official released a statement Monday expressing his concern after state lawmakers passed legislation over the weekend that would allow for vaccine exemptions in schools.
Dr. Steven Eshenaur, health officer at the Kanawha-Charleston Health Department, has been vocal in his opposition to the bill, saying the consequences of the legislation could have wide-reaching effects.
"By allowing philosophical exemptions to the law, we are weakening the publics ability to prevent measles, mumps, tetanus, meningitis and polio, Eshenaur said in the statement. Make no mistake, these are debilitating and deadly diseases for which immunizations have been proven to be safe and effective.
Childhood vaccines have kept the Mountain State free from Polio since 1970.
House Bill 5105, which originally just stripped vaccination requirements for students in virtual school, was amended to allow private schools to make their own requirements and then added a religious exemption.
The highly-debated bill was passed Saturday and now heads to the governors office.
Eshenaur called on Justice, who he said he knows cares a lot about children, to veto the legislation.
If Governor Justice signs this bill into law, he will join the legislature in turning the clock back nearly 100 years in immunization protection for our children, Eshenaur said. I pray he vetoes HB5105. Lets all pray he does.
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A new analysis of all-cause mortality of Hispanic and Latino adults published in Annals of Internal Medicine shows Mexicans and Central Americans were most affected by the pandemic.
The study was based on trends seen among 15,568 adults aged 18 to 74 years who participated in the HCHS/SOL (Hispanic Community Health Study/Study of Latinos). Baseline mortality trends from 2008 through 2011 were compared to trends seen in 2020 and 2021.
Participants were recruited from the Bronx, New York City; Chicago; Miami; and San Diego and were of Central American, Cuban, Dominican, Mexican, Puerto Rican, and South American backgrounds.
Prior to the pandemic, cumulative mortality risks were higher in the Puerto Rican and Cuban groups (6.3% and 5.9%, respectively) and lowest in the South American group (2.3%). Mortality was higher among those born in the United States and lower among immigrants, and the increased mortality risk among Puerto Ricans and Cubans was most often associated with lifestyle factors, including diet.
"During the pandemic, marginal 2-year cumulative mortality risks adjusted for age ranged from 1.1% (South American) to 2.0% (Central American), and CIs [confidence intervals] overlapped across all groups," the authors wrote. "Our findings (based on 2 years of follow-up) suggest that mortality risks varied during the pandemic after adjustment for lifestyle and clinical factorsthat is, risks were somewhat higher for persons of Central American and Mexican backgrounds than for those of Puerto Rican and Cuban backgrounds."
Risks were somewhat higher for persons of Central American and Mexican backgrounds than for those of Puerto Rican and Cuban backgrounds
Lifestyle factors were second to socioeconomic factors in contributing to mortality, the authors wrote, as the pandemic emphasized discrepancies among Latino groups. For example, according to the 2020 census, 20.3% of Mexican Latinos had no insurance, compared with 8% of Puerto Rican Latinos.
In an editorial on the study, authors write the HCHS/SOL, "holds great promise for the further development of theoretical models and frameworks on Latino mortality and health," an area of study missing in US public health research.
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Malaria is one of the greatest infectious killers in human history and, despite recent control efforts, an estimated 600,000 people still die from it each year. The recent approval of the RTS,S and R21 vaccines have reinvigorated hopes of eliminating malaria, but these vaccines are not perfect, and we will need more than one tool to defeat the disease.
Fortunately, other innovations are in the pipeline that could further bolster efforts to create a malaria-free world.
The scale-up and roll-out of vaccination campaigns involving the RTS,S and R21 vaccines will gain momentum in the coming months, but ongoing research is exploring the best dose and delivery strategy, particularly for the RTS,S vaccine.
"Some studies are planning to look at a way of using RTS,S with a reduced dose, which could make it even more cost-effective. There are also questions about how best to implement the schedules of immunisation, particularly in settings where malaria is highly seasonal, of which there are many in sub-Saharan Africa," said Dr Larry Slutsker, a consultant to PATH and former director of its Malaria and Neglected Tropical Diseases Program.
For instance, is it better in areas where malaria is highly seasonal to vaccinate children when they reach a certain age, or should we deliver the initial series in the months just before the high transmission season, or indeed use a hybrid approach that combines both approaches?
"There's also the question of whether you could mix doses of the two vaccines, so begin implementation with one vaccine and then switch to the other as you have access to it in real time," Slutsker said.
The RTS,S and R21 vaccines target the malaria parasite as it enters the human body and travels to the liver, before it infects liver cells and replicates inside them. But this strategy relies on clearing every parasite: "If one gets into the liver and you have no blood-stage immunity, you get malaria," said Prof Adrian Hill, chief investigator of the R21/Matrix-M programme and director of the Jenner Institute at the University of Oxford.
However, vaccines targeting other stages of the parasite's lifecycle are being developed. These include blood-stage vaccines that target the parasite during its most destructive stage, when it undergoes further cycles of replication inside red blood cells, which is also when malaria symptoms occur.
Another approach is inducing antibodies to prevent parasites from maturing inside a mosquito after it has fed on an infected person. While such vaccines wouldn't necessarily prevent the vaccinated person from being infected, they could reduce the number of infections in a community.
Assuming they can be made to work, combining different types of malaria vaccines could further enhance their efficacy. For instance, if a child received the R21 or RTS,S vaccine plus a blood-stage vaccine, then any parasites that did manage to infect the liver could be mopped up as they tried to infect blood cells.
Currently the two approved vaccines only target the Plasmodium falciparum parasite, the deadliest cause of malaria that is mainly limited to sub-Saharan Africa. Vaccines are also being developed against Plasmodium vivax, the dominant malaria parasite in the rest of the world.
Monoclonal antibodies have transformed the way we prevent and treat various diseases, from cancer to childhood viral infections. They are lab-produced versions of the proteins that the body naturally uses to defend itself against disease, but these ones have been designed to attach to specific molecules, such as proteins found on the surface of the malaria parasites.
Injected into the body, such antibodies could provide potent protection against infection or transmission of malaria, but because they wouldn't train the immune system to remember what the parasite looks like, as conventional vaccines do, such protection would not be long-lasting.
Even so, they could be useful in situations where someone requires robust protection for a relatively short period, such as during pregnancy. Other examples could include if someone is recovering from another illness that puts them at high risk of death if they catch malaria, or for travellers to malaria-endemic countries.
No monoclonal antibodies have yet been approved for malaria prevention, but a recent clinical trial suggested that a single dose of an antibody that neutralises malaria parasites before they infect liver cells protected healthy, non-pregnant adults from infection during an intense six-month malaria season in Mali, Africa.
Malaria is transmitted by mosquitoes and most of the reduction in disease burden over the past two decades has been through the control of these vectors. Even with the new vaccines, bed nets will continue to provide the mainstay of protection over the near- to mid-, or even long-term.
These nets are now being tweaked and improved, Slutsker said. "All first-generation bed nets are based on pyrethroid insecticides, and there's now a substantial amount of pyrethroid resistance out there in some countries. So, now there are dual ingredient nets being deployed, which contain other insecticides, and look like they are achieving good impact in areas where there's a lot of pyrethroid resistance."
Insecticides are also being developed that could be sprayed on the walls of people's houses. In the research stage are new tools such as spatial repellents devices that emanate a compound that repels mosquitoes from the surrounding area and attractive targeted sugar bait (ATSB) devices that lure mosquitoes to feed on poison-laced sugar. "Mosquitoes need sugar meals as well as blood meals, and if they feed on the sugar and die, then the malaria parasite doesn't have enough time to mature in the mosquito and be passed on to people," said Slutsker.
Further ahead, so-called gene-drive mosquitoes could be a powerful tool in malaria elimination, if the public is willing to accept them. Various researchers are using the gene-editing technology CRISPR to introduce a modification that spreads through mosquito populations and makes female mosquitoes sterile. Also being investigated is whether infecting mosquitoes with a bacterium called Wolbachia could limit their ability to transmit malaria, by inhibiting the development of the malaria parasite within their bodies. Trials of both technologies are ongoing.
Artemisinin-based combination therapies (ACTs) have been a mainstay of malaria treatment over the past 20 years. They combine a derivative of artemisinin a drug isolated from the sweet wormwood plant, which swiftly reduces the number of Plasmodium parasites in people's blood with a partner drug that eliminates the remaining parasites.
The problem is that the parasites are increasingly developing resistance to these drugs. While alternatives are in development, researchers are also deploying molecular methods to better understand what types of resistance are circulating in populations and tailoring drug combinations to specific groups or individuals within that population.
"The idea is to overwhelm the parasite by having multiple first-line therapies that you rotate or switch between," said Slutsker. The theory is that when more than one drug is employed in a population at any given time, the emergence and spread of resistance may be delayed.
As a bill that would loosen West Virginias school vaccine requirements heads to the desk of Gov. Jim Justice, some medical professionals are urging him not to sign the legislation into law.
As it is now, state law requires school students to be vaccinated against a series of contagious diseases such as polio and measles, unless they have been granted an exemption due to a medical reason.
House Bill 5105 would allow the states 143 private or parochial schools to develop their own rules for vaccines.
https://westvirginiawatch.com/2024/03/12/medical-professionals-call-on-justice-to-veto-school-vaccine-bill/
