STRATEGIC PLAN FOR CERVICAL CANCER PREVENTION AND CONTROL IN UGANDA
2010–2014
Ministry of Health
P.O. Box 7272 Kampala, UGANDA
APRIL 2010
MINISTRY OF HEALTH
STRATEGIC PLAN FOR CERVICAL CANCER PREVENTION AND CONTROL IN UGANDA
2010–2014
Ministry of Health
P.O. Box 7272 Kampala, UGANDA
APRIL 2010
MINISTRY OF HEALTH
TABLE OF CONTENTS
ACRONYMS ... v
ACKNOWLEDGEMENTS ... v
CONTRIBUTORS ... v
FOREWORD ...v
EXECUTIVE SUMMARY ... x
CHAPTER 1. BACKGROUND ... 1
CHAPTER 2. VISION, GOAL, OBJECTIVES AND IMPLEMENTATION STRATEGY ... 13
CHAPTER 3. PUBLIC EDUCATION AND ADVOCACY FOR CERVICAL CANCER PREVENTION AND CONTROL ... 19
CHAPTER 4. PREVENTION OF HPV INFECTION (PRIMARY PREVENTION OF CERVICAL CANCER) ... 25
CHAPTER 5. DIAGNOSIS AND TREATMENT OF CERVICAL PRECANCEROUS LESIONS (SECONDARY PREVENTION) ... 31
CHAPTER 6. SURGERY FOR CERVICAL CANCER ... 40
CHAPTER 7. TREATMENT OF INVASIVE CERVICAL CANCER USING CHEMOTHERAPY AND RADIOTHERAPY ... 43
CHAPTER 8. PALLIATIVE CARE FOR CERVICAL CANCER ... 47
CHAPTER 9. MONITORING AND EVALUATION OF THE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME ... 49
REFERENCES ... 53
List of tables Table 1. Proposed standard servces for cervcal cancer preventon and control n Uganda ... 12
Table 2. Proposed nterventons and target audences ... 23
Table 3. Vaccne types, schedules and elgble ages for vaccnaton ... 26
Table 4. Indcaton and excluson crtera for cryotherapy ... 35
Table 5. Elgblty and excluson crtera for LEEP ... 36
Table 6. Advantages and dsadvantages of cryotherapy and LEEP ... 36
Table 7. Advantages and lmtatons of the screen-and-treat approach ... 37
List of figures
Fgure 1. Number of cases and ncdence of cervcal cancer n
2002 ... 2 Fgure 2. New cancer cases n Uganda: estmates for 2002 ... 3 Fgure 3. Ten leadng causes of cancer deaths n Uganda:
estmates for 2005 ... 3 Fgure 4. Fve-year relatve survval of cervcal cancer patents,
Uganda and the Unted States (amongst black Amercans),
1993–1997 ... 4 Fgure 5. Phased approach to ntegratng cervcal cancer
programmes nto exstng servces ... 8
ACRONYMS
ABC Abstan, Be fathful, use Condoms
AIDS Acquired Immune Deficiency Syndrome CIN Cervcal Intra-epthelal Neoplasa
HIV Human Immunodeficiency Virus
HMIS Health Management Informaton System HPV Human Paplloma Vrus
IEC Informaton, Educaton and Communcaton LEEP Loop Electrosurgcal Excson Procedure
LLETZ Large Loop Excson of the Transformaton Zone M&E Montorng and Evaluaton
NCD Non Communcable Dseases
PATH Program for Approprate Technology n Health STI Sexually Transmtted Infecton
UNEPI Uganda Natonal Expanded Programme on Immunsaton VIA Vsual Inspecton wth Acetc Acd
VILI Vsual Inspecton wth Lugol’s Iodne WHO World Health Organsaton
ACKNOWLEDGEMENTS
• Makerere Unversty College of Health Scences, Obstetrcs and Gynaecology Department
• Makerere Unversty College of Health Scences, Pathology Department
• Mbarara Unversty of Scence and Technology, Obstetrcs and Gynecology Department
• Mbarara Regonal Referral Hosptal
• Ministry of Health, Ibanda District Health Office
• Ministry of Health, Nakasongola District Health Office
• Mnstry of Health, Non-Communcable Dsease Department
• Mnstry of Health, Reproductve Health Dvson
• Mnstry of Health, Uganda Natonal Expanded Programme on Immunsaton
• Mulago Natonal Referral and Teachng Hosptal, Obstetrcs and Gynaecology Department
• Pallatve Care Assocaton of Uganda
• PATH/Uganda
• PATH/Seattle
• Save A Woman Intatve
• Uganda Women Cancer Support Organsaton
• Uganda Women’s Health Intatve
• World Health Organisation, Uganda Country Office
CONTRIBUTORS
Prof. Anthony K. Mbonye Mnstry of Health, Communty Health
Department
Dr. Emmanuel Mugsha PATH/Uganda Mr. Edward Kumakech PATH/Uganda
Dr. Danel Murokora Uganda Women’s Health Intatve Dr. Olve Sentumbwe World Health Organsaton, Uganda
Country Office
Dr. James Sekajugo Mnstry of Health, Non-communcable Dseases Department
Dr. Jennfer Wanyana Mnstry of Health, Reproductve Health
Dvson
Dr. Possy Mugyeny Mnstry of Health, Uganda Natonal Expanded Programme on Immunsaton Dr. Irene Mwenyango Mnstry of Health, Uganda Natonal
Expanded Programme on Immunsaton Dr. J.B. Kgula Mulago Natonal Referral and Teachng
Hosptal
Dr. I. Luutu Mulago Natonal Referral and Teachng
Hosptal
Dr. Henry Wabnga Makerere Unversty College of Health Scences, Pathology Department
Dr. Bna Pande Mulago Natonal Referral and Teachng
Hosptal
Ms. Luwaga Llane Mnstry of Health, Health Educaton and
Promoton Dvson
Dr. Emmanuel Otheno Makerere Unversty College of Health Scences, Pathology Department
Dr. Carolyn Naksge Mulago Natonal Referral and Teachng
Hosptal
Dr. Judth Ajean Makerere Unversty College of Health Scences, Obstetrcs and Gynaecology
Department
Dr. Elzabeth Namukwaya Makerere Unversty College of Health Scences, Pallatve Care Unt
Dr. Vctora Walusansa Uganda Cancer Insttute Ms. Patence G. Kyomugsha Save A Woman Intatve
Dr. Mram Nakalembe Makerere Unversty College of Health Scences, Obstetrcs and Gynaecology
Department
Ms. Irene Betty Kzza Makerere Unversty College of Health Scences, Nursng Department
Dr. Ronald Mayanja Mbarara Unversty of scence &
Technology, Obstetrcs and Gynaecology
Department
Dr. Julus Bamwne Mnstry of Health, Ibanda Dstrct Health
Office
Dr. Gerald K. Ssektto Mnstry of Health, Nakasongola Dstrct Health Office
Ms. Rose Kwanuka Pallatve Care Assocaton of Uganda Ms. Hazel Nuun Uganda Women Cancer Support
Organsaton
Ms. Stella Ekallam PATH/Uganda Dr. José Jeronmo PATH/Seattle Dr. Vven Tsu PATH/Seattle Dr. Scott LaMontagne PATH/Seattle Ms. Jenny Wnkler PATH/Seattle
FOREWORD
Annually, an estmated 500,000 women are dagnosed wth cervcal cancer and more than 270,000 women lose ther lves to ths devastatng dsease.
Unfortunately, nearly 85 percent of the women who de lve n resource- poor countres lke Uganda, where there s lmted access to cervcal cancer preventon programmes (WHO, 2006). Vrtually all cervcal cancer cases (99%) are lnked to gental nfecton wth the Human paplloma vrus whch s the most common vral nfecton of the reproductve tract.
The burden of cervcal cancer n Uganda s enormous. Cervcal cancer rates n Uganda s one of the hghest n the world, and poor access to preventve screenng servces leads to hgh mortalty rates. Uganda’s ncdence and mortalty rates from cervcal cancer are at 45.6 per 100,000 women and 25 per 100,000 women respectvely (Parkn et al., 2002; Sankaranarayanan &
Ferlay 2006). In ths country, more than 80 percent of women are dagnosed wth late-stage dsease, when t s problematc or mpossble to treat. Cervcal cancer accounts for 40 percent of all cancers n Uganda, accordng to the Kampala cancer regstry, and s the leadng gynaecologcal cause of death n Ugandan women.
Organsed screenng and treatment programmes and effectve human Paplloma vrus vaccnaton are the best nterventons for preventng cervcal cancer, havng effectvely reduced cervcal cancer morbdty and mortalty rates n ndustralsed natons. Unfortunately, they are not wdely avalable n Uganda, save for a few ntatves n a handful of hosptals and health centres.
The Uganda Mnstry of Health recognses the devastatng mpact of cervcal cancer on the country, and has developed a health-sector polcy and strategc plan to gude mplementaton of a natonal cervcal cancer preventon and control programme that focuses on strengthenng exstng health systems to mprove accessblty to prmary and secondary preventon measures. The Mnstry s commtted to rollng out effectve cervcal cancer nterventons country wde as part of the NCD natonal polcy and medum term strategc plan.
It s my sncere hope that all stakeholders nvolved n the cervcal cancer preventon and control programme n Uganda wll utlse and adhere to ths strategc plan, to contrbute to a reducton n morbdty and mortalty from cervcal cancer.
Thank you,
____________________________
Dr. Sam Zaramba
Drector General of Health Servces Uganda Mnstry of Health
EXECUTIVE SUMMARY
The Strategc Plan for Cervcal Cancer Preventon and Control n Uganda descrbes the burden of cervcal cancer at global, regonal and natonal levels, and examnes the current strateges for cervcal cancer control n Uganda. It also detals the proposed strateges to acheve the set targets for cervcal cancer control n Uganda based on World Health Organsaton recommendatons.
Barrers to mplementaton of a country-wde cervcal cancer control programme are hghlghted, and a programme based on the varous levels of care, ncludng sector-wde approaches and communty nvolvement, are also outlned n the plan.
The broad prorty areas of the strategc plan are:
• Publc educaton and advocacy.
• Preventon of human Paplloma vrus (HPV) nfecton (prmary preventon).
• Screenng and treatment of cervcal precancerous lesons (secondary preventon).
• Treatment of cervcal cancer.
• Pallatve care for cervcal cancer.
• Programme montorng and evaluaton.
The core nterventons for preventon and control of cervcal cancer ndcated n the strategc plan nclude efforts to prevent HPV nfecton through HPV vaccnaton of grls 10–14 years old, for prmary preventon, and use of feasble cervcal screenng and pre-cancer treatment modaltes, such as vsual nspecton wth acetc acd and cryotherapy, for secondary preventon of cervcal cancer amongst women ages 25–49 years.
The strategc plan emphasses the need for cautous nvestment n cervcal cancer treatment modaltes such as surgery, chemotherapy, radotherapy, and pallatve care, because wth extensve publc educaton, HPV vaccnaton, and screenng and treatment of cervcal precancerous lesons, the demand for treatment and pallatve care servces wll be low.
Lastly, the strategc plan stpulates routne development of health servce data collecton tools, relevant research, and specal surveys for collectng data for montorng and evaluatng cervcal cancer preventon and control nterventons. The strategc plan further stpulates ntegraton of three key programme performance output ndcators nto the exstng health management nformaton system (HMIS) namely the number of grls/women mmunsed or screened, cervcal pre-cancer test-postve cases, and the
number of postve cases treated.
The goals are, by 2015:
• 90 percent of Ugandans wll be reached wth IEC materals about cervcal cancer.
• 80 percent of elgble grls ages 10–14 years wll be vaccnated aganst HPV n the mplementng dstrcts.
• 80 percent of elgble women ages 25–49 years wll be screened and treated for cervcal precancerous lesons.
• 80 percent of elgble women wth cervcal precancerous lesons wll be provded dagnostc servces.
• 10 percent of elgble cervcal cancer patents wll be provded surgcal treatment for nvasve cervcal cancer.
• 65 percent of elgble women wth cervcal cancer wll be provded radotherapy and chemotherapy servces.
• 25 percent of elgble cervcal cancer patents wll be provded pallatve care servces for mproved qualty of lfe.
To acheve these goals, the strategc plan stpulates the need for publc nvestment n advocacy and communcaton; procurement of HPV vaccnes, cryotherapy equpment, loop electrosurgcal excson procedure equpment, colposcopy equpment, surgcal theatre equpment, and radotherapy equpment; strengthenng of the cold chan system; tranng of health care provders; strengthenng of the HMIS; and relevant research; amongst others.
The health outcome ndcators of nterest are decreased prevalence of HPV nfecton, decreased ncdence of cervcal ntraepthelal neoplasm and cervcal cancer and mproved qualty of lfe and survval rates from cervcal cancer.
Prof. Anthony Mbonye giving a speech during the launch of HPV vaccine in Uganda. Centre is Hon Dr. Richard Nduhura, Minister of State for Health .
CHAPTER 1
BACKGROUND Introduction
Cervcal cancer s the uncontrolled growth of cells on the cervx. It s unque because t can take 10 to 20 years for nvasve cancer to develop after mild dysplasia is identified (WHO, 2006). This slow progression from early lesons to overt cancer provdes the bass for early screenng, detecton, and treatment.
Cervcal cancer s caused by nfecton wth the human Paplloma vrus (HPV).
HPV s one of the most common sexually transmtted nfectons (STIs). Most nfectons resolve spontaneously wthn one to two years, but some persst, becomng chronc, whch drves the cells of the cervx to grow abnormally, resultng n early precancerous lesons. Host factors lke early sexual debut (before age 16); closely spaced, frequent brths; and behavoural and envronmental factors may facltate cervcal cancer development.
Global burden
Accordng to the World Health Organsaton (WHO), cervcal cancer s the second most common cancer n women, globally, wth more than 500,000 new cases occurrng annually, nearly 85 percent of them n developng countres (2006). Cervcal cancer causes an estmated 273,000 deaths n women each year, and s one of the leadng causes of death n women n the developng world (Parkn et al 2003; WHO, 2006). It has also been noted to be the most common cancer of women n Sub-Saharan Afrca (Parkn et al 2003).
The hghest burdens of cervcal cancer have been reported n Asa, Southern Afrca, Central Amerca, Eastern Afrca, and South Amerca. In all of these regons, the rate s more than 40 cases per 100,000 women (Parkn et al., 2002; Sankaranarayanan & Ferlay 2006).
Figure 1. Number of cases and incidence of cervical cancer in 2002.
Burden of cervical cancer in Uganda
The ncdence rate for cervcal cancer n Uganda s 45.6 per 100,000 women (WHO, 2006), whch s one of the world’s hghest age-adjusted cervcal cancer ncdence rates. In Uganda, cervcal cancer s ranked as the leadng cancer n women, accountng for 40 percent of all cancers recorded n the Kampala cancer regstry.
Figure 2. New cancer cases in Uganda: estimates for 2002.
Figure 3. Ten leading causes of cancer deaths in Uganda: estimates for 2005.
Mulago Natonal Referral Hosptal s the man referral hosptal for cervcal cancer management and pallatve care n Uganda. Clncal reports for 2006 ndcate 30% bed occupancy on the Gynecologcal wards by cervcal cancer patents of whom 80% were dagnosed wth late stage dsease and could benefit from radiotherapy offered in Mulago (Katahoire et al 2008).
Katahore et al further observed that 35% (484/1400) of patents seen n the gynecology out patents had suspected cervcal cancer. The 2007 hosptal
records revewed revealed that patents wth cervcal cancer had 63.5% bed occupancy ndcatng an ncrease. Deaths due to cervcal cancer of the total gynecologcal deaths were at 70% (Katahore et al 2008). She further noted that nvestgatve surgery for cervcal cancer formed 40% of the theatre workload. The majorty of patents dagnosed had stage III/IV dsease classified as late stage disease (72%). This underscores the high burden that appears to be on the ncrease. Regardng the age dstrbuton of the patents most were between 41-50 years (40%). Noteworthy s the fact that 20% of patents seen were between 31-40years. There were also a number of patents above 70 years, whch s not typcal. Ths data s mportant f one s to plan an nterventon wth lmted resources. Earler reports n late 1980S ndcate that annually, cervcal cancer s responsble for 2.4–5.1% of all gynecologcal admssons and up to 65 percent of gynaecology oncology unt bed occupancy n Uganda natonal referral hosptal, Mulago (Okong 1989;
Kasuja 1988). By the tme of dagnoss, more than 80 percent of patents have advanced dsease, whch s assocated wth ncreased morbdty and low five-year survival rates (Okong 1989; Kasuja 1988).
The HIV/AIDS pandemc has worsened the pcture of the cervcal cancerhe HIV/AIDS pandemc has worsened the pcture of the cervcal cancer dsease. Women wth HIV have been found to have an ncreased ncdence of cervcal ntraepthelal neoplasa (CIN), the precursor leson for ICC, probably due to HIV-assocated mmunosuppresson, and ICC s recognzed as an AIDS-defining illness (Zorrilla et al., 1991; Sekirime & Gray 2007). It s estmated that wthout urgent acton, deaths due to cervcal cancer wll rse by almost 25 percent n the next ten years n developng countres due to the HIV/AIDS epdemc (Zorrlla et al., 1991; Sekrme & Gray 2007).
Figure 4. Five-year relative survival of cervical cancer patients, Uganda and the United States (amongst black Americans), 1993–
1997.
5 yr Relative Survival of Cervical Cancer patients, Uganda & USA – Black
Americans 1993-97
British Journal of Cancer. 2005;92(9):1808–1812.
Most women who de from cervcal cancer are n the prme of ther lfe, thus
robbng countres of ther mmense contrbuton to socal and economc development. Cancer control programmes can go a long way toward preventng cervcal cancer and reducng the unnecessary morbdty and loss of lfe from the dsease.
The overall goal of the strategc plan s to establsh a framework for a comprehensve cervcal cancer preventon and control programme n Uganda.
Determinants of the burden of cervical cancer
The burden of cervcal cancer s not merely represented by the alarmng figures. There is a lack of community awareness around the disease, and knowledge regardng cervcal cancer amongst health workers who should be engagng n publc educaton s low. These factors, coupled wth mnmal access to avalable screenng servces, whch are not routne, contrbute to late patent presentaton. In addton, data on cervcal cancer are insufficient. Available data are facility based, therefore not comparable, and no communty-based data exst.
Risk factors to HPV infection and cervical cancer
There s evdence that the followng factors ncrease the rsk of developng cervcal cancer:
• Rsk of acqurng HPV nfecton s hghest soon after sexual actvty begns, and n some cases, t has a second peak amongst women at menopause.
• HPV s sexually transmtted; however, penetratve sex s not requred for transmsson. Skn-to-skn gental contact s a well-recognsed mode of HPV transmsson.
• Sexual ntercourse wthout condom use ncreases the rsk of becomng nfected wth HPV.
• Persstent nfecton wth HPV types 16 and 18, whch causes the majorty of cervcal cancer cases ncreases the rsk of dsease development.
• HIV-nfected ndvduals are at hgher rsk of HPV nfecton, and persstence of the nfecton, even when they are on antretrovral therapy (Blossom et al. 2007)
• The rsk of HPV exposure appears to ncrease wth the number of lfetme sexual partners of women or men (Wner et al., 2003).
• Age at first sexual contact: In all regions of the world, age has been found to be a strong, consstent rsk factor for HPV nfecton. Intaton of sexual actvty at a young age s a rsk factor for HPV nfecton (Clfford et al., 2005).
Factors that contrbute to development of cervcal cancer after nfecton with HPV include immune suppression, multi-parity, early age at first delvery, cgarette smokng, long-term use of hormonal contraceptves, and co-nfecton wth Chlamyda trachomats or herpes smplex vrus.
Prevention of HPV infection and cervical cancer Primary prevention
Cervcal cancer s prmarly caused by HPV, a vrus transmtted through sexual contact; therefore, prmary preventon of cervcal cancer nvolves preventon of HPV.
Ths can be acheved through socal mechansms such as behavour change, or through bologcal mechansms such as HPV vaccnaton. Abstnence from sex and condom use s lkely to reduce transmsson of HPV. Vaccnaton aganst HPV has been proven to prevent the types of HPV that cause the majorty of cervcal cancer cases, therefore reducng the occurrence of the dsease. However, HPV vaccnes are stll very expensve therefore beyond reach for low-ncome countres such as Uganda.
Secondary prevention
Several methods are avalable for detecton of forms of cervcal pre-cancer, ncludng drect vsual nspecton of the cervx aded by chemcals lke 5 percent acetc acd and odne (vsual nspecton wth acetc acd [VIA]
and vsual nspecton wth Lugol’s odne [VILI]), whch cause recognsable colour changes. Other screenng technques, lke cytology (conventonal Pap smears, lqud-based cytology) and HPV DNA testng, and treatment of pre-cancer usng cryotherapy or the loop electrosurgcal excson procedure (LEEP), are helpful n reducng the burden of cervcal cancer. However, these servces are avalable n very few health centres n Uganda, contrbutng to low screenng rates and unequal dstrbuton of servces n the country.
Research s ongong to determne a system that wll work best, and be cost effective, accessible, and affordable. However, there is insufficient funding for establshng and mantanng screenng and treatment facltes for cervcal cancerous lesons at levels of health care.
Cancer treatment and palliative care
Ideally, the dagnoss of cervcal cancer should be done through hstopathologcal examnaton manly at hgher-level health care unts (general, regonal referral, and natonal referral hosptals). Dagnoss and treatment calls for specalsed tranng and the use of sophstcated equpment, and requres hghly experenced personnel, all of whch are n short supply. Uganda does not provde tranng n gynaecologcal oncology.
Furthermore, there is insufficient funding for establishing and maintaining hstopathology laboratores at the regonal referral hosptal level.
Most patents present wth advanced dsease, for whch treatment s very costly n terms of equpment, personnel, and tme. Methods avalable for treatment n Uganda nclude surgery, radotherapy, chemotherapy, and pallatve care. Early-stage dsease s treated by surgery and followed on occason by radotherapy. Few patents present early, and surgery s possble only n regonal and natonal referral hosptals.
Pallatve care s an essental element of cervcal cancer treatment. Emotonal support for patents and ther famles s a crtcal component of therapy.
Once a woman s dagnosed wth untreatable cervcal cancer, or treatment has failed, she qualifies to receive palliative care. This care helps to avoid unnecessary sufferng and mprove the qualty of lfe of women wth cervcal cancer and ther famles. It encompasses emotonal support, symptom control, end-of-lfe care, and bereavement support. It also addresses the physcal, psychosocal, and sprtuals needs of patents and ther famles.
Pallatve care s currently provded by a lmted number of health facltes n Uganda. Uganda does not have enough capacty n terms of human resources and supples for provson of pallatve care throughout the country.
Hospce Uganda has taken a leadng role n supportng provson of pallatve care n the country. Hospce Uganda s founded n 1993 and t has workedHospce Uganda s founded n 1993 and t has worked wth the Uganda Mnstry of Health to make morphne – purchased n powder form at less than one tenth of one US cent per mllgram and mxed on ste -- avalable to health facltes across much of the country by 1995.
In its first nine years of operation, Hospice Uganda served 4,000 patients – an extraordnary number, yet only a mnute proporton of those n need.
In 2002, the organzaton began offerng a dstance learnng dploma course n pallatve care to rase awareness and ncrease capacty among health professonals wthn Uganda and across the sub-contnent.
Current efforts in cervical cancer prevention and control in Uganda Programmes and servces offered n Uganda for preventon and control of cervcal cancer vary based on locaton and organsaton; however, Uganda s workng to establsh an organsed cervcal cancer screenng programme.
PATH, WHO, and the Uganda Women’s Health Intatve have opened screenng clncs n a few regons of the country, but ther efforts need to be ncreased to cover all regons of the country. Masaka, Mbarara, Ksoro and Mbale Regonal Referral Hosptals are three of the few hosptals currently provdng screenng and treatment for cervcal precancerous lesons usng the sngle-vst approach. Other screenng clncs are n Kampala Cty Councl and the Mldmay Centre. None of the centres have ncorporated an HIV testng component nto ther cervcal cancer screenng programme.
Figure 5. Phased approach to integrating cervical cancer programmes into existing services.
Gulu Hospital
Currently, cytology-based screenng s conducted upon request n a few selected hosptals, and a moble van has been provded to Mulago Natonal Referral and Teachng Hosptal, whch to date, has facltated the screenng of 500 women. These efforts do not meet overall demand n the country.
Ideally, all levels of health care, from health centre III upward, should routnely provde cervcal cancer screenng and treatment of precancerous lesons.
Other cervcal cancer ntatves, provded by cvl socety, manly focus on advocacy, communty moblsaton, and senstsaton for screenng.
Vaccnaton plots have been ntated n Nakasongola and Ibanda dstrcts for grls aged 10 years. There are plans to roll out ths plot, but plans to ensure sustanablty need to be developed.
Cervcal cancer treatment s manly provded n regonal referral hosptals, especally pallatve care and surgery on a mnmal scale. The Mulago hosptal offers surgcal treatment, chemotherapy, and pallatve care, and t s the only hosptal that provdes radotherapy. Treatment coverage s grossly insufficient.
Resources
Currently, health care financing comes from the Government of Uganda and a few development partners, prmarly the Unted Natons Populaton
Fund, WHO, and PATH. Human resources for health care n the form of screenng personnel, cytotechncans, and pathologsts are nadequate. Ths s further compounded by nadequate nfrastructure, equpment, supples, and financing for cervical cancer control.
Rationale for the strategic plan
Recognsng that Uganda has one of the world’s hghest ncdences of cervcal cancer, a leadng cause of cancer death n women, and knowng that cervcal cancer can be prevented, t s mperatve that Uganda establsh a focused plan to deal wth ths burden.
Wthout a natonal screenng programme, current strateges for preventon and control of cervcal cancer are far from deal, and have had lttle mpact on reducng morbdty and mortalty from the dsease. Efforts to prevent development of cancer and to provde approprate treatment and pallatve care are fragmented and poorly coordnated. Furthermore, resources avalable for the already proven cost-effectve nterventons are mnmal.
Therefore, there s a need to develop a strategc plan to gude and coordnate mplementaton of programmes and servces and enable the country to rase resources to ensure avalablty of servces at all levels of care.
Implementation modalities
Overall coordnaton of mplementaton of the cervcal cancer preventon and control programme wll be conducted by the Mnstry of Health. Servce provision will be offered by level as specified below.
Vllage health teams, communty-based organsatons, and communty leaders:
• Communty moblsaton and senstsaton.
Health centre II:
• Health educaton.
• HPV vaccnaton of target groups.
• Referrals for screenng and treatment.
Health centre III:
• Health educaton and counsellng.
• HPV vaccnaton of target groups.
• Cervcal screenng usng VIA.
• Referral for cryotherapy.
• Basc pallatve care.
• Referrals for LEEP, cervcal cancer dagnostc tests, surgery and radotherapy.
Health centre IV/health sub-dstrct:
• Health educaton and counsellng.
• HPV vaccnaton of target groups.
• Cervcal screenng usng VIA.
• Cryotherapy treatment for cervcal pre-cancerous lesons.
• Referrals for LEEP, cancer dagnoss, surgery, and radotherapy.
• Budgetng for cervcal actvtes for the health sub-dstrct.
Dstrct hosptal:
• Health educaton and counsellng.
• HPV vaccnaton of target groups.
• Cervcal screenng usng VIA or cytology or both.
• Colposcopy.
• Cryotherapy.
• LEEP.
• Surgcal treatment (f possble).
• Referral for Cytology and hstology for cancer dagnoss and stagng.
Regonal and natonal referral hosptals:
• Health educaton and counsellng.
• HPV vaccnaton of target groups.
• Cervcal screenng usng VIA or cytology or both.
• Colposcopy.
• Cryotherapy.
• LEEP.
• Cytology and hstology for cancer dagnoss and stagng.
• Surgery for early nvasve cancer.
• Techncal support of lower health unts.
• Radotherapy.
• Chemotherapy.
Dstrct health teams:
• Budgetng for cervcal cancer preventon and control actvtes for the dstrct.
• Techncal support of health unts.
• Communty moblsaton and senstsaton.
• Moblsaton of human resources.
• Assstng n plannng for HPV vaccnaton of target groups.
• Supportve supervson and montorng and evaluaton.
Mnstry of Health:
• Development/revew of polcy on cervcal cancer preventon and control.
• Communty moblsaton and senstsaton.
• Development of the natonal operatonal plan on cervcal cancer preventon and control.
• Mobilisation of resources (financial, material).
• Organsaton of vaccnaton campagns n conjuncton wth dstrcts.
• Supportve supervson and montorng and evaluaton.
Development partners:
• Mobilisation of resources (financial, material).
• Provson of techncal support.
Cvl socety organsatons:
• Communty moblsaton and senstsaton.
• Provision of palliative care in conjunction with district health offices.
Parlamentarans:
• Communty moblsaton and senstsaton.
• Advocatng for further resource allocaton for cervcal cancer preventon and treatment.
Table 1. Proposed standard services for cervical cancer prevention and control in Uganda.
Health facility level Services required (standard) Equipment required (standard) Regional and
national referral hospitals
• Health education/social mobilisation
• HPV vaccination
• Cervical screening using VIA or cytology
• Colposcopy
• Cryotherapy
• LEEP
• Surgery and
• Radiotherapy (if available)
• Colposcopy equipment
• Cryotherapy equipment
• Gas tanks
• Electrosurgical generator
• Cervical screening equipment (speculums, consumables, and supplies)
• LEEP equipment
• Radiotherapy unit District hospitals • Health education/social mobilisation
• HPV vaccination
• Cervical screening using VIA
• Cryotherapy
• LEEP
• Surgical treatment (if possible)
• Referral for radiotherapy
• Colposcopy equipment
• Cryotherapy equipment
• Gas tanks
• Cervical screening equipment (speculums, consumables, and supplies)
Health centre IV • Health education
• HPV vaccination
• Screening using VIA
• Cryotherapy
• Referrals for LEEP, surgery, and/or radiotherapy
• Cryotherapy equipment
• Gas tanks
• Cervical screening equipment (speculums, consumables, and supplies)
Health centre III • Health education
• HPV vaccination
• Screening using VIA
• Referral for cryotherapy
• Referrals for LEEP, surgery, and/or radiotherapy
• Cryotherapy equipment
• Gas tanks
• Cervical screening equipment (speculums, consumables, and supplies)
Health centre II • Health education and mobilisation
• HPV vaccination
• Referrals for screening and treatment
• Educational materials
CHAPTER 2
VISION, GOAL, OBJECTIVES, AND IMPLEMENTATION STRATEGY Vision
Ugandan women free from cervcal cancer.
Goal
To reduce HPV ncdence and or prevalence, cervcal cancer ncdence and or prevalence and mortalty, mprove qualty of lfe and survval rates through educaton and advocacy, HPV vaccnaton (prmary preventon), screenng and treatment of cervcal precancerous lesons (secondary preventon), treatment wth surgery, rado-chemotherapy and pallatve care servces.
Objectives
• Rase awareness around and advocate for cervcal cancer preventon and treatment n Uganda.
• Reduce the ncdence and prevalence of HPV n Uganda through vaccnaton.
• Decrease cervcal cancer ncdence by 50 percent through screenng of all elgble women and treatment of cervcal precancerous lesons.
• Increase access to cervcal pre-cancer screenng and treatment servces amongst elgble women ages 25–49 years by provdng vsual nspecton and cryotherapy n lower-level health facltes, and/or VIA, cryotherapy, cytology, hstology, colposcopy, LEEP, or LLETZ (large loop excson of the transformaton zone) at hgher-level health facltes.
• Buld nsttutonal and techncal capacty at the regonal and natonal referral levels n order to perform approprate surgery for cervcal cancer.
• Increase the one-year cervcal cancer survval rate through dagnoss and effectve treatment, ncludng surgery, chemotherapy, radotherapy, and pallatve care.
• Improve the qualty of lfe of patents wth cervcal cancer and ther famles through management of pan and other physcal, psychologcal, socal, and sprtual problems.
Targets by 2015
• 90 percent of Ugandans wll be reached wth IEC materals about cervcal cancer.
• 80 percent of elgble grls ages 10–14 years n the mplementng dstrcts
wll be vaccnated aganst HPV .
• 80 percent of elgble women ages 25–49 years wll be screened and treated for cervcal precancerous lesons.
• 80 percent of elgble women wth cervcal precancerous lesons wll be provded dagnostc servces.
• 10 percent of elgble cervcal cancer patents wll be provded surgcal treatment for nvasve cervcal cancer.
• 65 percent of elgble women wth cervcal cancer wll be provded radotherapy and chemotherapy servces.
• 25 percent of elgble cervcal cancer patents wll be provded pallatve care servces for mproved qualty of lfe.
Implementation strategy
The mplementaton strategy for scalng up cervcal cancer preventon and control wll emphasse galvansng efforts of all stakeholders, ncludng the Mnstry of Health. Ths approach wll focus on:
• The Natonal Techncal Advsory Commttee, guded by clear terms of reference, whch wll act on behalf of the Mnstry of Health and all stakeholders. Ths group wll gude mplementaton of the strategc plan, oversee tranng of health care provders, and drect qualty assurance functons. It wll revew the current polcy on cervcal cancer screenng and treatment and regularly update the polcy based on avalable new evdence. The commttee wll hold regular meetngs wth stakeholders and polcymakers, and techncal plannng meetngs wth the Mnstry of Health and all relevant departments of health, ncludng the drectorate of clncal servces, health educaton and promoton, non-communcable dseases, reproductve health, dsablty, and the resource centre. The committee will ensure that cervical cancer prevention and control fits n wth the Mnstry of Health strategy for reproductve health and s effectvely ntegrated at the polcy, programmatc, and health servce delvery levels, and that resources are avalable for sustanablty.
• The Mnstry of Health, whch wll carry out a needs assessment to dentfy the major gaps to address for the strategc plan to succeed, ncludng tranng needs and servce provson sklls mprovement amongst health care provders, nfrastructure gaps, avalable capacty to provde cervcal cancer screenng and treatment servces, qualty assurance needs and montorng and evaluaton requrements, and level of awareness around cervcal cancer and ts preventon.
• Infrastructure mprovements, whch wll be carred out based on the findings of the needs assessment and the projected client load. This
wll focus on establshment of facltes for VIA, colposcopy (where approprate), and treatment wth cryotherapy and LEEP at approprate health faclty levels. The Mnstry of Health wll strengthen surgcal servces at regonal referral hosptals to meet the needs of the antcpated ncrease n clents requrng surgery, mprove theatre facltes and anaesthetc servces, and ensure the necessary supples.
• Tranng of health care provders, whch wll begn wth a tranng-of- traners course for all gynaecologsts, who wll then provde local tranng n VIA and cryotherapy. Gynaecologsts wll also be traned to provde colposcopy, LEEP, and other treatment servces for cervcal precancerous lesions. They will be provided with on-the-job training to perform difficult surgery for nvasve cervcal cancer. For dstrct hosptals and health centres III/IV, the approach wll be to tran health workers n VIA and cryotherapy. The tranngs wll use lectures, demonstratons, audo/
vdeo presentatons, and hands-on practce n screenng. Pre/post-test evaluatons wll assess performance. Stes wll be traned n the order n whch mplementaton wll occur.
• A natonal advocacy campagn, whch wll be amongst the key preparatory activities. This is justified to ensure increased awareness around cervical cancer and screenng and treatment servces. Communty moblsaton and educaton, as well as clent counsellng, wll be used to elmnate myths and msconceptons assocated wth cervcal cancer, and to ensure support for effectve servce utlsaton. Advocacy wll target polcymakers, and communty moblsaton and educaton wll focus on clents of cervcal screenng and pre-cancer treatment servces. Provders wll support polcy formulaton, programmng, and updates whlst also supportng resource re-allocaton for preventon programmes.
• Elmnatng barrers to screenng and vaccnaton, whch nclude lack of awareness due to under-apprecaton of the burden of cervcal cancer, and poor understandng of the prncples of effectve preventon.
• Adoptng broad-based advocacy efforts to acheve programme and polcy support for cervcal cancer preventon nterventons.
• Ensurng an enablng polcy envronment, treatment gudelnes, and servce standards.
• Engagng decson-makers and stakeholders throughout the process to ensure that supportive policies and regulations are developed to reflect natonal realtes.
• Communty advocacy campagns, whch wll be held regonally and
natonally to target clents, as well as people who have the power to sway decson-makng and uptake of servces.
• Intally, strengthenng of screenng servces at Mulago Natonal Referral and Teachng Hosptal and the regonal referral hosptals. Servces wll then be extended to dstrct and nongovernmental hosptals n the respectve catchment areas of the referral hosptals.
• Cervcal pre-cancer screenng and treatment clncs, whch wll be establshed to provde screenng servces n a phased manner by regon.
Clnc protocol wll nclude communty moblsaton; health educaton;
consent; screenng wth VIA/VILI; colposcopy where avalable; bopsy when applcable; and cryotherapy, LEEP, or surgery. The servces provded wll depend on the level of the health care faclty and avalable resources. Mulago Natonal Referral and Teachng Hosptal wll provde VIA/VILI, cryotherapy or LEEP, surgery and/or radotherapy, and pallatve care. Regonal referral hosptals wll provde all servces, some wll have radotherapy. Health centre IVs, dstrct and nongovernmental hosptals wll provde VIA/VILI and cryotherapy. Health centres III wll carry out VIA and then refer clents wth cervcal precancerous lesons to the nearest dstrct or regonal referral hosptal for further care.
• As much as possble, ntegraton of cervcal pre-cancer screenng and treatment of precancerous lesons nto exstng servces, such as breast cancer screenng, gynaecologcal outpatent servces, voluntary HIV counsellng and testng, antretrovral therapy, famly plannng, and postnatal servces to ensure sustanablty usng avalable resources.
Vaccnaton wll be delvered through the Uganda Natonal Expanded Programme on Immunsaton (UNEPI).
• Utlsaton of UNEPI’s cold chan nfrastructure. Vaccnaton wll be conducted either in schools or on Child Health Days Plus. (The final roll-out strategy will depend on demonstration project findings.)
• Implementng an effectve communcaton and moblsaton strategy for both women and men. Ths strategy wll be developed before commencement of screenng and mproved upon thereafter. Informaton, educaton, and communcaton (IEC) materals are almost ready for plotng. The advocacy component wll focus on poltcal leaders, polcymakers, Mnstry of Health techncal personnel, other relevant mnstres that mpact health, and communty servce organsatons. The communty moblsaton strategy wll be mplemented at the communty level for all women and ther spouses. Other avenues to reach women wll nclude campagns nvolvng local communty leaders, churches, mosques, women’s groups, radio messages, and/or the use of film vans
or publc address systems at the communty level.
• Montorng, evaluaton, and qualty assurance, whch wll be ncluded n the tranng programme for all health workers, to ensure the screenng programme meets ts objectves. Montorng and evaluaton at the dstrct, regonal, and natonal levels wll be conducted by the Natonal Techncal Advisory Committee. New sites will be supervised monthly for the first three months, then quarterly for up to one year and sem-annually thereafter. In the long run, montorng and evaluaton wll be ntegrated nto the exstng supportve supervson strategy, and cervcal cancer data wll be ntegrated nto the exstng health management nformaton system (HMIS).
Implementation phases
Implementaton of HPV vaccnaton, cervcal pre-cancer screenng, and the pre-cancer treatment programme wll be phased as follows.
First year: 2011
• All governmental, nongovernmental, and prvate health facltes n two plot dstrcts wll mplement a brdgng programme for HPV vaccnaton.
• All regonal and natonal referral hosptals wll start cervcal pre-cancer screenng and treatment programmes.
Second year: 2012
• All governmental, nongovernmental, and prvate health facltes n two plot dstrcts wll contnue wth mplementaton of the brdgng HPV vaccnaton programme.
• All dstrct hosptals wll mplement cervcal pre-cancer screenng and treatment programmes.
Third year: 2013
• All governmental health facltes throughout the country wll mplement an HPV vaccnaton programme.
• All health centres IV wll mplement cervcal pre-cancer screenng and treatment programmes.
• All nongovernmental and prvate hosptals wll mplement cervcal pre- cancer screenng and treatment programmes.
Fourth year: 2014
• All governmental, nongovernmental, and prvate health facltes throughout the country wll mplement an HPV vaccnaton programme.
• All health centres III wll mplement cervcal pre-cancer screenng and referral for treatment programmes.
Fifth year: 2015
• All health centre II wll mplement communty moblzaton and senstzaton for cervcal cancer preventon programmes.
• Evaluaton of the 2010-2014 strategc plan for cervcal cancer preventon and control.
Expected Health Outcomes
• Decreased prevalence of HPV nfecton among women both vaccnated and non-vaccnated
• Decreased ncdence of cervcal ntraepthelal neoplasm (CIN) among women wth hgh rsk HPV nfecton
• Decreased ncdence of cervcal cancer
• Increased 1-year and or 5-year survval rates from cervcal cancer
• Improved qualty of lfe of cervcal cancer patents
CHAPTER 3
PUBLIC EDUCATION AND ADVOCACY FOR CERVICAL CANCER PREVENTION AND CONTROL
Introduction
Cervcal cancer s the most common cancer n Ugandan women, and one ofthe most common cancer n Ugandan women, and one ofone of the leadng causes of morbdty and mortalty amongst women n Uganda.
There s a need to ncrease awareness around the cause of cervcal cancer, thea need to ncrease awareness around the cause of cervcal cancer, theneed to ncrease awareness around the cause of cervcal cancer, thearound the cause of cervcal cancer, thethe cause of cervcal cancer, the preventable nature of the dsease, and avalablty of screenng and treatment servces.
Health education messages will reflect national policy and will be culturally approprate and consstent at all levels of the health care system (ncludng the communty level). Health promoton, ncludng educaton and counsellng of women and men, wll be an ntegral part of the cervcal cancer control, wll be an ntegral part of the cervcal cancer control wll be an ntegral part of the cervcal cancer controle cervcal cancer control cervcal cancer control strategy. Health workers wll be traned to dscuss sexualty n a nonjudgmental way, and be able to address behavoural ssues related to cervcal cancer and, and be able to address behavoural ssues related to cervcal cancer and and be able to address behavoural ssues related to cervcal cancer and HPV.
HPV s a common vrus whch s transmtted by penetratve and non- penetratve sexual contact. A large proporton of women and men are nfected wth HPV at some tme n ther lfe; therefore, women, men, and adolescents; therefore, women, men, and adolescents therefore, women, men, and adolescents, women, men, and adolescents women, men, and adolescents, and adolescents and adolescents need to know about the vrus and how t s transmtted, and apprecate the factors that are assocated wth the development of cervcal cancer n women nfected wth HPV. Strateges wll be developed to dssemnate nformaton on behavour change, such as reducng the number of sexual partners, delayngchange, such as reducng the number of sexual partners, delayngsuch as reducng the number of sexual partners, delayngthe number of sexual partners, delayngnumber of sexual partners, delayngsexual partners, delayngpartners, delayng sexual debut, and usng condoms., and usng condoms. and usng condoms.
Communty educaton wll take place n a varety of settngs, such as n relgous, such as n relgous such as n relgous or communty groups, n schools, at sports actvtes, on Health Awareness Days, or wthn the context of a screenng campagn. Varous members of thewthn the context of a screenng campagn. Varous members of then the context of a screenng campagn. Varous members of the communty, ncludng medcal professonals, teachers, communty leaders,, ncludng medcal professonals, teachers, communty leaders, ncludng medcal professonals, teachers, communty leaders,ncludng medcal professonals, teachers, communty leaders,medcal professonals, teachers, communty leaders, health promoters, tradtonal healers, and mdwves, wll be traned to delver, and mdwves, wll be traned to delver and mdwves, wll be traned to delver, wll be traned to delver wll be traned to delver key messages. Wrtten materals, rado and televson messages, newspaper artcles, and pamphlets wll be used to reach people n the communty.
There has been some publc educaton on the need to screen for cervcal cancer,on the need to screen for cervcal cancer,the need to screen for cervcal cancer, n selected health facltes and communtes where screenng servces are available. There has also been community education on the benefits of HPV vaccnaton and screenng servces at the natonal level; however, t has been; however, t has been however, t has been most ntensve n the two dstrcts where mplementaton s takng place.
Natonal advocacy for ncreasng resources for cervcal cancer screenng and
treatment servces has been underway. There s a need for sustaned advocacy efforts to realse the desred quantty and qualty of servces.s to realse the desred quantty and qualty of servces. to realse the desred quantty and qualty of servces.
Ths chapter hghlghts the objectves, strateges, core nterventons, actvtesstrateges, core nterventons, actvtesore nterventons, actvtesnterventons, actvtesnterventons, actvtesactvtes and requred resources for an effectve advocacy, communty moblsaton,requred resources for an effectve advocacy, communty moblsaton,moblsaton, and senstsaton campagn.
Goal
• 90 percent of Ugandans wll be reached wth IEC materals about cervcal cancer.
Strategic objectives
• Rase awareness around cervcal cancer preventon, control, early dagnoss, and treatment., and treatment. and treatment..
• Increase demand for utlsaton of cervcal cancer preventon, control, dagnostc, and treatment servces., and treatment servces.and treatment servces..
• Increase allocaton of resources to mprove access to qualty cervcal cancer preventon, control, dagnostc, and treatment servces., and treatment servces. and treatment servces..
Strategies
• Senstze women, men, adolescents, polcymakers, health care workers, adolescents, polcymakers, health care workers,adolescents, polcymakers, health care workers, polcymakers, health care workers,makers, health care workers, care workers,care workers,, and opnon leaders about the causes of cervcal cancer and effectve about the causes of cervcal cancer and effectveabout the causes of cervcal cancer and effectve methods of preventon.
• Senstse communtes about cervcal cancer preventon servces, about cervcal cancer preventon servces, ncludng screenng, dagnostcs, and avalable treatment optons, andscreenng, dagnostcs, and avalable treatment optons, and, and avalable treatment optons, and and avalable treatment optons, and, and and where to access them to ncrease servce utlzaton.
• Lobby the government to allocate necessary resources to cervcal cancer preventon, control, dagnostc, and treatment servces to ensure they, and treatment servces to ensure they and treatment servces to ensure they are effectve, avalable, affordable, and accessble to those who need, and accessble to those who need and accessble to those who need them..
Core interventions
• Behavor change communcaton..
• Advocacy.
• Communty moblsaton.moblsaton.
Activities
Behavior change communication The public
• Desgn, develop, pre-test, and dssemnate IEC materals to raseIEC materals to rase materals to rase awareness around cervcal cancer, methods of preventon, and control,, and control, and control,,
ncludng HPV vaccnaton, cervcal screenng, dagnostcs, anddagnostcs, and treatment. These will include leaflets and posters, which will need to be, whch wll need to be whch wll need to be translated nto 11 key local languages.
• Develop and mplement mass meda campagns, ncludng rado and, ncludng rado and ncludng rado and televson messages, rado advertsements, and bllboard advertsng to, and bllboard advertsng to and bllboard advertsng to rase awareness around cervcal cancer preventon and control.
• Hold talks and presentatons wth survvors to rase awareness aroundand presentatons wth survvors to rase awareness aroundpresentatons wth survvors to rase awareness aroundwth survvors to rase awareness aroundsurvvors to rase awareness around cervcal cancer, and methods of preventon, control, and treatment., and treatment. and treatment.
• Hold meetings pioneered by peer educators specifically targeting men, to educators specifically targeting men, toeducators specifically targeting men, to, to to senstze them to support ther wves to attend cervcal cancer screenng and ther daughters to receve HPV vaccnatons.
• Partner wth popular local artsts to develop songs about cervcal cancer preventon and control.
• Develop youth-focused IEC materals to rase awareness around cervcalIEC materals to rase awareness around cervcal materals to rase awareness around cervcal cancer, its prevention, and the benefits of HPV vaccination., and the benefits of HPV vaccination. and the benefits of HPV vaccination..
• Senstze the publc about cervcal cancer preventon, ncludng HPV, ncludng HPV ncludng HPV vaccnaton, the ABC strategy (Abstan, Be fathful, use Condoms [whch offers partal protecton]), and screenng.
Women with cervical cancer and their families
• Hold workshops or counselng sessons for women wth cervcal cancer regardng treatment optons for dsease management, ncludng pallatvetreatment optons for dsease management, ncludng pallatveoptons for dsease management, ncludng pallatvencludng pallatve care..
• Hold workshops or counselng sessons wth famly members of cervcal cancer patents to demystfy and reduce stgma of the dsease.the dsease.dsease..
Health workers
• Conduct tranngs wth health care workers on messagng and care workers on messagng andcare workers on messagng and communcaton on cervcal cancer preventon, control, dagnoss, and, and and treatment..
• Orentate dstrct health management teams to enable n-charges n health settngs to talk to the publc about cervcal cancer preventon, early dagnoss, and control, ncludng ensurng they mplement approaches, and control, ncludng ensurng they mplement approaches and control, ncludng ensurng they mplement approaches, ncludng ensurng they mplement approaches ncludng ensurng they mplement approaches for male nvolvement..
Other key organizations and individuals
• Identfy and moblze cervcal cancer champons, who may nclude communty or relgous leaders, cervcal cancer survvors, or others wth, or others wth or others wth influence.
• Hold tranng workshops for cervcal cancer champons, vllage health
teams, meda organsatons, women’s groups, HIV/AIDS groups, and organsatons, women’s groups, HIV/AIDS groups, and, women’s groups, HIV/AIDS groups, and/AIDS groups, andAIDS groups, and, and and other communty-based organsatons to enable them to provde accurate nformaton to ther communtes about cervcal cancer preventon and control.
• Desgn, develop, pre-test, and dssemnate fact sheets for use by cervcal sheets for use by cervcalsheets for use by cervcaluse by cervcalcervcal cancer champons and other key organzatons to renforce tranng.
• Integrate cervcal cancer preventon messages nto the ABC strategy for HIV/AIDS and other STIs./AIDS and other STIs.AIDS and other STIs.
Advocacy
• Establsh advocacy group(s) to lobby at dfferent levels, targetng dstrct,, targetng dstrct, targetng dstrct, regonal, and natonal polcymakers on cervcal cancer preventon, polcymakers on cervcal cancer preventon,makers on cervcal cancer preventon, control, dagnoss, and treatment ssues. Group(s) should nclude, and treatment ssues. Group(s) should nclude and treatment ssues. Group(s) should ncludeGroup(s) should ncluderoup(s) should nclude academcans, clncans, representatves of professonal bodes, medaans, clncans, representatves of professonal bodes, medas, clncans, representatves of professonal bodes, meda organsatons, communty and relgous leaders, parlamentarans, andand cervcal cancer survvors..
• Desgn, develop, and pre-test advocacy materals, ncludng fact sheets,, and pre-test advocacy materals, ncludng fact sheets, and pre-test advocacy materals, ncludng fact sheets,, ncludng fact sheets, ncludng fact sheets, sheets,sheets, survvor testmonals, rado and televson documentares, common queston-and-answer sheets, and collateral materals.-and-answer sheets, and collateral materals.and-answer sheets, and collateral materals.-answer sheets, and collateral materals.answer sheets, and collateral materals.and collateral materals.collateral materals..
• Hold workshops to lobby polcymakers and other key stakeholders atpolcymakers and other key stakeholders atmakers and other key stakeholders at the natonal level to moblse funds to ensure effectve, affordable, andnatonal level to moblse funds to ensure effectve, affordable, and, and and accessble cervcal cancer preventon, control, dagnostc, and treatment, and treatment and treatment servces for all who need them..
o Preventon and control: Advocate for roll-out of HPV vaccnaton to: Advocate for roll-out of HPV vaccnaton to Advocate for roll-out of HPV vaccnaton toAdvocate for roll-out of HPV vaccnaton todvocate for roll-out of HPV vaccnaton to all girls ages 10-14 years in Uganda, and for provision of sufficient-14 years in Uganda, and for provision of sufficientyears in Uganda, and for provision of sufficient, and for provision of sufficient and for provision of sufficient screenng servces for all women of 25-49 years of age.
o Dagnostcs: Lobby for development of health professonals’: Lobby for development of health professonals’ Lobby for development of health professonals’Lobby for development of health professonals’obby for development of health professonals’development of health professonals’health professonals’
tranng modules on cervcal cancer dagnostcs, ncludng cytology,, ncludng cytology, ncludng cytology, colposcopy, and hstology, and for provson of the necessary, and hstology, and for provson of the necessary and hstology, and for provson of the necessary equipment so that sufficient services are available for women whoalable for women wholable for women who need them.
o Treatment: Advocate for addtonal techncal equpment, specalst for addtonal techncal equpment, specalstaddtonal techncal equpment, specalsttechncal equpment, specalst staff, and tranng. Ths wll nclude lobbyng for the purchase, and tranng. Ths wll nclude lobbyng for the purchase and tranng. Ths wll nclude lobbyng for the purchase of seven new radotherapy unts; renovaton of exstng unts n Lacor and Gulu; the establshment of an ntra-cavty radotherapy treatment faclty and bunkers (treatment rooms) n those two health unts n Lacor and Gulu; the purchase of gynaecologcal surgcal equpment; and the hrng and tranng of therapy radographers, medcal physcsts, oncology nurses, gynaecologcal oncologsts, and mantenance techncans for each faclty. for each faclty.
• Hold workshops to lobby health subdstrct, dstrct, regonal, and national officials to provide support for cervical cancer prevention and control.
• Lobby the Ministry of Education and other key officials to include cervcal cancer preventon and control and HPV vaccnaton n the school and control and HPV vaccnaton n the schoolcontrol and HPV vaccnaton n the school n the schooln the schoolthe schoolschool currculum..
• Advocate for tranng of health care workers on cervcal cancer preventon, care workers on cervcal cancer preventon,care workers on cervcal cancer preventon, dagnoss, and treatment., and treatment. and treatment.
Community mobilisation
• Support drama and folk-meda groups to rase awareness around cervcal cancer..
• Use mobile film and sensitisation vans in communities to raise awarenesses to rase awareness to rase awareness around cervcal cancer. cervcal cancer..
• Develop and test gudelnes for communty moblsaton for cervcal cancer preventon and control..
• Orentate and provde cervcal cancer preventon and control tools totate and provde cervcal cancer preventon and control tools to and provde cervcal cancer preventon and control tools toe cervcal cancer preventon and control tools to cervcal cancer preventon and control tools to partner organsatons, ncludng communty-based organsatons andorgansatons, ncludng communty-based organsatons and ncludng communty-based organsatons and communty-based organsatons andcommunty-based organsatons and health care provders. care provders.care provders..
• Integrate cervcal cancer preventon, early dagnoss, and control, and control and control messages nto exstng famly plannng, HIV/AIDS, mmunsaton,/AIDS, mmunsaton,, mmunsaton,saton,aton, school, and college programmes., and college programmes. and college programmes.
Table 2. Proposed interventions and target audiences.
Level Interventions Target audiences
National level Advocacy meetings • Policymakers
• Parliamentarians
• Stakeholders (including line ministries)
• Media
District level Behaviour change
communication and advocacy
• District leaders
• Health workers Community level Community mobilisation • Community leaders
• Village health teams
• Women’s groups
• Religious leaders Health facility level Advocacy, orientation, and
supportive supervision
• Health facility in-charges
• Health workers
• Health unit management committees
Inputs
• IEC mechansms and materals, ncludng rado and televson, newspapers, film van, audiovisual materials such as DVD players, Video CD, DVDs, posters, flyers, counselling flipcharts, and information booklets for health care provders and the communty.
• Personnel and champons for advocacy.
Output indicators
• Government polcy, gudelnes, and strategc plan for cervcal cancer preventon and control.
• Number of posters, radio and television messages, films, and advocacy meetngs.
• Government polcy statements on cervcal cancer preventon and control.
• Increased publc awareness about cervcal cancer.
Health Outcome Indicators
• Behavour change, abstnence, condom use, fathfulness to sexual partners
• Greater partcpaton rates n the cervcal cancer preventon and control programme amongst the targeted populatons ncludng partcpaton n HPV vaccnaton, screenng, and treatment programs. .
• Government and cvl socety budgetary allocatons for the cervcal cancer preventon and control programme.
• Stakeholder nvolvement n cervcal cancer preventon and control actvtes.
Key Assumptions
• Cervcal cancer IEC strateges and messages wll be acceptable culturally and relgously
• Government wll allocate funds for IEC about cervcal cancer
• Government lne mnstres, Poltcans, polcy makers, dstrct leaders, communty leaders, health workers, teachers and parents wll be nvolved n IEC about cervcal cancer.
• Non-Governmental Organzatons wll be nterested to partcpate n cervcal cancer preventon and control
CHAPTER 4
PREVENTION OF HPV INFECTION (PRIMARY PREVENTION OF CERVICAL CANCER)
Introduction
There are two ways to prevent HPV nfecton: behavour change (abstnence) and vaccnaton aganst HPV, the vrus that causes cervcal cancer (prmary preventon).
Behaviour change
Cervcal cancer s caused by the HPV vrus. HPV s sexually transmtted;
therefore, avodng sexual exposure s a cornerstone to preventon of cervcal cancer. The ABC strategy can help to reduce the rsk of HPV nfecton.
Immunisation against HPV
Vaccnaton s an mportant tool n the preventon of mmunsable dseases.
UNEPI s responsble for all vaccnatons n Uganda.
A school girl receiving an injection of HPV vaccine
HPV vaccines
Currently, there are two types of HPV vaccne:
bvalent, whch manly protects aganst HPV genotypes 16 and 18, and quadrvalent, whch protects aganst genotypes 6, 11, 16, and 18. The vaccnes have shown to provde cross-protecton aganst other oncogenc HPV genotypes as well.
HPV genotypes 16 and 18 cause the majorty of cervcal cancer cases. Types 6 and 11 cause gental warts.
The vaccnes are prepared from vrus-lke partcles
produced by recombnant technology. They do not contan a lve bologcal product or DNA, so they are non-nfectous.
Table 3. Vaccine types, schedules, and eligible ages for vaccination (WHO, 2007).
Quadrivalent vaccine Bivalent vaccine
Manufacturer: Trade name Merck: Gardasil® GlaxoSmithKline: Cervarix®
Virus-like particles of genotypes: 6, 11, 16, 18 16, 18
Three doses at intervals of: 0, 2, and 6 months 0, 1, and 6 months Recommended age at first dose: Females: 9–15 years Females: 10–14 years
Eligibility for HPV Vacination
HPV vaccne s more effectve for grls and young women before onset of sexual actvty. In Uganda grls ages 10–14 years are elgble for vaccnaton.
Catch-up vaccnaton s recommended for grls older than 14 years, provded they have not yet become sexually actve (thus exposed to HPV nfecton).
Currently, HPV vaccnaton s not recommended for adolescent boys because t s not cost effectve.
HPV Vaccine management
HPV vaccnes, lke many other vaccnes, are senstve to freezng and hgh temperatures. It s recommended that HPV vaccne be stored at between 2 and 8 degrees Celsus. The HPV vaccne management protocol/health workers’
field guide should be followed.
HPV Vaccine administration
HPV vaccne s gven as a seres of three 0.5 ml ntra-muscular njectons over a sx-month perod. In Uganda, HPV vaccne s gven n the upper arm. HPV vaccne can be co-admnstered wth other vaccnes, lke tetanus toxod, but at dfferent stes.
Protection offered by HPV vaccines
Current avalable data ndcate that HPV vaccnes offer protecton aganst HPV nfecton for at least eght years, but they are lkely to protect for a longer perod of tme. It s mportant to complete all three doses at the recommended ntervals for maxmum protecton. The major bass of protecton aganst nfecton s a neutralsng antbody. HPV vaccnes nduce antbodes (whch protect the body aganst HPV nfecton) n vrtually all vaccnated ndvduals before exposure to HPV. Antbody levels after vaccnaton have been several tmes hgher than those seen after natural HPV nfecton n all age groups evaluated (Schwarz & Leo 2008). Further, antbody levels after vaccnaton have been hgher n young adolescents than n older people (Schwarz & Leo 2008).
The First Lady, Hon. Janet K.Museveni cutting a tape to open Mbarara Hopsital Cervical cancer screening clinic Behind the First Lady is Hon. James Kakooza,
Minister of State for Primary Healthcare
