By Dr. Peter O. Adefuye (1), and Mrs Bola Idowu-Ajiboye (2)
- Department of Obstetrics & Gynaecology Olabisi Onabanjo University & Olabisi Onabanjo University Teaching Hospital Sagamu, Ogun State, Nigeria
- Centre for Research in Reproductive Health Sagamu, Ogun State, Nigeria and Mrs Bola Idowu-Ajiboye
Global burden of cervical cancer is high, accounting as the seventh most common cancer in men and women world wide and fourth most common cancer in women globally. An estimated 528000 new cases and 266000 deaths from the disease were made in 2012 (GLOBOCAN 2012). About 85% of this burden of incidence and overestimated 87% burden of deaths occur in Sub-Saharan Africa, central and south America, Caribbean, south central and south eastern Asia. Cervical cancer accounts for 7.5% of all cancer deaths in the females. Remarkable reduction in incidence and mortality from the disease in advanced countries of North America and Western Europe have been attributed to population based screening using cervical smear (Pap smear) and cytology. The strength of this method of screening lays in its specificity, that is, its ability to identify more accurately the normal test results. Specificity of Pap smear and cytology has been put at about 94%, and its sensitivity 72%.
Implementation of cervical smear and cytology requires high tech-equipment and specialized skills. In addition, ancillary adjunctive tools at arriving at more specific diagnosis (i.e. colposcopy and histology) make it more impracticable in low and medium income countries where the resources are either non-available or to poor to implement. Screening in these countries are largely opportunistic resulting in less than 5% of women in need of screening being covered. Currently there is a shift in the paradigm of cervical cancer screening from cytology based screening to include testing for high risk Human Papillomavirus (HrHPV) DNA or RNA in smear sample or tissues in addition to Pap smear and cytology.
In the absence of effective screening programs in low and medium income countries efforts had been made to explore the feasibility of using the existing infrastructure to develop effective low-cost screening methods. This had engendered the concept of visual inspection screening methods with either acetic acid (VIA) or Lugol’s iodine (VILI). In these methods the result is immediately available and where appropriate equipment is available, the disease can be treated at the same visit by burning it with extreme freezing (cryotherapy). Visual inspection screening methods are cheap and can be performed reliably by trained paramedical workers and doctors, thus making them effective screening options in low resource settings.
Demonstration of Feasibility, Acceptability and Effectiveness of Screening for Cervical cancer using Visual Inspection with 3-5% Acetic acid (VIA) and Treatment of Cervical dysplasia with Cryotherapy at screening (“See and Treat”)
The World Health Organization (WHO), in collaboration with the African Population and Health Research Centre (APHRC) and the International Agency for Research on Cancer (IARC), conducted a multi-center study of the effectiveness and acceptability of visual inspection with acetic acid (VIA) and treatment of cervical dysplasia with extreme freezing (Cryotherapy) in six African countries namely Madagascar, Malawi, Nigeria, Tanzania, Uganda and Zambia. The project was structured to take place in two phases; the initial local demonstration and then the national scale up, both of which spanned between September 2005 and May 2009. The local demonstration was to address the main objective of the project; feasibility, acceptability and effectiveness of VIA and Cryotherapy (“See and Treat” one stop screening technique as screening tools in low resource settings), and the national scale up was about building capacity in rural communities across Nigeria.
In Nigeria, the project was undertaken at the Center for Research in Reproductive Health [CRRH], in collaboration with staff of the Olabisi Onabanjo University Teaching Hospital and the Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu. The Principal Investigator is Dr. Peter Oladipupo Adefuye, a consultant Obstetrician and Gynaecologist with the University. The project nurse is Mrs. Bolanle Idowu-Ajiboye, a nursing officer with CRRH.
As was done in the five other participating centers, the Nigerian local team demonstrated the feasibility, acceptability, and effectiveness of VIA and Cryotherapy as alternative to cytology-based screening method at all levels of healthcare system (WHO Bulletin 2012). During the demonstration period 5529 women were screened using VIA and 317 (5.7%) were VIA positive and 52 (1.0%) were found with lesions suspicious for invasive cervical cancer. One hundred and twenty-one out 127 women that returned for rescreening one year after treatment with cryotherapy had negative VIA result, giving a cure rate of 95.3%. Ninety-four point three percent of women perceived procedure VIA tolerable as counseled and 98.9% will recommend the method to another women. Similarly 98.2% of women treated with cryotherapy perceived the procedure as tolerable as counseled, and 95.0% will recommend the treatment to other women.
Building the capacity of health workers in Nigeria for prevention of cervical cancer through screening using the “See and Treat” method.
The most remarkable aspect of this demonstration is the national scale-up phase. This phase of the project witnessed the incorporation of VIA and cryotherapy into the cervical cancer prevention services in existing reproductive health services in Nigeria and is considered a practical alternative to cytology-based screening in the country.
The WHO Country Office (Department of Reproductive Health) collaborated with both Federal and States ministries of Health to scale-up “See and Treat” approach by building capacity at community levels (both rural and urban areas) in the country. This capacity building involved training of doctors and nurses in the Federal health facilities across all the regions and in States that adopted the VIA and Cryotherapy as alternative screening method for cervical cancer in their reproductive health services.
In order to achieve this objective, training of adequate number of healthcare providers was needed. The implementation center (CRRH) undertook a series of coordinated training programs that commenced with the building of a competent local team of 17 doctors and Nurses through a rigorous ‘training of trainers program. The Centre with its team evolved as a ‘center of excellence’ for training and provision of VIA and cryotherapy services. The team has since continued to serve as resource team in the training and supervision programs as requested by various State Governments, governmental agencies and national NGOs.
The training curriculum used in all the training sessions was based on that developed by World Health Organization/JHPIEGO and as prescribed in “The Manual of Teaching Visual Inspection of the Cervix with Acetic Acid”, (prepared by the Program for Appropriate Technology in Health (PATH) with funding from Bill and Melinda Gates through Alliance for Cervical Cancer Prevention (ACCP)). The curriculum has had appropriate adaptations made by CRRH in consideration of the Nigerian environment and has been used since 2006 in its national training programs. The training programme is usually conducted in a ‘training of trainers’ format and with emphasis on the trainees acquiring adequate practical competencies in both VIA and VILI procedures, in addition to the theoretical knowledge.
A commendable lead in the national efforts at building capacity at community levels for cervical cancer prevention was the decision of the Nursing and Midwifery Council of Nigeria (NMCN) to include cervical cancer prevention measures into the training curriculum of midwives in Nigeria. The NMCN partnered with the CRRH to provide comprehensive training in VIA and Cryotherapy for nominees from each of the 73 the Schools of Midwifery as well as 15 University Departments of Nursing in the country. The cascade effect of this foresight by the NMCN is that competencies in cervical cancer screening are now spreading throughout the country.
To date 734 healthcare professionals (doctors and nurses) have been trained in VIA and cryotherapy as shown in the Table below.
The burden of cervical cancer continues rise globally and in particular in low and medium income countries. Prevention programs in developed countries have evolved from periods of down staging through cytology based programs, and now, to paradigm of screening for high risk Human Papillomavirus and vaccination against the virus. All through these milestones the under developed nations of Sub-Saharan Africa, South America, south central Asia, South Eastern Asia, and eastern Europe continue to lag behind resulting in high incidence and mortality from the disease. Alternative approach in these countries would be development of cheap screening methods that will utilize the existing infrastructure. Visual inspection screening methods using acetic acid (VIA) and Lugol’s iodine (VILI) have been found feasible, acceptable and effective in many demonstrations across these countries. If the low and medium income countries will witness a decline in the incidence and mortality from cervical cancer they must, as individual countries, commence robust and extensive capacity building of healthcare professionals across the countries.
Table 1. VIA Training programmes in 2006 – 2014
|Period of training||Sponsor||Program & site||No trained|
|24-28 July, 2006||World Health Organization||Training of Trainers (Doctors & Nurses) For Remo Health zone in Ogun State, Nigeria/CRRH, Sagamu, Ogun State, Nigeria||7||36|
|9-11 October, 2006||World Health Organization||Training of Trainers (Doctors & Nurses) For Abeokuta Health zone in Ogun State, Nigeria/General Hospital, Ijaye Abeokuta Ogun State, Nigeria||5||13|
|18-20 December, 2006||World Health Organization||Training of Trainers (Doctors & Nurses) For Yewa Health zone in Ogun State, Nigeria/General Hospital, Ilaro, Ogun State, Nigeria.||3||12|
|21-23 January, 2007||World Health Organization||Training of Trainers (Doctors & Nurses) For Ijebu-Ode Health zone in Ogun State, Nigeria/State Hospital, Ijebu-Ode, Ogun State, Nigeria.||3||20|
|13-15 April, 2007||World Health Organization||Training of Trainers programme: Training of Consultant Gynaecologists and Senior Nurse/Midwives from the Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria./CRRH, Sagamu, Ogun State, Nigeria||5||10|
|10-12 September, 2007||World Health Organization||Training the Trainers for Federal Capital Teritory department of Health/CRRH, Sagamu, Ogun State, Nigeria||3||5|
|August – October, 2008||Federal Ministry of Health||National Scale-Up: Training of Trainers for Federal Ministry Health of nominees from Federal Medical Centers from the six geopolitical zones of the country/CRRH, Sagamu, Ogun State, Nigeria||30||60|
|17-20 December, 2008||Lagos State Ministry of Health||Training the Trainers program for Lagos State Ministry of Health/Lagos Island maternity Hospital, Lagos Island, Lagos State, Nigeria.||8||20|
|19-21 January, 2009||Lagos State Ministry of Health||Training the Trainers program for Lagos State Ministry of Health/General Hospital, Kirikiri Road, Apapa Lagos, Lagos State, Nigeria.||6||20|
|26-28 January, 2009||Lagos State Ministry of Health||Training the Trainers program for Lagos State Ministry of Health/Primary Health Center, Pen Cinema, Ogba Lagos, Lagos State, Nigeria.||8||24|
|6-8 April, 2009||The BLOOM Cancer Care Center, Ikeja Lagos, Lagos State, Nigeria.||Training the Screeners for The BLOOM Cancer Care Center, Lagos (aimed at establishing a screening centre at the Bloom Cancer Centre, Lagos)/BLOOM Cancer Care Center, Ikeja lagos, Lagos State, Nigeria.||1||3|
13-17 July, 2009
|Nursing & Midwifery Council of Nigeria||Training the Screeners program for graduating Midwifery students||49|
|12-16 October, 2009||Edo State Ministries of Health & Women/Youth Affairs & AMEN Foundation, Nigeria.||Training the Trainers and Screeners programs in Edo State, Nigeria/Central Hospital, Benin, Edo State, Nigeria.||8||64|
|May 2010||Glaxo Smith Kline Plc, Lagos||Training of Screeners program for Doctors and Nurses selected from some Private health facilities in Lagos State/ CRRH, Sagamu, Ogun State, Nigeria||5||15|
|April 2011||WOYWA Foundation||Training of Screeners program for Doctors and Nurses selected from some Private health facilities in Ondo State/ CRRH, Sagamu, Ogun State, Nigeria||4||14|
August – October, 2011
|Nursing & Midwifery Council of Nigeria||Training of Midwife educators consisting of Midwifery Tutors from each of the 73 the Schools of Midwifery as well as 15 University Departments of Nursing in Nigeria/ Centre for Research in Reproductive Health, Sagamu||2||135|
|April 2012||Ogun State Ministry of Health||Refresher Training of Nurses from PHCs in Ogun State: Centre for Research in Reproductive Health, Sagamu||4||30|
|October 2013||National Obstetric Fistula Centre, Abakaliki, Ebonyi State, Nigeria||Training the Trainers and Screeners programs for National Obstetric Fistula Centre, Abakaliki, Ebonyi State, Nigeria||4||10|
|October 2014||Lagos State Ministry of Local Government/ Cancer control Department of Lagos State Ministry of Health||Training the Trainers and Screeners programs for Doctors and Nurses from Health centers in Lagos Sate||6||36|
|November, 2014||Kano State Ministry of Health||Training the Trainers and Screeners programs for Doctors and Nurses of Kano State, Nigeria||8||40|
Photo: In-country WHO Director of Reproductive Health, Dr (Mrs) Odujirin, giving a speech at the flag off of the project in Nigeria in July, 2006.
Submitted by Dr. Peter O. Adefuye