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Nkhoma Cervical Screening Programme

Prof Heather Cubie and Dr Christine CampbellUniversity of Edinburgh

Heather.Cubie@ed.ac.aukChristine.Campbell@ed.ac.uk

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33.5+26.1 - 33.5+19.4 - 26.114.5 - 19.410.0 - 14.56.2 - 10.0<6.2

SOURCE: GLOBOCAN 2012, IARC

Age-standardised rates

Global Cervical Cancer Burden

528 000 cases, 266 000 deaths annually

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Burden of cervical cancer in Malawi• 83% of cervical cancers

globally are in resource constrained countries

• Malawi has the highest incidence in the world

• In Malawi cervical cancer is commonest cancer in women (45.4% of registered female cancers)

• Estimated that the number of cervical cancer cases could rise by 60% over the next decade.

• Government policy supports screening using visual inspection with acetic acid (VIA), but provision is limited

KEY COMPONENTS

• Provision of a ‘screen and treat’ programme of cervical screening, including treatment– Upskilling VIA, introduction of thermo-coagulation– Ensuring robust follow-up pathways for all non-negative VIA patients

• Exploring use of HPV testing for potential triage to VIA

• Developing a teaching module on cervical cancer screening and prevention

Nkhoma Cervical Cancer Screening Programme

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Steps in the development of the ‘screen and treat’ programme of cervical screening

• Obtaining support from Ministry of Health; creation of clinic space

• Raising awareness among health professionals, communities and patient (including meetings with traditional authority regional and village chiefs)

• Provision of training in VIA and thermo-coagluation, including development of bespoke SOPs

• Integrating care of women attending ART clinics

• Outreach to community health centres and populations • provide consistent starter pack to every outreach clinic

Year 1Nkhoma Hospital

Year 3Kalulu

Year 2Diamphwe

Year 3Mthenthela

Year 2Nathenje

Year 3Tsoyo

Year 2MatapilaYear 3

Chimbalanga

Year 2St Joseph

Year 3Mayani

Year 2Kasina

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Taking screening to rural health facilities

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Current project statistics• Reached 100,000 people through sensitisation • Trained 37 healthcare staff • Established daily Cervical Cancer Prevention Clinics at Nkhoma Hospital • Established weekly clinics in 8 Health Centres and screening campaigns in 2

others• Provided screening to >17,000 women previously unscreened women• Reassured >91% of women that they were VIA negative and could be rescreened

in 5 years’ time as per Malawi guidelines • Treated >70% of VIA+ women on same day as screening with thermo-

coagulation• Ensured good attendance at follow-up clinics• Had positive feedback from Local Chiefs, clinicians, patients

In HIV infected women:• Encouraged attendance for ‘screen and treat’ from ART clinics (>6%) and HIV

testing of those whose status is unknown• Confirmed VIA and HPV positivity were each twice as common in HIV+ infected

women• Shared training with Partners in Hope, Ministry of Health, others• Provided an additional national trainer for VIA screening and treatment

Raising the profile of the ‘Nkhoma model’to Government and Ministers

Beatrice Kabota, Project co-ordinator

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World Rural Women’s Day and Year of Women’s Empowerment, Lilongwe 30th October 2015

Explaining cold coagulation to First Lady and Vice-President’s wife, August 2015

Meeting Scottish Minister, Mr Yousef at MaSP, October 2015

Developed with Nkhoma team and Scottish colleagues

Detailed evidence review in Appendix, but aims to be practical and useful in Malawi

Has been endorsed by the Association of Obstetrics and Gynaecology of Malawi

Nkhoma Hospital considered the leading practitioner of thermal coagulation in sub-Saharan Africa - now training Ethiopian and Zambian teams

Lessons learnt• Build on established trust between the hospital and health centres, with

community awareness sessions in months preceding screening

• Spend time on building relationships with local and national stakeholders, e.g. TA leaders, national screening coordinator, Safe Motherhood Committee, etc.

• A ‘hub and spokes’ approach enabled consolidation of skills within the hospital team.

• Integrate with HIV/ART services, and with women’s health services

• Shared CPD critical to an environment of mutual learning, and to avoid complacency regarding skills

• Support from community health workers critical to local acceptance

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HPV testing and challenges in L(M)ICs• Labs are simple, not physically suited to molecular work needed to

detect HPV• Trained personnel are lacking - most staff competent at

microscopy, HIV, TB and malaria testing• Equipment can be prohibitively expensive & space challenging• Lack of easy access to technical support, maintenance and regular

delivery of supplies• Disposal of waste fluids and plastics is major problem• Limited IT systems and connectivity with intermittent internet• HPV tests themselves are confusing with almost 200 HPV

genotypes, almost 200 distinct and unregulated tests commercially available worldwide but orientated towards Western markets

• The aim of our study was to identify means of reducing costs and waste from HPV testing while maintaining a reproducible assay simple to perform and with short turnaround time to allow same day ‘screen and treat

GeneXpert IV

Results in 58 mins

Cepheid Xpert® HPV

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HPV lessons learnt• Collection systems designed for cytology are unnecessary,

expensive and wasteful• Much smaller collection volumes are cheaper and make

disposal of plastics and fluids easier• Self-collected vaginal specimens gave comparable results to

provider taken cervical samples• Simple blood collection tubes (always available), tampon-like

collection device favoured by women and easy to take• This combination needs validation in larger study• Xpert®HPV is most suitable test at present for same day

‘screen & treat’ programmes (<2hr from clinic back to clinic)• HPV results to date shows 20% positive rate across the age

range• HPV31+ much more common than HPV 16/18

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Our Malawian colleagues are now delivering a complete care package for cervical disease reduction

• Daily ‘screen and treat’ clinics at Nkhoma Hospital and weekly clinics at 8 Health Centres (CHAM and Government) in the catchment area

• Over 80% of early pre-cancers treated on same day with good attendance at follow-up clinics (3-6m and 12m post treatment).

• Out-patient biopsy of suspicious cervix with ‘high risk clinic’ on first Monday of each month- extra effort to ensure women return for this clinic

• Increased surgical skills - radical hysterectomy• Specific palliative care clinic in VIA setting• HPV testing…. when needed

End of Project Symposium 9th September 2016

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Next steps• Endorsement of thermo-coagulation training manual by Ministry of Health • Increase number of personnel and sites trained in thermo-coagulation and

with access to equipment• Roll-out across all 139 sites which can currently offer VIA but lack quality

assessment, access to treatment facilities or ability to provide appropriate clinical care when abnormalities discovered

• Eventually, ensure Malawi has a national network of ‘screen and treat’ facilities as endorsed by the First Lady and Ministry of Health

• Expand beyond Malawi – interest already widened to USAID-supported HIV centres in Malawi, Zambia and Ethiopia

• Secure further funding and expand partnerships

First Lady urges women to utilise cancer screening services

Malawi First Lady Madam Gertrude Mutharika has urged Malawian women to periodically go for cancer screening to save their lives.Speaking in Lilongwe where she participated in a monthly meeting of the Lilongwe chapter of Zokonda Amayi Women Club, Madam Mutharika said Malawi is losing a lot of women to cervical cancer.“As you might have heard, at least four women are dying from cervical cancer every day. This is just too much and this trend must not be allowed to continue. The only way to achieve this is for us women, as well as girls going for screening,” Madam Mutharika said.Zokonda Amayi Clubs are groups of women formed out of their on-air interaction through Malawi state broadcaster MBC greeting programme called Zokonda Amayi.Mutharika described the women’s daily interaction on radio as the best forum for them to share meaningful information on various issues that affect women, children, and the youth.“We need to encourage one another to go for cancer screening and HIV testing. This is the only way we can get the necessary help in time and save our lives to contribute to the development of our communities and the nation at large,” she added.The First Lady also appealed to the women to ensure that girls are kept in school and are protected from all practices that threaten their education.During the meeting, Desk Officer for Cervical Cancer in the Department of Reproductive Health Twambilire Phiri gave a talk on cervical cancer where the women had a chance to ask questions on the topic……………….

Extracted from SMP Bulletin, 17/0217

17th February 2017

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True Partnership!Thanks to

Scottish Team:• Professor Heather Cubie, NHS Lothian and University of Edinburgh• Dr Christine Campbell, CPHS, University of Edinburgh • Dr Graeme Walker, Cons. Gynaecology Oncologist, NHS Lothian • Sr Hilary Walker, Cons. Nurse Colposcopist, NHS Lothian• Dr Liz Grant, Director, Global Health Academy, UoE • Dr Isabel Bruce, M&E Consultant• Dr Miriam Deeny, Cons. Gynaecologist, NHS Greater Glasgow & Clyde

Nkhoma team:• Dr Reynier ter Haar, Medical Director & Surgeon• Dr David Morton, Deputy Medical Director & Physician• Mr Edson Kawonga and Mr Mike Mautanga, Laboratory• Mrs Beatrice Kabota and Mr Savel Kafwafwa, Project Co-ordinators and the Scottish Government for funding