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• Cervical cancer - major public health problem in SEAR countries • About 10.9% of the Asian women are estimated to harbour cervical HPV infection • • • 190,000 new cervical cancer cases every year in SEAR 35% of the global burden of the disease Two-pronged strategies for prevention - HPV vaccination - population based organized cervical cancer screening.
None of the SEAR countries have effective screening programs due to resource and logistic constraints Develops slowly over 10 to 15 years Human Papillomavirus (HPV) infection, HPV 16 and 18 most common high risk types implicated in 65-80% of cervical cancers
Primary Prevention – HPV Vaccination
Secondary Prevention- Detection and treatment of the disease at the HSIL stage through cervical cancer screening
Tertiary Prevention – treatment of invasive cervical cancer and palliative care
.Components of cervical cancer control Preventive strategies Treatment of invasive cancer Palliative care Success of the cervical cancer control program depend on pragmatic selection of service delivery models good centralized control system of quality assurance.
.Objective To guide and assist member countries to develop or strengthen their national strategies to • improve cervical cancer control activities • reduce the burden of morbidity • Reduce disability and deaths from cervical cancer • promote women’s health.
cost-effective interventions through effective service delivery strategies across the different levels of health care • Strengthen health systems to ensure equitable access of all eligible women to cervical cancer screening services.Objectives of Framework • Introduce or scale up delivery of HPV vaccine to girls between 9 to 13 years of age through a coordinated multi-sectoral approach involving national programs of immunization. reproductive and adolescent health • Implement or scale up organized cervical cancer screening program utilizing evidence based. with particular attention to the socio-economically disadvantaged population groups. . cancer control.
Objectives of Framework Augment management facilities for invasive cancer and introduce palliative care services as part of comprehensive cancer control program Bring convergence of related health programs to ensure a coordinated and operationally feasible approach for cervical cancer control within the health system .
102 3 416 360 156 484 16 .733 2.853 2.558 7 181 11.559 7 186 11.174 3 389 360 175 465 16 10 years 1.556 7 190 11.135 3 407 362 161 481 16 13 years 1.177 3 392 363 171 473 16 11 years 1.549 7 178 11.Estimated Female Population Country Estimated Female Population (in thousands) in single age cohorts (9-13 years) 9 year Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri lanka Thailand Timor-Leste 1.162 3 399 364 166 478 16 12 years 1.752 2.529 7 174 11.790 2.722 2.
of cases/yr ASR (/100.4 942 26. Hospital based data 12.9 13762 6434 32.000) No. Hospital based data Indonesia Maldives Myanmar Nepal 3504 Sri lanka No PBCR.5 10.6 72825 12.000) Bangladesh 17686 29.9 518 15.6 814 5216 No PBCR.0 No PBCR.Cervical Cancer Incidence And Mortality • • • • • • • • • • • • • • Country Cervical Cancer Incidence Cervical Cancer Mortality Source of Incidence & Mortality Data No. No data No PBCR. of deaths/yr ASR (/100.9 No PBCR. Hospital based data Bhutan 50 DPR Korea India 134420 20.9 No PBCR.8 24. Hospital based data No PBCR.3 No PBCR.8 10364 17.4 1872 11. No Data Thailand 9999 population covered) Timor-Leste - .0 15. Hospital based data 6. Hospital based data PBCR in select areas (<5% population covered) 7.2 7493 3536 17.4 1395 27 6. Hospital based data 3.7 26.8 PBCR in select areas (~40% No PBCR.
CERVICAL CANCER CONTROL INITIATIVES .
ensuring steady supply of consumables and monitoring and evaluation of the program. subsequently expanded to the subdistrict and rural health centers Currently screening offered at 57 district hospitals. Nurses and gynaecologists trained to perform VIA. A national Coordinating Center set up at Bangabandhu Seikh Mujib Medical University.Bangladesh National Cervical Cancer Screening Program launched in 2005. VIA services set up Initially in the district hospitalS. 61 maternity clinics. Dhaka is responsible for training of all service providers. Recommended screening of women aged 30 years or above by VIA at an interval of 3 years. . 70 sub-district hospitals and 50 rural health centers across the country. setting up screening and colposcopy centers across the country.
Colposcopy and treatment are performed by trained gynaecologists and nonspecialist clinicians. If high grade lesions are suspected on colposcopy. No population based cancer registry in the country. .000 women screened every year and the VIA positivity is consistently around 5%. HPV vaccines are licensed in the country for opportunistic vaccination.Bangladesh Referral centers for colposcopy and treatment set up at the Medical College hospitals maintaining a linkage with screening centers. Nearly 100. immediate treatment offered (‘see and treat’) without waiting for histology confirmation.
The program scaled up in 2005 by establishing new cytology laboratories and recruiting more trained cytotechnicians and pathologists & centers with colposcopy and treatment facilities program remained ineffective due to lack of sustained motivation of the staff. DRAWBACKS • • • • • • • Pap smear was of suboptimal quality (high rate of unsatisfactory smears) long reporting time for pap smears.BHUTAN • • Pilot project on cervical cancer screening was initiated in 2002. Recently VIA by nurses mobile outreach approach introduced. The screening program is still opportunistic with low uptake and reaching the women in geographically remote areas is a major challenge. irregular supply of the consumables and low participation rates. Recommended screening of 20 to 60 year old women using Pap smear cytology and referral of all positives to one designated colposcopy center. loss to follow up was high with very few cytology positive women attending the colposcopy center. .
.BHUTAN February 2011.quadrivalent vaccine introduced in the national immunization program. Every year all the girls reaching the age of 12 years are being vaccinated There is no population based cancer registry in the country.
Colposcopy and biopsy will be arranged at the Provincial Hospitals where the specialist gynecologists will be trained to do the procedures. .DPR KOREA Pilot project has been launched to screen women between 30-55 years by VIA The Family Health Doctors during their home visits counsel and motivate eligible women to undergo screening. The HPV vaccines are not available There is no population based cancer registry. VIA will be done in the rural Hospitals and district/county hospitals by the nurses and gynecologists.
. Pap smear cytology facilities available in select laboratories National guideline for cervical cancer screening drafed in 2005. augment capacity of health system to make screening and colposcopy services accessible to women train a critical number of health care providers to deliver the services.Well-organized population based cancer registries in several provinces under the National Cancer Registry Program but still population covered is less than 5% .INDIA • • • • No organized cervical cancer screening program . Recommendations were to screen women between 30 to 59 years using VIA and to set up a two-tier system to perform screening at the primary health centers and colposcopy at the district hospitals • The need of the hour is drafting of a pragmatic operational guideline to integrate screening in the health facilities.Both bivalent and quadrivalent vaccines are licensed in India but administered only to those who pay from their own pocket .
The Cervical and Breast Cancer Prevention (CECAP) Project. .To screen 30 to 50 year old women every 5 years. Services are grossly inadequate for the large target population and lot of investment is required. There is no population based cancer registry.very successful in achieving high coverage of other childhood vaccines. Both the HPV vaccines are available in the private market and are considered too costly to be considered for the national immunization program. only hospital based cancer registries exist in 23 teaching hospitals. The existing health promoting schools (UKS) and adolescent friendly health services (PKPR) program targeted towards boys and girls aged between 6 to 19 years of age provide great opportunities for introduction of the HPV vaccines. Single visit approach by VIA followed by cryotherapy of the VIA positive women was evaluated.INDONESIA National Cervical Cancer Screening Program launched in 2007 Objective . School based vaccine delivery services .
There is no plan to introduce the HPV vaccines in the national immunization program in the near future. VIA positive will be referred to the tertiary hospitals where colposcopy units will be set up.MALDIVES There is no radiation therapy facility Currently only one tertiary care hospital in the capital city of Male has a laboratory equipped to process and read pap smear cytology. There are no population based or hospital based cancer registries . Women between 30 to 50 years of age will be screened by VIA to be performed by the trained nurses. A pilot cervical cancer screening project is being planned to be implemented in Male and another province. Pap smears are advised only to women suspected to have cervical cancer and is rarely followed up with colposcopy.
• A policy of introduction of new vaccines in the National Immunization Program drafted in 2012 and accepted by the Ministry of Health advocated HPV vaccine. • There are no population based cancer registries. • financing and ensuring the logistics for a three dose vaccine are challenges for the future HPV vaccination program.MYANMAR • High burden of cervical cancer • lack of any organized screening program. . though as a second priority. • National Cancer Control Program was launched in 2008 • HPV vaccines are available in the private sector.
Lack of regular power supply makes maintenance of cold chain a challenging task.NEPAL • • • • The National Guideline for Cervical Cancer Screening and Prevention drafted in 2010 recommendation . A linkage between the screening centers and hospitals offering colposcopy services have been created and efforts are on to connect the cervical cancer screening database to the Medical Information System. A group of medical officers and gynecologists have been trained in colposcopy and management of cervical precancers. Nepal Network for Cancer Treatment and Research (NNCTR) initiated vaccination of small cohorts of 12 to 14 year old girls every year starting from 2008 with funding support from Australian Cervical Cancer Foundation.VIA as the screening test and single visit approach (VIA followed by cryotherapy of the VIA positive women in the same sitting To screen women between 30 to 60 years at least once in the next 5 years screening services presently are more community oriented and additional midwives and nurses have been trained to do VIA. • • • • . There is no population based cancer registry in the country.
no population based cancer registry.once in a life time screening using conventional Pap smear cytology for the women of 35 years of age more than 800 Well Woman Clinics (WWC) Every year more than 100. . There is a 6-8 weeks of lag period between smear taking and delivery of reports. Hospital based cancer registries present. 20 colposcopy centers at the provincial hospitals or tertiary Institutes.000 women have pap smear.SRILANKA • • • • • • • • • • • Screening program is predominantly opportunistic with certain components of organized screening program A Guideline for Cervical Cytology Screening and Reporting in Sri Lanka was formulated in 2010 Recommendation . no immediate plan to introduce the vaccine the national immunization program. Drawbacks .No linkage between the WWCs with the Colposcopy centers Lack of system of proper monitoring and quality assurance Both bivalent and quadrivalent vaccines are available.
THAILAND • • • National Cervical Cancer Screening Program was launched in 2005 Target age for screening is 30 to 60 years. The Department of Health is responsible for screening of women using VIA in select districts and the Department of Medical Services is responsible for screening women with pap smears linkage between screening and colposcopy services and developing a mechanism of identifying the non-compliant women Records entered in a computerized screening registry • • • • Single visit approach (cryotherapy for VIA positive women) is followed in places where women are screened by VIA. Population based cancer registries present .
.TIMOR LESTE • No population based cervical cancer screening program. • Pap smear abnormalities are managed by hysterectomy. • Pap smear cytology is performed only on symptomatic patients and is of uncertain quality. • There is no facility for colposcopy and management of cervical cancer precursors by cryotherapy or LEEP. • No radiation therapy facility • No population or hospital based cancer registry.
PRIMARY PREVENTION • The vaccination is most effective if administered prior to sexual debut and exposure to HPV infection.Cost of the vaccines is a major limitation .Eligible to procure the vaccines through Global Alliance for Vaccine & Immunization (GAVI Alliance) at a much subsidized cost . High coverage of the target population Adherence to the three dose schedule . Recommended age .9 to 13 year old girls • Vaccinating a single age cohort within the target age range .a cost-effective approach • key factors for the success of the program.
Involve the parents and obtain their explicit consent Health Centre Based Vaccination Procurement and Logistics . stock levels and wastage rates.program managers are expected to regulate the vaccine procurement. storage and transport capacities.Orientation training and supervision of the existing staff are critical components of a delivery strategy. Capacity Building . since nearly 30% of all cervical cancers are caused by HPV types not targeted by the currently available vaccines • • • .• • • School Based Vaccination. supply chain. and report regularly on progress against targets. temperature monitoring. Specified funds for preparation of manuals and training materials. The vaccinated population will also need screening in future.
Few pilot studies Pap. HPV 30-59 yrs Insignificant NA Only opportunistic vaccination NA NA Indonesia Opportunistic. Pap 30-60 yrs Insignificant NA Small number vaccinated each year 12-14 Yrs External donation Sri lanka Opportunistic with good central coordination Pap 35 yrs High Poor Only opportunistic vaccination NA NA Thailand Opportunistic with good central coordination Pap. VIA 30-60 yrs High Good in places where ‘screen & treat’ approach followed Only opportunistic vaccination NA NA Timor-Leste NA Opportunistic Pap NA Not defined Insignificant NA Vaccine not available . VIA 20 -60 yrs Insignificant Poor Part of National Immunization 12 yrs External donation DPR Korea NIL. VIA. through ‘see and treat’ approach Only opportunistic vaccination NA NA Bhutan Opportunistic Pap.Cervical cancer control activities • • • • • • • • • • • • • Countries Cervical Cancer Screening HPV Vaccination Nature of Program Screening test used Recommended target Population Coverage achieved Link between screening & treatment Nature of program Target age Funding source Bangladesh Opportunistic with good central coordination VIA 30 yr and above Low Good. Few pilot studies VIA 30-50 YRS Insignificant Good in places where ‘screen & treat’ approach followed Only opportunistic vaccination NA NA Maldives Opportunistic Pap Not defined Insignificant NA Vaccine not available NA NA Myanmar Opportunistic Pap Not defined Insignificant NA Only opportunistic vaccination NA NA Nepal Opportunistic VIA. Pilot planned VIA for pilot 30-55 yrs NA Vaccine not available NA NA India Opportunistic.
• Disease surveillance data (data on reduction of the disease burden targeted by the vaccines • Linking up the vaccine database to a cancer registry will provide information on the vaccine efficacy in prevention of cervical cancer in the long run. • Continued surveillance to detect and report side effects and complications of the new vaccine is most crucial.Monitoring & Surveillance Two key indicators for performance monitoring : • Vaccination coverage .in terms of proportion of girls in the target age group vaccinated and proportion of vaccinated girls received all three doses of the vaccine. .
• Countries having appropriate capabilities should promote research for the indigenous production of the vaccine .Key Strategic Directions to Introduce HPV Vaccine in National Immunization Program Strategic Direction 1: Define the target population • The vaccine should be given to girls only until there is a new recommendation for vaccinating the boys • The countries can decide to vaccinate initially all girls in the age group of 9 to 13 years and then fix one specific age at which girls will be vaccinated every year • Vaccinating a single age cohort considered most accessible to the school-based health program or the health facilities is also acceptable Strategic Direction 2: Arrange for Sustainable Financing • Sustainability should be ensured prior to launch of nationwide program • The member countries eligible for donations from GAVI Alliance may approach the Alliance for initial support to the program • The startup cost for introduction of new vaccine for the first year (estimated to be 3$ per girl) and the operational cost of vaccine delivery (estimated to be 4.20$ for delivering 3 doses) every year should be considered while budgeting for the HPV vaccination program .
maintenance of cold chain. uninterrupted supply of consumables and high coverage with all three doses of the vaccine should be ensured .ContinuedStrategic Direction 3: Select Appropriate Delivery and Coverage Strategy • Appropriate delivery strategy should be selected to ensure highest coverage of the target age group • A school based vaccination program may be considered if a good proportion of the girls attend middle and high schools in the country • Vaccination can be done in the health facilities at the primary and the secondary levels • Combination of both delivery strategies along with out-reach or campaign approach to vaccinate the socio-economically disadvantaged population will ensure high coverage • Whatever delivery strategy is selected.
Continued Strategic Direction 4: Integrate immunization. coordination between various levels and quality assurance • The opportunity of getting access to the adolescent girls through the vaccination program should be utilized to deliver other health services targeted to the same population • Regular programme evaluations should be conducted at local. district and national levels and should be linked with routine coverage evaluation surveys of immunization . surveillance and other related health interventions • The health system should be strengthened to reduce the barriers to immunization and improve post-vaccination surveillance for adverse events • A program officer at national/regional level should be responsible for planning and execution of the services.
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