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Harshad Sanghvi Medical Director, JHPIEGO

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1 Harshad Sanghvi Medical Director, JHPIEGO
Moving from Research to Practice: Expanding Cervical Cancer Prevention in Low Resource Settings Harshad Sanghvi Medical Director, JHPIEGO

2 Continuum of Care for Cervical Cancer Control
15 years 30 years 45 years Screening and treatment Vaccination Cancer treatment Source: WHO 2006

1 Counseling 2 Speculum Exam to see Cervix 3 Apply 3-5 % Acetic Acid to Cervix 4 Inspect Cervix for acetowhite lesions 5 Discuss results with the woman. Offer treatment option if positive

6 Speculum exam to re-view cervix 7 Apply Cryoprobe and freeze for 3 minutes 8 Defrost for 5 minutes 9 Re-freeze for 3 minutes 10 Post treatment and followup instructions Cryotherapy Before and After

5 Results of CECAP SAFE study
5999 clients recruited in 9 months, 58.6% at village health centers Of the 798 (13.3%) VIA positive, 738 (92.5%) received cryotherapy An additional 18/51 women classified as indeterminate received cryotherapy Of 4 suspected cancers, 1 was confirmed. 4.4% of women made an unscheduled post treatment visit, 2.2% requiring minor treatment No major complication was noted Correlation between Nurses and Gynecologists on VIA finding and treatment decision was 93% and 92% respectively Nurses could effectively mount a comprehensive cervical cancer prevention program: could be trained to detect and treat precancer. Require 5 days training All training materials and Program implementation guides available from JHPIEGO Source RTCOG/JHPIEGO Cervical cancer prevention group: The Lancet, March 2003

6 Thailand Results to Date
Upto March 2006, approximately 180,000 women in age group (30-45 yrs ) tested with VIA 8-10% of those women offered treatment with cryotherapy 2.2 % minor complication rate. No major complications Thirteen provinces now using this approach and women highly satisfied with decision to be tested Some districts now approaching 50% coverage Fully integrated into MOH program with insurance subsidising costs

7 CERVICARE Program: Ghana
Problem Screening largely unavailable Treatment of precancer available only at large hospitals Intervention 8 rural midwives trained in visual inspection and cryotherapy: the single visit approach. SVA fully integrated in RH services Result Over 48 months, 19,326 women have been tested 1456 (91.7%)received cryotherapy immediately or return visit 16 cervical cancer patients identified (downstaging) Note: these nurses are offering additional service of SVA in addition to routine tasks CECAP Program, JHPIEGO 2004, and Sylvia Deganus, Sydney Adadevoh, Ghana

Identify and Nurture Support from Key Stakeholders Professionals Public Sector Civil Society Organize action group to champion Cervical Cancer Prevention Establish a network of multi-sectoral advocates Develop and implement awareness campaign Dr. Kobchitt Limpaphayom, CECAP Director for Thailand with former Permanent Secretary of Ministry of Public Health Dr. Vallop Thaineua and Provincial Health Director Dr. Kamron Chasiri at a 2004 dissemination meeting in Cha-am, Thailand

9 Capability Development: Site Selection
Establish selection criteria Political Commitment Management support Personnel to train Access to referral center Minimum infrastructure Geography Client base Conduct site visits Recommend sites Assessment team conducting a visit to a rural health center in Malawi

10 Capability Development: Demand Generation
Communication campaign Develop targeted messages Integrate CECAP message into General Health Messages Multimedia Coverage Community Outreach Community events Educational talks within health facility Outreach activities by health facilities Referral from other health services Community Durbar Festival held in Rural Ghana to raise awareness about cervical cancer prevention services

11 Capability Development: Human Resources
Develop cadres of: Local champions capable of advocating for cervical cancer prevention at the local, regional/provincial and national levels; Trained Service providers to deliver screening and treatment; Clinical Supervisors who can provide quality assurance and manage referrals; and Local (regional/provincial) training teams to conduct training courses, maintain quality and ensure adherence to performance standards. VIA and cryotherapy course for new service providers in Kumasi, Ghana

12 Capability Development: Training
Training Step 1 Conduct 3-day VIA and Cryotherapy clinical skills course for physician supervisors Conduct 10-day VIA and Cryotherapy clinical skills course for service providers Training Step 2 Conduct Clinical Training Skills course to develop 1st generation clinical trainers Conduct Advance Training Skills course to prepare VIA : Most difficult aspect of training: learning curve for decision making, identifying SCJ, manipulating the cervix fully, During training make sure trainees see lots of normal cases (or images) (90%) Cryotherapy: Following repeated practice on models: require between 2-4 cases to achieve competency. Most difficult aspect of training : degree of pressure, the wait for defrosting between two freezes Gas Supply can be a rate-limiting step CO2 vs. Nitrous Oxide : also both have different nozzle types Commercial grade Co2 needs drying chamber Reliable local suppliers critical Cryotherapy Equipment: Infrequent breakdown with good maintenance Must create local capacity for repair and maintenance Thai nurses practice clinical skills during a training session.

13 Capability Development: Service Delivery Model
Step 1: Service Site Preparation Physical and environmental setup Equipment and instruments Supplies SOP Step 2: Service Provision Operational Time Record Keeping and Retrieval Use of Performance Standards Monitoring Ghanaian provider practices clinical skills during a training course.

14 Supporting High Quality Program Performance
Functional health information system for cervical cancer; Responsive referral system; Operational Repair and Maintenance Center; Sustainable Quality Assurance process; Defined monitoring and evaluating program indicators

15 Are the Limitations of the Solution Acceptable
Selected Key Conclusions: Alliance For Cervical Cancer Prevention (ACCP) Prevention programs based on visual screening or HPV testing can be cost effective Cryotherapy is a safe and effective method and can be delivered by a range of health providers, including non-physicians. The single visit (screen-and-treat) approach is safe and effective in low resource settings. This is a major paradigm shift in cervical cancer prevention

16 Are the Limitations of the Solution Acceptable
ACOG/SOGC/RCOG/FIGO Policy Statement Validates the “single-visit approach,” which links a detection method with an immediate management option, as a safe, acceptable and cost-effective approach to cervical cancer prevention Calls for obstetric-gynecologic organizations worldwide to advocate for sustainable cervical cancer prevention programs Obstet Gynecol, March 2004

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