Scottish experience working in partnership with Nkhoma Hospital to reduce the burden of cervical cancer

Transcription

1 Scottish experience working in partnership with Nkhoma Hospital to reduce the burden of cervical cancer Christine Campbell and Heather Cubie University of Edinburgh 1

2 Extending Scottish Expertise to Malawi Funding from the Scottish Government International Fund for Development in Malawi, to reduce the burden and mortality from cervical cancer cancer in Nkhoma Hospital and associated health centres by: Sensitisation of healthcare professionals and local population to value of cervical screening Upskilling VIA Providing treatment by cold/ thermal coagulation through Scottish professionals spending time in Nkhoma Ensuring good follow-up of all non-negative VIA patients Increasing awareness of data collection and analysis Providing HPV testing for potential triage to VIA Interacting with Colleges of Nursing 2

3 What can the Scottish clinicians provide? - Cold coagulation as an alternative to cryotherapy 3

4 Clinical visits through week visit from Dr Deeny, May 2015 competence of providers and cpd sessions show good skill levels 3 week visit by Dr Stanczuk, June 2015 pilot of self-sampling in clinic settings; cpd for providers 1 week visit by Sr Hilary Walker, September 2015, supported mobile outreach campaign; established battery use of coagulator; cpd for providers 1 week visit by Sr Hilary, April 2016; cpd for providers 2 week visit by Dr McMullen and Sr Hilary, September 2016; to consolidate service and assessment, culminating in this Symposium 4

5 Academic expertise in cancer screening Experience in data collection, analysis, and interpretation for health policy Health services research to improve cancer screening promote community health engagement improving patient pathways understanding barriers and facilitators to health care utilisation Strong global health links through the International Cancer Screening Network Experience with mentoring international research projects and MPH students 5

6 Evidence for cold coagulation -1 Gordon HK, Duncan ID. Effective destruction of cervical intraepithelial neoplasia (CIN) 3 at C using the Semm cold coagulator: 14 years experience. Br J Obst Gyeac. 1991: 98; The primary success rate was 95% at 1 year and 92% at 5 years Included data on 266 post-treatment pregnancies no increase in rates of miscarriage, pre-term or operative delivery Parry-Smith W, et al. Success rate of cold coagulation for the treatment of cervical intraepithelial neoplasia: a retrospective analysis of a series of cases. J Low Genit Tract Dis Retrospective review 577 patients in England between 2001 and 2011: the cure rate was 95.7% at around 1 year. 6

7 Evidence for cold coagulation studies, analyses of proportion cured were conducted with data stratified by lesion grade and study region Among 4569 patients, summary proportion cured of 96% [95% confidence interval (CI) 92 99%] and 95% (92 98%) were obtained for CIN1 and CIN2-3 disease, respectively. Fewer studies from LMICs Cold coagulation has generated recent interest because it uses relatively low temperatures (100 to 120 degrees C), is likely to be appropriate for low- to mid-level providers, and is low cost 7

8 Data in the Nkhoma CCSP Committed to dissemination of high quality evidence and sharing of best practice Publication in the International Journal of Cancer, reporting first use of thermo-coagulation in Africa, and demonstrating non-inferior outcomes compared to cryo-therapy Working on a follow-up paper will full project data, and guidance on implementing hub and spokes model of screening delivery Only anonymised data 8

9 Use of data to ensure quality Essential to improve any service, in any country! Across Malawi as more centres use thermocoagluation, an opportunity to develop national data (Beatrice Kabota leading database network) Internationally, more countries now adopting thermo-coagulation: can Malawi lead in the development of a robust evidence-based service? HIV positive women insufficient understanding of long-term natural history and hence protocols of care need to use Malawi data to inform care 9

10 Lessons learnt Build on established trust between the hospital and health centres: the project did not start in a vacuum Spend time on building relationships with local and national stakeholders, e.g. TA leaders, national screening coordinator, Safe Motherhood Committee, professional bodies A hub and spokes approach enabled consolidation of skills within the hospital team. Flexibility to local circumstances, and sensitivity to staffing challenges and other health priorities (e.g. malaria, TB, HIV/AIDS) Shared CPD critical to an environment of mutual learning, and to avoid complacency regarding skills Ongoing campaigns to address myths and misconceptions 10

11 Cervical screening in Malawi Real potential to benefit Malawian women, now Establishing a service: involves commitment to protected time for trained personnel in health centres Buy-in from District Health Offices and provision of basic consumables: 5% vinegar, cotton wool, gloves Close working with hubs to ensure prompt treatment Robust mechanisms for follow-up Ongoing Competence Assessment and CPD 11

12 Human Papilloma Virus - HPV Persistent infection with HPV is the real cause of cervical disease and cancers >80% of people (men and women) who have ever been sexually active will have had an HPV infection at some time and cleared it without ever knowing it was there HPV testing is more sensitive than cytology for detecting high grade disease So, many countries are moving towards HPV testing for primary screening WHO recommends HPV testing followed by VIA of positives BUT it is an expensive test 12

13 Could Scottish expertise in HPV influence cervical screening strategies in Malawi? Understanding of HPV genotpyes, natural history and clinical implications >180 types of HPV; >30 types can be sexually transmitted >12 types High Risk (HR-HPV cause cancer) Types identified by a number e.g. HPV 6,11 = genital warts HPV 16 = highest type; majority of cervical cancer; more carcinogenic than nicotine Scottish HPV Reference Laboratory national testing laboratory based on 20 years of experience in HPV test development and use. 13

14 Nhkoma Hospital Lab, HPV room and training 14

15 HPV outcomes in Nkhoma Nkhoma has been using the Xpert HPV test to explore the potential for primary screening here Publication on prevalence accepted by Journal of Clinical Virology: HR-HPV prevalence 20% overall in women coming to Nkhoma VIA clinics 43% in women with HIV VIA positivity also double in women with HIV HPV 16 and 18/45 each account for 4.8% but HPV other HR types accounts for 12.8% HR-HPV positivity was highest in women aged 20-39: 32.2% of women aged % of those aged

16 Strengths & Weaknesses of HPV primary screening in Africa Weaknesses Women have to be examined twice in single visit once for HPV sample and once for VIA unless self sampling is used Procurement and transport Disposal of cartridges and PreservCyt in pots Adherence to clean environment and daily maintenance Appropriate temperature of clinic, transport to lab and storage All HPV tests too expensive for routine use for high numbers Strengths Ease of use of Xpert HPV Wide experience of Xpert platform for TB Rapid turnaround Self-sampling works with Xpert HPV Reproducibility of QC results Could be used in clinic not quite a near patient test 16

17 It has been an immense privilege to work with the wonderful team in Nkhoma, whose commitment, leadership and good governance has been impressive We are delighted to have been able to join you for this important Symposium and dissemination of successful outcomes We are very grateful to the Scottish Government for funding this programme Every and MKw has been used very effectively! ZIKOMO KWANBIRI 17

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