8 Inspiring women who work in infection

International Women’s Day (IWD) takes place on the 8^th of March every year as a day of global activism and celebration of forging women’s equality. The first IWD took place in 1911, so it has over a century of history and change. This year’s campaign theme is Inspire Inclusion.  

The UK healthcare system isn’t inclusive; too much has been designed around the needs of half of the population: men. Men have frequently been treated as the default patient in clinical practice and medical research, and women’s health and healthcare needs have often been marginalised. However, researchers at Imperial are trying to change this.  

In an opinion piece for the BMA, Professor Neena Modi, Professor of Neonatal Medicine at Imperial College London’s School of Public Health, points out that although many health issues have disadvantaged women globally, in 2021, the UK had the widest gender health gap in the G20. In general, women do worse than men in disease prevalence, access to healthcare, and outcomes after treatment. And pregnancy is associated with specific risks of infection. “Over 70% of medicines used in pregnancy have no, or insufficient, safety information, and in the last 30 years, only one medicine has been developed explicitly for use in pregnancy,” said Professor Modi. Pregnant and breast-feeding women were also excluded from the first wave of COVID-19 vaccine trials, which led to inconsistency in the advice issued by governments around the world. Professor Modi said: “This contributed to vaccine hesitancy, and the unvaccinated status of pregnant women substantially increased their likelihood of adverse outcomes following COVID-19 infection.”

Women’s health also directly affects the well-being of future generations. If a woman has an infection, she can pass it on through pregnancy or to her newborn baby. This is another aspect of women’s health that needs more research. 

Imperial’s focus on improving women’s health is exemplified by the recent establishment of the Women's Health Network of Excellence, which promotes interdisciplinary research in women’s health and gender-based health equity.

To mark International Women’s Day, we highlight some of the work now underway in Imperial to understand challenges and gaps in knowledge on infection in women and what can be done to combat them. This includes vaccine research, diagnostics, human challenge studies, engagement, and policy.  

Dr Helen Skirrow (Child Health Unit, School of Public Health) works on pregnancy and childhood vaccinations. She researches which pregnant women and children under five years don’t get vaccinated or get vaccinated late and why. This is a significant public health concern because it risks the health of the individual and the wider population. For example, not enough children in the UK have had their two recommended doses of Measles, Mumps and Rubella (MMR) vaccines. This has resulted in recent measles outbreaks in areas such as London and the West Midlands. Dr Skirrow also focuses on how to make it easier for pregnant women and children to be vaccinated to improve uptake. 

In the UK, pregnant women are recommended to be vaccinated against seasonal influenza, whooping cough and COVID-19. These vaccines protect pregnant women and their babies as antibodies transfer through the placenta. Newborn babies can be vulnerable to infection before they get their first vaccinations at eight weeks old. 

Pregnancy offers an excellent opportunity for healthcare professionals to talk to families and pregnant women about vaccinations and answer any questions or concerns they may have. They can also discuss the routine childhood vaccination programme and check if any other children in the family are up to date with their vaccines. The second dose of MMR vaccine is usually offered to children as part of the preschool vaccinations at three years and four months. Dr Skirrow describes this as a problem with “concerningly low uptake in some areas of London”. However, “it is not too late if you think your child may have missed a dose” as GPs can be contacted. Women should also check they’re up to date with their vaccines; if they’re not, they can be vaccinated after their baby is born. This will help manage the current measles outbreaks in the UK and prevent future outbreaks.   

Five years ago, Dr Skirrow started working with The Mosaic Community Trust - an organisation based in an ethnically diverse area of London with historically low childhood vaccine uptake. They first collaborated on an NIHR Imperial Biomedical Research Centre (BRC)-funded public involvement project to discover why some pregnant women in North West London don’t get vaccinated.  

Following this, Dr Skirrow and Lena Choudary-Salter (Head of The Mosaic Community Trust) co-produced an NIHR-funded project called ‘Why did nobody ask us?!’.

Dr Skirrow’s research and interests have been informed by her own experiences (she is currently on maternity leave with her third child), including during her pregnancy with her first child in early 2013 when the whooping cough vaccine had just been introduced due to an increase in cases amongst newborn babies in the UK. She explains: “I had the whooping cough vaccine because I felt very clearly as a doctor that that was the right thing to do. But lots of my non-medical pregnant friends were asking, ‘Why are we being offered this?’ which made me realise how many questions you have when pregnant about vaccines.” 

Further interest in vaccine uptake was informed by Dr Skirrow’s experience managing measles outbreaks as a public health registrar. This led her to want to research which children don’t get vaccinated and how outbreaks can be prevented. Later, during the COVID-19 pandemic, she focused on pregnant women’s attitudes towards COVID-19 vaccines and how routine vaccine services were affected by the pandemic. “New vaccinations need to be communicated really clearly to pregnant women with information tailored specifically to address pregnant women’s questions,” she says.

Dr Anika Singanayagam is an NIHR Academic Clinical Lecturer in the Section of Adult Infectious Disease. Her research aims to improve strategies to control the transmission of respiratory viruses using vaccines, antivirals, or diagnostic testing.  

She is Principal Investigator in the UK’s second SARS-CoV-2 ‘human challenge’ study. Human experimental infection challenge studies recruit young, healthy volunteers who are intentionally inoculated with an infectious agent in a safe and controlled way. Samples from volunteers are collected before and after the participants are challenged, which allows investigators to study an infection in great detail. For Dr Singanayagam and colleagues' study, the collected samples allowed them to examine how the virus replicates, how immune responses can control it, and how infectious people are to others. Another aim was to identify the number of viruses that cause mild infections in more than half of the infected participants. “Following this, we can go on to test novel vaccines using the challenge model, for example, those that can reduce or block transmission or provide cross-variant protection.”    

Gender is an integral component to consider when conducting the human challenge. It influences how patients are monitored and what is regarded as the “normal range”, as these vary for men and women. Gender differences may also influence immune responses. Thus, gender is essential not only in determining how studies are conducted but also in analysing the data that is generated.  

Dr Singanayagam also noted other impacts of infectious disease epidemics or pandemics disproportionally experienced by women. A report by the IFS found that mothers in the UK were more likely than fathers to have quit or lost their jobs during lockdown, so would contribute a large share of childcare and household responsibilities. It’s also worth noting that maternal and foetal infection risks are unknown when a new pathogen emerges, making decision-making around the best care difficult. This includes potential delays in using new treatments because of a lack of data during development. More research is also required to investigate further the differences in biology between men and women, such as their immune response to vaccines. 

Alison Perry, originally from Canada, is a British-trained midwife. “Midwifery has been my main lens into women’s health, and in some ways, the profession's challenges mirror the issues in women’s health,” she says. She’s supported by the Parasol Foundation to do her PhD and is an honorary research fellow in the Women’s Health Research Programme at the George Institute for Global Health.  Patient and public involvement and engagement (PPIE) are now commonly featured in our expectations of women’s health research.  

Alison’s research is related to improving our understanding of community engagement mechanisms so that it can be reflected in the quality of research and improve outcomes in women’s health. Alison’s research is concerned with the equitable inclusion of people in research and health, which requires critiquing entrenched structures and assumptions within health systems. “Involvement in the midwifery profession has featured some of the same considerations," she says. "More directly, though, midwifery gives me first-hand knowledge of maternity, which is the setting of the Blood in Action Project.”   

The Blood in Action (Bia) Project (funded by the Parasol Foundation) is a research project looking to better utilise routinely collected samples in maternity. Blood samples are collected to screen for a range of viruses in pregnant women, and the research team is keen to put these samples to an even better effect to inform population-level issues such as the current rising level of measles in the UK. The team are aware that health policy and care are built upon research that has excluded the experience and anatomical/ biological reality of women, which is an unacceptable bias that affects the quality of life.  The Bia Project stands to contribute to redressing the systemic exclusion of women by harnessing the potential of everyday NHS pathways already in place.  

Alison’s doctoral work alongside the Bia Project provides more creative methods and modes of engagement at the intersection of arts and health, including storytelling and mosaic arts. “In general, if we focus more on the creation of relationships versus exclusively on outcomes, we will begin to get things right,” she says.  

Cancer Research UK estimates that around 80% of people will be infected with Human papillomavirus (HPV) at some point in their lives, and the World Health Organisation state that 99% of cervical cancer cases (the most common cancer in women) are linked to infection with high-risk HPV. Paula Christen (School of Public Health), says: “Cervical cancer remains a global health issue, disproportionately affecting women in countries in the African region, where 85% of global mortality from cervical cancer occurred based on 2020 estimates.”

In many countries, women don’t have access to or can’t afford appropriate treatments. Therefore, there is a critical need for comprehensive research on HPV and the development of effective prevention strategies, including vaccination and screening programmes.   

Paula is a social scientist and epidemiologist. She specialises in researching evidence-informed decision-making in infectious disease control policies and programmes. During her PhD research, she focused on how decision-makers can be integrated into modelling HPV vaccination in Mozambique for evidence to be relevant for policy and health programme development.   

During her work in Mozambique, Paula developed a framework encompassing three main parts:   

1. Probing evidence needs of stakeholders to formulate research questions. She conducted and analysed interviews to identify key evidence needs that can be addressed using mathematical models.   
2. Address evidence needs with an appropriate method. Paula estimated how current policies impact vaccination programmes on health, cost savings for the healthcare system, and broader economic benefits.  She showed that vaccination programmes can reduce health and financial disparities across socioeconomic populations and free up medical staff capacity.   
3. Science communication. Evidence for the HPV vaccination programme was summarised in an evidence brief, presented and discussed with previous interview participants.  

Policies need to consider entrenched income inequalities, access to treatment and the distribution of cervical cancer within populations. Paula's research in Mozambique showed that the benefits of HPV vaccination would mainly affect wealthier women. So, policies need to focus on rural and poorer populations. For catastrophic health expenditure incidence to be reduced by 50% in Mozambique, the treatment would have to be almost entirely paid for by the government for patients in the poorest areas. Policies addressing inequalities need to be developed with stakeholders at the community level.

Globally, there is an increasing number of licensed vaccines and national vaccine introductions, so eradication of HPV types which cause cancer is becoming more feasible, significantly reducing the need for preventive measures in the future. In the past few years, studies have shown that HPV vaccination reduces the burden of cervical cancer. By 2094, immunisation of girls born between 2005 and 2014 with vaccines that target cancer-causing genotypes is estimated to prevent 8.7 million cases globally.   

While highly accurate tests like PCR exist for HPV detection, the efficacy of preventive measures hinges on overcoming barriers to screening, particularly the discomfort associated with sample collection methods, such as the smear test, which poses a significant obstacle for women.  

Sanziana Foia (Department of Bioengineering) is the founder of Papcup, an electrochemical device that is compact, reusable, and about the size of your fist. Unlike traditional smear tests, the device uses menstrual blood samples, and its electrochemical biosensor detects HPV efficiently and reliably.   

Sanziana was motivated by a passion for science and commitment to social justice; she embarked on a mission to create Papcup to provide access to life-saving screenings, particularly for underprivileged and marginalised communities. With her invention, Sanziana reached the semifinals of the We Innovate competition at Imperial College London, which provided the first catalyst for Papcup’s development.   

She says: “Creating a user-friendly, comfortable, and intuitive device for sample collection is crucial in encouraging more widespread participation in life-saving screenings. By developing Papcup, which offers an easier and more accessible alternative to traditional smear tests, we can empower women to take control of their health and prevent cervical cancer effectively.”   

There is also potential for developing tailored diagnostic tests and screening guidelines aimed explicitly at detecting HPV infections and related complications in men.  

Since March 2023, when Sanziana and her team won the Hackstarter competition, she has focused on building the business and securing funding to propel her vision forward. She has participated in the Summer Accelerator at Imperial, the Venture Builder Incubator at the University of Edinburgh and a Cancer Research Horizon programme. The team have also recently been accepted into the NHS CEP Patient Entrepreneur programme. Now, they’re directing their efforts towards validating the market and developing their Minimum Viable Product.

Besides Sanziana’s entrepreneurial journey, her PhD research focuses on developing a microneedle biosensor for detecting anti-malarial drugs to create a diagnostic tool in regions lacking laboratory infrastructure. This will optimise drug dosages and combat drug-resistant malaria strains.