Mombasa Cervical Cancer Screening Project

OBJECTIVES

To assess the success of community outreach to enhance the coverage of at risk women with cervical pre-cancer.
To assess the performance of different methods for cervical cancer screening (Papanicolaou (PAP) smear, visual inspection with acetic acid (VIA) and testing for Human Papilloma Virus (HPV)) in field conditions in poor resource countries.
To evaluate outpatient treatment, including "see and treat" for cervical pre-cancer when applied in field conditions.
To set up a cervical cancer task force in an urban setting in Kenya.

ACTIVITIES

Set up of a cervical cancer screening programme for Mombasa District, Kenya through integrated interventions at different levels: community, primary health care (PHC)(Gov of Kenya and Mombasa City Council) and referral level (Coast Provincial General Hospital (CPGH)). The target population : women aged 30 and above who have not been screened in the last five years.
Several stakeholders (health institutions, women’s groups, community leaders) were consulted regularly through a cervical cancer task force for set-up of the programme and feed-back.
Community awareness was created through community outreach activities, involving an existing volunteer health outreach organisation (Bamako Initiative).

RESULTS

At community level, 16 volunteer community health workers (CHW’s) were trained to intergrate cervical cancer awareness in their outreach activities. They reached the target population through women’s groups, church groups, professional organisations and public manifestations. In total, they invited 10.724 women, of which an estimated 24.5% presented for screening. The average age of these women was 34 years, 4 years older than women who were screened trough opportunistic screening at the PHC. This approach was successful and greatly appreciated by the communities, as they felt ownership over the activities.
Thirty-three nurses from nine primary health care centres with family planning activities were trained in Pap smear taking and visual inspection with acetic aced (VIA) as cervical screening techniques.
At the provincial hospital, a cytology lab and a colposcopy clinic was set up.
Three thousand nine hundred and twenty-five Pap smears were taken as primary screening at the PHC level, for which three thousand five hundred and twelve VIA’s are available. 10.6% of Pap smears were atypical squamous cells of unknown significance (ASCUS) or worse (with 2.9% high grade squamous intraepithelial lesions). 11.8% of VIA examinations were positive, however, the concordance between positive Pap and VIA was very low (Kappa = .08). Two hundred ninety colposcopies and 264 biopsies were performed to confirm positive screening tests, out of which 74 cases of high grade disease (cervical intraepithelial neoplasia grade 2 or worse (CIN2+)) were identified. These cases had a positive pap smear (Low grade or more) in 59% and a positive VIA in 48% of cases, which gives a proportional sensitivity for High grade or worse disease of Pap/VIA of 1.2.
HPV samples were collected at random (15 – 55+, stratified in 100 women per 5-year age group) in order to assess age-specific HPV distribution in the population. A total of 556 samples were collected and 500 analysed to date. A high prevalence of 44.5% was detected in the overall group, with a peak in the age group 31- 35. 43.3% Of the positive samples were multiple type infections, which is very high. The HPV-type distribution was quite variable across the age groups with most important types being 16, 18, 31, 33, 35, 39, 45.
A cervical cancer screening task force has been set up at the grass root level, constituted of local chiefs, local health authorities, women’s groups representatives and the screening nurses involved. They gave significant local stimulus to cervical cancer awareness creation, as well as steering of the screening programme.