 Good afternoon and welcome back to our third set of discussions, our third panel this morning or rather this afternoon. My name is Katherine Bliss. I'm a senior associate here with the CSIS Global Health Policy Center. And it's my pleasure to welcome you to this panel on developing country experiences with respect to introducing the HPV vaccine to prevent cervical cancer. Now we've already had quite a robust discussion this morning about the experience in advanced and emerging economies. And as has already been mentioned as well, the prevalence of cervical cancer in low and middle income countries has created enormous challenges for health systems already struggling to balance multiple priorities in the areas of communicable and non-communicable disease and at the same time to extend universal health coverage and undertake multiple commitments. We've also understood that cervical cancer places a particular burden on families as the effect on younger women becomes particularly pronounced. We've heard just now in the previous panel about the approach that the pink ribbon red ribbon partnership is taking in key countries on prevention and treatment approaches. And we now have an opportunity to build on that discussion and delve further into developing country experiences with designing, financing and launching HPV vaccine programs. I think you'll agree with me that we've got a great lineup to share their perspective and experience on country experiences and institutional strategies for supporting country efforts to analyze and plan for their population's particular needs. So I'd like to introduce very briefly because you have their full bios with you. To my far left, Natasha Bilamoria, who is the director of U.S. Strategy for Gavi the Vaccine Alliance, and at Gavi, Natasha leads efforts to mobilize U.S. support to fund childhood immunization in poor countries. To my right is John Yang, Senior Program Officer for Vaccine Delivery at the Bill and Melinda Gates Foundation, and in this role John leads strategies and initiatives that are aimed at catalyzing the introduction of new and underutilized vaccines in low-resourced settings. Susan Wong, to my immediate left, serves as Associate Director for Research within the Global Immunizations Division at the United States Centers for Disease Control and Prevention within the Center for Global Health. A pediatrician by training, she has worked closely with the World Health Organization and with Gavi on HPV vaccine financing and implementation issues. And as I understand it, these three in one way or another have also collaborated together and worked very closely over the years. So I think we'll have an opportunity for a vibrant discussion and exchange. What I want to do is start by posing a question to each panelist and then give them a chance to respond to each other and then move to a broader conversation and discussion with the audience at large. And so Natasha, I'd like to start with you. You've heard a little bit about this this morning, but in 2008, the Gavi board prioritized adding HPV vaccine to the list of new and underutilized vaccines with supports for the lowest income countries. And in 2011, the board opened a funding window for the introduction of the vaccine conditional on reaching an agreement with manufacturers for a lower-than-market price. So as I understand it, there are currently at least eight countries, maybe more, that are undertaking HPV vaccine demonstration projects right now. So I wanted to ask you to start us off by saying a bit about the factors that went into the board's decisions, both in 2008 and 2011, how the sites for the demonstration projects or programs have been selected and what the experience so far has been. And then if you would reflect a bit about the future of Gavi support for the HPV and how sites for future support will be determined and where you see the direction or what direction you see the discussion about pricing going. So we'll start with you. Great. Well, thank you, Catherine, and thanks to CSIS for pulling really a terrific day of discussion on a very important issue. It's really a pleasure to be here. You know, obviously, you know, we're Gavi, the vaccine alliance. So I think it's obvious to say that we're really convinced about the power of vaccines and, you know, what it can do for public health and global health. And obviously, our ability to roll out the HPV vaccine as an important part of cervical cancer prevention is something that we're incredibly proud of. You know, obviously, everybody this morning has heard about the toll that has that cervical cancer has taken on women all over the world, but specifically in the developing world. And, you know, if these numbers, if we're not making any changes to what's happening, the numbers will continue to rise. And that's something that I think really went into our decision about including HPV in our menu of vaccines and opening up the funding window. And as you said, in November of 2011, we did open up that funding window. And let me just talk a little bit about that process because it's a little bit different than what sort of we do with our other vaccines. So first of all, when you ask about how the demonstration sites were chosen, we are a country-led organization. So that means that countries actually do apply to Gavi to introduce vaccines. And from that perspective, that was very much the case with HPV. Countries decided they wanted to do this and they applied for the vaccine support. Now, the difference is that we did have an opening for national rollout, which is what we do with all of our vaccines. But given the fact that this vaccine is a little bit different and countries, many countries just didn't have the experience working with this particular population of adolescents and also having it be, you know, a number of doses that were required to inoculate, we decided to move with a demonstration set of projects, too. And what this meant was, is countries were able to apply and get support for the HPV vaccine and also health system strengthening, where they would roll out the vaccine in one or two areas of the country and, you know, see what happened and really be able to look at how it worked, what worked, what didn't, and then as they moved up in coverage and if they were able to do 50% or more in coverage, they would be able to apply for a national, you know, national rollout. And basically, a number of the countries actually chose to do this learn by doing approach. So actually, there are a total of 27 countries that are getting the HPV vaccine. Three decided on national rollouts and those are Rwanda, Uganda and Uzbekistan. And then the others are 24 countries are doing demonstration projects. And as a whole, what we're hoping, if things continue going the way we've seen them, you know, we hope to reach 30 million girls in 40 countries by 2020. So as far as where we stand right now, obviously, you know, the funding started just a few years ago and, but what we've seen is that demand is rather high. I think, you know, the numbers of countries that have applied has been high. But I think the acceptance by communities has also been high. And I think, you know, part of that is because people in these communities have seen the toll of this disease. They've had a mother or an aunt or a sister die needlessly and really often in the prime of their lives. So I think that it has been something that people have been very interested in. And the other piece that you mentioned is around price. You know, part of the board decision was about getting a good price for the developing world. And, you know, I think that was a big barrier initially in getting the vaccine to poor countries. The price was just very high. And, you know, one of the other areas of innovation that Gaby has is around market shaping. And what that means is we basically pool, do a large pooling of requests for the, for the vaccines are really able to work with the manufacturers to drive down the price. And so we were able to do that in this case and reduce what was initially the lowest price of $13 per dose down to $4.50 per dose. And given that you need two doses for the vaccine, basically it's now $9 to vaccinate. So you asked about sort of the greatest potential for this. I mean, I think, you know, the greatest potential is probably the most obvious is really to prevent cervical cancer in women in the developing world. I think, you know, vaccination is one of the, you know, it's really the most gender equitable public health approach there is. And I think we have, you know, a key opportunity to deliver this particular vaccine as we have with other vaccines to kids around the world. But what is very interesting about this is we're targeting adolescent girls. And I think overall this has been a population that, you know, really has been neglected for many things and they are unique. And I think that this particular vaccine really gives countries a platform to look at reaching these girls and really connecting the dots about, you know, not only this vaccine, but what are the other things that adolescents really need to be healthy women when they grow up. The other area that I think is really important and has a lot of potential is this is an opportunity for all of us to be working together. I mean, you know, it's a way to bring in new partners, you know, working with cancer groups, the education system, which is different, I think, than with other vaccines. And that's been very important. And through that, we're also, you know, part of the Gavi process is really to work with partners in country to not only review and design the HPV demonstration projects in country, but also really looking at the country's national cervical cancer plans and in strengthening them and ensuring that, you know, they are doing what they need to do. And then finally, I think, you know, a big piece of, a big area of potential is around the equity gap. You know, there are a number of girls in school, but, you know, between 25 and 30 percent in some countries even more, you know, girls are not in school. And that's for a number of reasons, but they, you know, these girls tend to be the most vulnerable. And so, again, as part of Gavi's work on this issue, we really ask countries to include a strategy and how they're going to include to reach these girls who often are at the highest risk for HPV and cervical cancer. The obstacles. So, you know, we talked about the good news. I think the challenge is, you know, I think, again, reaching those target populations, both in and out of school in a sustainable way, is, you know, not going to be easy. We know that obviously there's, you know, likely a higher coverage rate in a school where there, you know, where girls, where there's a high enrollment. But again, how are we going to deal with the girls who are not in school? And then how does it work with the country's health care system? Do they have the kind of health workers that can go into schools? So I think that is a challenge. And I think the other issue is also communications. I mean, HPV is, vaccine is different than other vaccines. There's sensitivities involved, given that it is a sexually transmitted disease. And so we really require that countries have a strong communication plan to really educate their communities about it and implement those plans prior to rolling out the vaccine. And as far as what we need in the future, I think, you know, one of the biggest things is really around political commitment. We need political leaders and decision makers in these countries to really prioritize women's and girls' health. And obviously that would include this vaccine. And then we also need to ensure that while we're working on improving the cervical cancer plans in countries, that countries are actually able to implement them. So it's not only having a good plan but having the systems in place to actually go ahead and implement them. And so, you know, the last thing I'll say is, you know, we're incredibly proud of having the vaccine and being able to roll it out as a primary prevention tool. But as, you know, we've heard today, I think it's also really important in tandem for countries really to commit to and receive support on, you know, better prevention and treatment programs. Because, you know, we at GAVI, you know, we want to continue building strong partnerships in country and globally to ensure that we're not passing along the burden of cervical cancer to the next generation. Natasha, thank you very much for both providing an overview of the board's decision making around opening the funding window. But as well, what has happened in the short time since that decision was made with 27 either full national scale programs or pilot projects underway. So, Susan, you've been working with CDC in a number of different capacities focused on the issues of HPV vaccine and vaccination programs and countries' ability to both cost and plan those launches for a number of years now, including during a detail, as I understand at WHO, working very closely on some of the work with GAVI. So I wanted to ask you to say a bit about how CDC works with both low income and middle income countries in thinking about adopting HPV vaccine programs. And some of the challenges that CDC has and in collaboration with WHO and others have been helping to address in terms of thinking about the cost of the plans, the design of the plans and what may make sense in particular contexts for particular needs. And I'd also ask you just to reflect a bit on some of the common challenges that you're seeing both low income and middle income countries face as they prepare to adopt and then roll out HPV vaccine programs. I thank you. I appreciate the opportunity to join in this CSIS day today. I think it's been very broad ranging and that really typifies exactly what the whole cervical cancer prevention work really involves. And before I get into the specifics of CDC and WHO work, I just want to know where we actually are with introduction in terms of the national programs that are using HPV vaccine. At this point out of about 194 countries, 63 have introduced nationally as of March 2015. And of those 63 countries, one is a low income country, Rwanda. So that's roughly 3% of low income countries have introduced HPV vaccine. 14% of low middle income countries have introduced about 7 out of 50. And that of upper middle income countries, 18. And that's an increase from last year. There was about, I believe about, I'm sorry, there was, last year, there was about four low middle income countries. And this year, there's seven low middle income countries that have introduced the number of upper middle income countries that stayed the same in the last two years, 18 countries. And there's about 36 high income countries. So I just want to note that if you think of it, 63 out of about 194 countries, that's really still only a third of global countries, of countries around the world that have introduced. And of the high income countries, so Australia, UK, so on and so on, only 48%, so less than half of the high income countries have introduced. So I just want to note that, as ambitious as we are and impatient as we are to introduce HPV vaccine, and certainly we want the lowest income countries to introduce because they're the ones that stand the most to gain from the vaccine, especially if they don't have cervical cancer screening programs because perhaps that really reduces their size and need and frequency of screening that they're going to need to do. But we also have actually a fair way to go, even with the middle and the high income countries. And given that context, there's really still a lot of learning going on across the board. There's no country that has introduced the vaccine that hasn't learned something in their first two or three years, whether it's with media events about how much anti-vaccine issues there are or the politics because HPV vaccine has been featured in a number of political campaigns, whether in the United States or in developing countries, or all of the issues around STIs and the communications, and simply even the delivery strategies and the fact of the need of identifying who is this target population, where are you going to find them, how are you going to actually access them. And the work that CDC has been doing has been really intertwined with the WHO work in terms of really wanting to provide a very robust technical foundation for all of the HPV vaccine introductions globally, particularly in the developing countries. And this has ranged from policy areas, so the technical backgrounds for the SAGE recommendations of 2009 and also of 2014. So the 2009 was when the first global recommendation from WHO came out. And then last year when recommendations about the possibility of using just two-dose schedules came out. Also in 2010, there was a lot of work done on HPV vaccine coverage monitoring and also HPV vaccine impact monitoring so that when we actually reach the further process of program implementation, how are we going to measure our success, how are we going to understand what we've accomplished. And in the last three years or so, especially also in very tight and close collaboration with the Agave work, is understanding all the challenges and solutions, potential solutions for program implementation. And that is really a brand new area of work because although we've been vaccinating infants successfully for many years, I mean basically the expanded program on immunization was created in 1974, so it had its 40th year anniversary last year as an offshoot of the smallpox eradication efforts. So switching from campaign mode into routine prevention, basically a facet of primary care, preventive care for infants. We're now basically having perhaps version 2.0 of the EPI program and going beyond infancy to now really innovatively consider the opportunities that HPV vaccine gives us to launch primary care, preventive services, wellness care, again in the life cycle and now for adolescent girls, for 9 to 13 year old girls. And this is incredibly exciting but it's also a foundational piece of work because you're creating a health system, you're creating an immunization system. You have to solve problems of how are you going to get these girls to come back or how are you going to get them in the first place. And there's a number of different issues than there are for infant immunization. It's not just adding rotavirus vaccine or pneumococcal vaccine which are new vaccines of these recent years that we've added to the infant immunization platform but instead HPV vaccine for developing countries is the first vaccine unlike in the developed countries where people are using tetanus or meningococcal vaccine or so on like in the United States. So it's really the leading edge and the opportunity to collaborate with the adolescent health groups has been a big piece. So just briefly there's been a number of different tools that CDC and WHO have created. One is a costing tool for HPV vaccine introduction. Another module was also created for cervical cancer screening programs how to actually cost that and you can actually play with it in terms of envisioning different scenarios delivering HPV vaccine via campaigns in schools or on a routine basis in clinics. How much does it cost with your cost structure in your country? So they can actually play out those different scenarios and see what it means for them budgetary wise. A school vaccination readiness assessment tool was developed so that countries could try to figure out whether they could use their schools whether they had the facilities and ability to actually use that system. There's vaccine communication work done. There was a lot of work also done in tandem with UNFPA and also the UNICEF gender and rights group to develop an adolescent health services assessment so that we can understand is there opportunities to create synergy in terms of introducing the HPV vaccine delivering it in tandem with other health services. So that's just a brief background and I guess we'll be talking a little bit more about some of the challenges and I'll touch on that but I don't want to take time away from John. All right well thank you very much both for explaining some of the work that CDC and WHO have done in collaboration and the many different country levels and experiences that you've already been able to observe. John let me let me turn to you and ask you know we've we've heard this morning a bit about some of the you're with the Bill and Melinda Gates Foundation we've heard this morning about some of the historic work that the Foundation supported you know early on around some of the issues around advocacy in cervical cancer prevention. I wanted to ask you to say you know now if you could tell us a bit about where work on the HPV vaccine fits into the Foundation's overall strategies around immunizations and if you could you know also just talk about what some of the current goals are as you think about the Foundation's work with GAVI and with other organizations you know around vaccine HPV vaccine. Thank you Catherine and CSIS for the invitation this opportunity to contribute to the discussion. I think the conversation today so far laid a perfect context for articulating our strategy. So Foundation's strategy on cervical cancer prevention has two pillars one is vaccination that's to address to reduce the risks today in young adolescent cohort and the other one is screening and preventative treatment program to reduce mortality in older ages. And for you know this combined kind of primary and secondary prevention strategies is essential in our perspective because for the next 30 years the increased global burden is going to be entirely pretty much entirely going to be on developing countries. So we view this is essential the two pillar approach for us. So let me talk a little bit about the vaccine program. The vaccine program has kind of a two dimension to it. One is the delivery implement implementation dimension. The other one is a research and within the delivery space our goals are very much connected to GAVI's goals in vaccine introduction and coverage and our priority is to remove barriers and to achieve scale for the vaccine in GAVI eligible countries. The questions that we're focusing on for example and I kind of resonate to the questions Natasha and Susan had raised you know can we accelerate the introduction from demonstration to national can we make it faster. You know what are the bottlenecks is that policies that evidence is that is a delivery model or is that cost and that's sort of the focus that we have. And you know interesting Susan also mentioned about EPI program. Let me just make also comment on this. I think the GAVI Alliance plus the EPI system is an exceptional mechanism for vaccine introduction. It's something that many other health service deliveries you know they don't have and exceptional because it's it's end end delivery support infrastructure from policy decisions to problematic planning to social mobilization injection post-injection and post-introduction the whole entire chain that infrastructures in place and I should say many partners play a role in that infrastructure and we're just one of them. So that's kind of a delivery space. One more thing I need to mention on the delivery space is that we focus on is cost of vaccine program where we have in mind not just affordability but also sustainability of HPV program especially this is in GAVI countries especially for those countries that are entering the graduation. So a little bit more about the research. There are a number of activities we're focusing on the research space. The bulk of our investment are going to the development of low cost vaccines. And we're also working with WHO recommending body on immunobridging as a potential shortened pathway for regulatory approval for the new vaccines. What it means is you know the new vaccines if they're using similar technology as the ones that are approved today available today there's a potential regulatory pathway for them to to bypass the full efficacy trial trials therefore shorten the time and the cost to the market. And also as Dr. Trimble mentioned this morning that we're also exploring alternative schedule without colleagues at the National Cancer Institute and under sort of pin in all these activities we have cross cutting advocacy you know effort and focusing on both you know vaccine vaccination and also screen and treat programs. So kind of a that's kind of a nutshell you know quick summary of how how the different pieces fits in the foundation strategy. Well thank you. I want to before moving on to a second set of questions I want to ask Natasha and Susan or if you want to take a chance to respond to any of the the comments that have been made before we move on maybe to discuss a little bit more about some of the sustainability issues in the long term. Yeah I mean I think that obviously as you started the conversation there's been a lot of work between all of the organizations represented up here and you know I do think you know just to build a little bit on what what you had said about really it's an opportunity to build on the adolescent health set of immunization. And I think that as you said I think it is building a whole new system the needs of that particular population is are very different than what they are for infants and and I think that this vaccine gives us an opportunity to really help lay that help lay that groundwork. And you know obviously Gaby and Gates have a long standing relationship and and I know that on on HPV and on both on you know the delivery side but also on how do we or sorry on the vaccine side move from demonstration to to full national scale but how do we get that delivery strength and is an important part of what we're doing. Susan? Yeah I wanted to just add two pieces one is I think you mentioned the importance of the out-of-school girl piece and the equity component and I think that's something that throughout this design process or the encouragement of countries developing countries in figuring out their delivery strategies we've emphasized the importance of really trying to the initial process of the actual design of delivery strategy to consider equity and to prioritize equity because if one doesn't do that from the outset the problem is that if you are only vaccinating the girls who are attending schools and developing countries then the girls who grow who are not attending schools grow up also to be the women who won't get screened because they'll be the poorest women they won't access screening so you're basically magnifying the health disparity and unless you from the outset try and ensure because in fact immunization has been successful in so many scenarios of getting of accomplishing equity for bringing this wonderful you know vaccination this primary prevention to so many populations so well so successfully in developing countries that if you don't do it with that primary prevention you're usually more challenged at getting those secondary tertiary interventions done in an equitable fashion so this is something also I think we're also discovering in immunization that we know that we're reaching 80 percent coverage pretty routinely for DTP3 things like that the routine infant immunizations and now everyone's always talking about how are we going to get that last 20 percent but can we design already from the outset that delivery strategy so you're not doing a catch-up 20 years later to get that last hardest most vulnerable population but actually design a system early on so that it's just one little piece that I was going to say and then the other thing is just that we talk about lowering the cost of the vaccine which is critical and which has been a really great success of Gavi but the other piece is certainly the cost of delivering the vaccine because we know that for from the studies of HPV vaccine delivery that it can cost in the developing country something like two dollars per girl per dose so that's in addition that's not including the vaccine cost so in a startup year we've estimated that it costs roughly six to eleven dollars per girl for the startup cost plus we're delivering the two to three doses and again that's not including the vaccine cost so if you add say nine dollars or whatever then you're getting to like you know twenty dollars per girl which is a lot of money in the developing country so unless we can really figure out efficiencies in delivery strategy in addition to that cost not only we're not going to reach all of the Gavi countries but then the next tier up that aren't of countries that aren't fortunate enough to access Gavi support they're even you know going to be the ones that are going to struggle to purchase the vaccine and deliver it thank you John just two quick comments one is on the Gavi demonstration program Natasha described and what's interesting is now we should have over 10 countries completing year one of the demonstration and there's going to be a critical mass of data coming together but probably by the end of this year and and this is a very important milestone because it really informs its evidence-based kind of process to inform what what the cost scenario is as Susan said how much does cost to deliver the doses and what scenarios you know in different models of delivery and how sustainable that is and how's that and what are the lessons learned in terms of successfully reaching hard to reach girls the cohorts and so that that would set us up in terms of thinking about what's the next kind of stage of the policy in terms of policy and also in terms of design of Gavi programs so that's a very important thing to keep eye on and the second thing I just want to echo Susan's point on the cost of delivery as something that people don't usually look into but it's it could be as prohibitive as the cost of vaccine and and I remember Susan and I had this conversation many many times in the past few years about how we should encourage country to think more innovatively yes school-based program is it's approval you know it's it's a proven model but can you think a little bit differently you know can you sustain all these costs associated with the transportation with the prudence increase the staff and what is it going to take what's the trade off there for your other you know for your other immunization program there's got to be give something has to give so this is something that we're exploring together with Gavi this particularly strategic components how do we actually think innovatively a little bit differently than traditionally well thank you you know we've we've spoken so far largely about you know to some extent about the launch and introduction of campaigns and you know kind of thinking about what you know what it takes to to get to to that point of either initiating a demonstration project or or initiating at the national level all three have already kind of jumped to some of the sustainability questions as well particularly around financial resources but I wanted to just pose a general question to the three of the panelists and then give them an opportunity to respond and then move to to conversation with the audience but you know as as kind of this process moves from introduction and scale up to kind of thinking and planning for sustainability in the long term I guess I would just ask you to to reflect a little bit more since we've talked about finances maybe if you do we can focus on some of the other issues but you know in addition to the financial resources what will it take in terms of health education John has talked a little bit about program innovation technical innovation and in particular political will to sustain HPV vaccine programs in the lowest income countries in the long term so I'll start with you sure well I mean you talked about a lot of them but you know from my perspective and sort of where I sit in the world I think that you know political leadership is is really key to you know to get these vaccines in country I mean you know as you said we're not even seeing this in the developing or developed world fully and respecting expecting a lot out of these countries and I think that you know we've seen some great examples of strong political will in many of these countries and I think that that that needs to happen and you know again more broadly on women's and girls health you know I think again where we're not there yet but how do we move from campaigns and to actually incorporating this into routine immunization you know GAVI has always been catalytic right and and I think from our perspective you know we've got to introduce this vaccine into countries but how do we make it part of the routine immunization cycle so that again all girls are getting this we're not you know leaving behind a set of girls who will turn into women who are more vulnerable and then you know I think the other point and again it's really continuing the strong partnerships of the alliance I think that you know we have partners that we're working with on the ground you know everybody here and but also what is happening with this particular vaccine is we have a whole new opportunity with new partners and really being able to continue that alliance model that strong support going from you know the purchase of the vaccine all the way down to putting that shot in that girls arm thanks Susan I think HPV vaccine has really multiple and really very diverse stakeholders I mean with the cancer groups with women's groups with school health with adolescent health with vaccine or immunization programs and it's very atypical really in terms of the when you convene a group in the different regions WHO regions or in the countries and you actually need to cross multiple different departments and divisions and sectors even with whether it's within agencies or within WHO within CDC within WHO or then within ministries of health and actually get all of them to come together to have the discussions and they're all very passionate about it and I think part of it is it's they're also coming from different cultures and ways of thinking of handling things and even bringing together again the HIV groups because there is so much potential matrixing and cross work that can be done but it takes a while to learn how to work together and to solve problems together and to get onto the same page so there's a lot of work just in those relationships to make that work but I think that's where actually the potential is just amazing because that I think is what's going to lead us towards sustainability being able to combine these different needs efforts and desires to get into the same place and that's what's pretty exciting I think thank you John I'll just mention three things quickly one is there's a there's a backbone for for immunization and this is a routine immunization system in the country not just applicable to HPV so you have this you know by routine immunization I mean your immunization data who gets immunized who's not you know where's the area where you have lowest coverage and I'm talking about supply chain coaching you know logistics I'm talking about adverse event monitoring and training and so but that whole backbone needs to be strengthened and I think if you overlook that one and you just lay another vaccine on top of it I mean there's some risk so that's another component for sustainability and the other one is impact data you know we need a we need evidence to show to to the you know to your political leadership that this vaccine vaccine actually works and and can achieve the reduction of the burden and and and it kind of builds the advocacy and builds the the power strengthen the policy and the third thing I want to mention very quickly is is just going to the point that Susan mentioned about primary care and if there's a way to build some primary care you know bundle the service delivery package around the same age cohort I mean that posing demand that that reduces system cost I mean that that's perhaps another way of sustaining HPV vaccine vaccination. Okay well thank you thank you very much I want to turn to the audience because I know there have been a number of interventions already this morning that are very much you know related to to what the panelists have described have described here if you have a question or a comment let me ask you just to raise your hand we've got one or a couple of people with microphones who will be able to to come to you and if you would particularly for our web-based audience that isn't here with us in person right now if you could please say your say your name as well so let's start over here in the back the gentleman in the blue tie let's take a couple of questions we'll also go over here afterwards please thank you my name is Gonzalo Perez I work for Merck I would like to start by saying I am OBGYN oncologist and spent about 25 years of my professional life in working at the National Cancer Institute in my country Colombia and before joining Merck six years ago I've been deeply involved with the development of HPV vaccines and I was very very pleased to hear about the dimension of the importance of the impact data because we are seeing very impressive results in all the countries where HPV vaccination has been implemented especially in the developed countries so we hope that we are going to see also impact data in many middle-income countries and low-income countries very soon so that's the expectation but recently we saw some data that is being collected by by some groups internationally about what is the coverage currently with HPV vaccination it's about 1.4 percent of women who should be vaccinated who have been actually being vaccinated so it's still a lot of work to be done here so but I wanted to highlight the importance of the impact data that's the main point I want to make because for some countries like Japan for example and countries where we are facing difficulties the vaccine is facing difficulties that would be very very important for them to understand what can be achieved if they will implement successfully the HPV vaccination so that's basically the point I wanted to make and also ask perhaps Susan how the impact data is being used by CDC and some other organizations when it comes to having this discussion with the countries because you have mentioned a lot of the support you are providing to the programmatic implementation of vaccination programs but how are you using this impact data because we know that the CDC has been also involved with generation of impact data but how is that being used for the countries to to learn about what they can achieve and then let's take just another two questions we'll stay on this side of the room then we'll come over here in the next round please hello Nancy Harris from John Snow you mentioned equity and I think it's in a very important point I'm asking any of the panelists to talk about the hundreds of thousands of refugees displaced and people living in failed states which are some somewhere below low income countries and what's being done and what could be done to to achieve these people are sort of really at the bottom of the totem pole to achieve HPV coverage in these communities okay thank you and then I think there was one other question over here on the leading the the red coat I'm Edna Jonas an independent consultant all the discussions going on right now for the sustainable development goals post 2015 are an excellent opportunity for raising the profile about HPV vaccine and gaining political commitment and I'm wondering whether there have been has this been incorporated into any of the discussions or thought about the linkages with the new SDGs okay so we have we have three questions one about the impact data the uses of the impact data or who's using it and the data about immunization coverage a second one about the question of equity and the ways in which programs are able to or what's being done to try to reach refugees and people in living in in failed states that may not have access to to some of the same kinds of programs as other countries and then a final question about the place of the discussion about cervical cancer and HPV vaccine in the discussion about the sustainable development goals so let me perhaps I'll start with John on the the impact question I would defer the impact question to Susan okay we'll turn to Susan then okay so impact data have has definitely been something that's been shared with countries from Australia the UK from the United States where we've seen also herd immunity implications and in terms of when the countries are having their national immunization technical advisory group discussions so their NITAC discussions for policy for decision to introduce obviously so far in terms of the length of time that HPV vaccine has been used in large populations we don't have big population data to demonstrate yet reduction actually in cervical cancer because we're usually showing reduction in the precursors to cervical cancer because the vaccines just haven't been used for 20 years yet to just demonstrate the reduction in cancers but those data have no question have been shared and are shown in policy discussions for the decision to introduce the vaccine WHO and IRC international agency for research on cancer are actively working in Bhutan which was the first you know low developing country to introduce vaccine in 2010 and also in Rwanda which introduced HPV vaccine in 2012 so in a few years we anticipate we will see HPV vaccine impact data from those two developing countries which will be really important for for making further decisions and for documenting as as John has said what the importance is for these populations thank you Natasha do you want to address the equity question sure so you know for Gavi you know we work in set of 73 countries and and obviously there are a number of fragile states in there and some of the most poorest most poor countries and so but again the way we function is that it is a country-led approach so countries do come to us and not not for HPV but for a number of our other vaccines we have introduced in a number of these difficult fragile and failing states and I just wanted to comment on the SDG process this actually is an area where Gavi has been involved you know the sustainable development goal process is is pretty big I can't remember how many goals there are but there are a lot as opposed to last year and we have really been working hard to ensure that vaccines including HPV are part of the health goals that move forward because these are the things that we are going to be judged on in the next in the next period and obviously vaccines and specifically HPV will be an important part of that thanks John do you want to touch on the question of the SDGs yeah perhaps not specifically to to SDGs but I would make a comment on on a GVAP that's a global vaccine action plan and GVAP has sort of as a agreed framework at the World Health Assembly and with the very specific targets and indicators if you look at these indicators the vaccine preventable disease is still I mean quite a big lag and a chunk of that vaccine prevent preventable diseases is HPV in there so this is an opportunity you know this is the kind of you know agreeable framework to to discuss the burden of diseases and the relevant to cervical cancer and yeah I would start from there that's probably a lot more specific and the relevant and established okay let's take a second round of questions are there some questions here in the middle we've got two up here at the the front tables so perhaps we'll start again my name is Rosemary my organization is called Hope for Tomorrow we are here in Washington DC down from Africa I still go back again to affordability especially those women who are unable in the rural areas and she just mentioned there women who stay in refugee camps we just finished a World Bank IMF meeting last week's spring meeting and I was talking about the same the women in conflicts and refugees there women there they are cows there how do we rig them we can't even talk about affordability because they don't how do they get the income and they are most of them are the victims of this disease how do we get this done just supporting them those in conflicts countries those the poor women and those in refugees they are just also women like us here also one day attention how do we get to them and help them looking at affordability well even one dollar they cannot afford thank you let's take another one right here please great hi again I'm Sarah Goldsmith cervical cancer action I was wondering if you could present your perspectives a little bit in contrast to what we heard this morning when we were talking about advanced economies and middle income country uptake there was a lot of news of challenges a lot of us have been involved now for a number of years on this vaccine at least my personal sense is that it's gone extremely well compared to other vaccines and extremely well compared to what we've seen in more advanced economies and it certainly heard this morning so my question is do you share that perspective and if so why has it gone well what's what's the upside that we're seeing with this vaccine in so many countries and if so if you agree with that then how can we extend that now to screening how can we amplify the concern and the political commitment that we've seen for this disease so that we're actually tackling it from a comprehensive perspective okay thanks let's take one other question kind of here in the center um in the right back here yes thanks thank you millie cayonga from apt associate so my question is several of the speakers discussed implementation challenges could you talk about the specific health system barriers that you think countries can start to work with because one of the themes that seems to be underlying this this discussion right now is like it's difficult it can't get done and i feel like that's if many of the agencies that are represented have a lot of clout at the country level and if that's the message the health system i mean the ministers of health are getting it's difficult it's um the implementation delivery is a challenge i think it will detail countries from taking this on and i just feel we need to to have more specific guidance to countries on what are the critical issues that they can start with and and i would i would appreciate your comments specifically in the health system challenges three themes here one is you know asking for a little more reflection or discussion about you know how do we reach reach women in the most remote areas and in the conflict areas where there is conflict what what are some of the solutions that you've seen that that facilitate that kind of outreach and access what lessons perhaps from other kinds of interventions second we talked a lot this morning about challenges and i think there's always a propensity to think about what are the challenges what are the obstacles but what has gone well and what are some of the what are why has it gone well what are the some of the factors that that feed into that and i think the question was you know considering some of the the positive results from the introduction of HPV vaccine how can some of those lessons be shared with screening programs did i did i capture that fairly well okay and then a third question then um to have a little more reflection on the implementation challenges what kind of guidance can be provided to countries in terms of strengthening health systems and identifying opportunities for for not just the introduction of vaccines but a broader variety of of services around cervical cancer prevention and treatment is that is that fair okay um susan perhaps we can can start with you on on some of these questions around implementation and and what's going well um yeah i think in terms of what's going well and maybe it's a combination of the last two questions in terms of what's going well but also what the challenges are i mean as i mentioned in the beginning i think that there's been no country that has done this even the wealthy countries that has done this without a hitch in terms of national introduction there's always been something that's needed to be solved or addressed that they didn't really consider when they first implemented that they had to solve in process and i think the what we've seen is understanding the target population reaching that target population dealing with the media the communication component all of those have been the elements that people have had to handle as well as if they don't have routine delivery of other services trying to create that so there's there are multiple things that need to be tackled but i think what has been very successful is that if people realize this is for the long haul this is not an overnight success and there is continuous process quality improvement you do something you fix it you do you do some more you fix the next thing and you keep on incrementally improving what you're doing so i don't think it's hopeless at all i think it's actually been and i i do agree that some of the successes that we see most enthusiastically and some of the highest coverage sometimes that we see are actually in the developing countries because there is such adamant enthusiasm and desire for this vaccine and recognition of what the success really will translate into in terms of impact so i mean we see sometimes low coverage in places like the united states or austria i mean high income countries and then we go to rwandan we're seeing 80 90 whatever percent coverage so it's it's not a given that because you have a lot of money that you're going to be better at doing this it's really how you manage to corral and your different stakeholders and how you manage to problem solve along the way so i think that many different places can can be successful and i don't think it's going to be only financially based although that's going to have an important component to it thanks john interesting about a different perspective on a success of sorry low income countries i i i would think the gavi alliance plays a played a significant role in in its its achievement on hpv and this you know kind of refers back to this exceptional mechanism i described and this infrastructure of support that's in place today and this is many many partners in in countries you know down to specific cost analysis coverage survey how do you do this this is the template you know that sort of support level and and it makes tremendous differences now that's that that's set aside you think about the countries that are better off economically and infrastructure wise health system wise probably what would it take for these countries to achieve the success is not going to be as much of an hurdle as it would for the low income countries where gavi is so you can learn a lot from what gavi has done but also recognizing the hurdle perhaps a little smaller because you have a more mature more advanced infrastructure in place that's a quick comment and that just a thought on the screening you know scaling the screening prevent preventative treatment program and i think it's it's a really critical that we do sort of two-pronged approach and this one we just you know simply we need more attention more resources more commitment global level country level to scale this thing we have inexpensive tools not down to the cents but inexpensive enough that can save a lot of lives and it just need to be scaled Natasha yeah i mean i don't really have much to add i mean i think just to again reiterate on what susan said i think that when you know gavi is a learning organization and you know we've done this again not just with HPV but with all of our vaccines and as we are we're learning a lot as we're doing and and i think you know given the fact that a number of these demonstration projects will be coming in in a year with more data i think we'll be i mean we have some of it already we know where some of the challenges are but again i think that as more information comes in we'll be able to work with our partners to really figure out how we can improve upon things and you know in some places it may just be tweaks and in other places you know there's going to be a real need to do more but but again i think that's sort of you know that's one of the great things about gavi is that you know we're we're moving forward on things and doing it but also learning as we as we go along thank you so let's let's turn to i don't know if there were any questions in this far side of the room over here are there one or two that that we can pose to our panelists before i ask them to offer some final reflections and wrap up going going okay so we will um we will turn to the panelists for their their final reflections and thoughts and if there were some issues that got raised that you feel like you you didn't have a chance to respond to or answer now it's an opportunity to do that as well but you know i guess i would ask you you know looking ahead you know over the next um 10 to 15 years you know what what do you expect to see um in terms of the introduction and sustainability of of hpv vaccines in in the developing countries where do you think um what kind of conversation do you think we'd be having in in 10 or 15 years about what has worked well and and what hasn't and some of this i know will will be teeing up in in our next session on what does the future hold but you know as you think in particular about the developing country experience what are some of the lessons that are being generated from the current introduction and and scale up of programs that you think will um offer fodder for reflection 10 to 15 years from now okay well catherine thanks again for having this panel and again thanks to steven everybody for doing the you know such a great meeting today um you know i think uh what do we expect to see i mean i think i think we will see a lot of success moving forward i think what you know what i have seen is that there is a real desire to introduce this vaccine in a number of countries and um and like i said just in a matter of a few years we've seen um you know a lot of acknowledgement of that and and countries wanting to do this and i think that you know a big part of this moving forward is going to be you know i sort of said this a few times but i think it's important is really around the political leadership um on supporting the health of women and girls and and this vaccine is is an important um an important part of that um i think the second thing that we're going to see more of which i think is again extremely positive when you look at sort of where we are in global health directly is bringing in all sorts of different kinds of stakeholders i completely agree with you that you know a lot of a lot of work gets siloed into being just very health oriented and i think that um what we're seeing here is bringing um a lot of different players in a country and globally for that matter um uh to really support the introduction and success of this vaccine and i think the more we can get buy-in from you know all sorts of different players and communities the better off will be and and you know and again i think there'll be some lessons learned um on this that we can hopefully put into other areas um of health uh that we're working on um and you know lastly i i would say that you know i think what this vaccine um is also doing is again putting a light on what has been a neglected population which is adolescents and i think um you know we're hearing a lot more about that and um and i think um this vaccine has a lot to do with it and i hope that you know in you know i would hope less than 10 years but that you know adolescents are very much a part of this discussion because their needs um are different um than than small kids and adults and um and really they are the future of these um of these places and we have to make sure that they're being given every chance they can to live a healthy and productive life. Thank you. Susan um i would echo what Natasha was just saying it and i think i can already see at least two or three examples of where um the HPV vaccine has made a difference not just in immunization and vaccination of adolescents but in um actually cancer work and in uh just the global um and and even well basically two two specific areas of vaccine in cancer work one is that um there was a whole piece of work done about vaccine donations and what sort of the requirements should be for countries accepting them and UNFDA looked at some of these vaccine donation statements that WHO put together and said you know we actually need similar sort of requirements for donation of equipment for screening because sometimes we get equipment that doesn't match the needs or um can't be maintained and all kinds of things so they basically wholesale copied a lot of the elements of of the principles of what was thought about for vaccine donation for those um equipment screen uh screening equipment donations for uh cervical cancer screening so that was an immediate just because we were all in the same meetings together and we were seeing these things together another element was that for HPV vaccine very early on um it was decided that for impact monitoring again it was important to have cancer registries and um there had not been any document to recommend how countries developing countries should develop cancer registries and as a result of again interaction from HPV vaccine and from some funding from GAVI um we sort of instigated that IRF would actually write a document which was published a year ago on how country development countries need to create cancer registries and the population-based cancer registries and that will have an impact on hepatitis B which is also a cancer vaccine preventing vaccine HPV and then a whole slew of cancers that are not HPV vaccine preventable at this point uh as well so that those were important um things that were catalyzed by HPV vaccine and similarly I think the interactions on analysts and health services is also another one so I think it's quite amazing to me process wise what this vaccine has already accomplished in the early stages and I'm sure that in the next 10 years we'll see even more amazing results as because of the availability of the vaccine and the implementation of it. Thank you so John I share the enthusiasm and optimism for the future uh you know maybe just 10 years of say 10 years down the road I definitely see much higher coverage of the vaccine in the implementing countries today and more so I definitely see the vaccines from developing country manufacturers are coming out and that is a actually quite a critical step for some of the countries because domestic manufacturing is the first step before they introduce you know bring the vaccine to the national program so this is kind of you know removing a barrier unlock that demand huge demand these large country, high burden country so that that would have a huge hit on the global burden and I also agree with the externalities of HPV vaccination you know it brings in terms of building a platform offering additional services actually uh increasing the attention on the backbone that I was talking about the routine immunization to strengthen the routine immunization data and supply chain and so forth so uh and also I think the that brings an attention actually elevated the visibility of women's health you know as a overall agenda and also uh as a sort of health priority for the country so it drives a lot of a positive momentum into these different topics okay well thank you very much we will now turn to a panel on what's in store for the future so more discussion on what's happening 10 or 15 or more many more years down the road but first I want to thank you the audience for joining us and for your participation and let me ask you to please join me in thanking our panelists