Elsevier

Vaccine

Volume 31, Supplement 5, 29 December 2013, Pages F47-F52
Vaccine

Review
Infrastructure Requirements for Human Papillomavirus Vaccination and Cervical Cancer Screening in Sub-Saharan Africa

https://doi.org/10.1016/j.vaccine.2012.06.066Get rights and content

Abstract

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Gobal Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3–5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9–13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript.

This article forms part of a regional report entitled “Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region” Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled “Comprehensive Control of HPV Infections and Related Diseases” Vaccine Volume 30, Supplement 5, 2012.

Highlights

► Primary prevention through HPV vaccination needs appropriate infrastructure. ► A major barrier to vaccine implementation is cost. ► Screening efforts in sub-Saharan Africa have largely focused on visual inspection. ► HPV DNA testing linked to treatment requires a low-cost technology/molecular test.

Introduction

Progress has been made on several fronts in the prevention of cervical cancer, both in primary prevention by vaccination and in screening, which will have substantial application in reducing cervical cancer incidence and mortality globally and in developing countries. The current high burden of cervical cancer in less developed countries is exemplified by the fact that more than 85% of cervical cancer cases (452,000 of 530,000 cases globally) and deaths (242,000 of 275,000 deaths globally) are observed in less developed countries [1]. The suboptimal performance of cytology screening programmes and challenges in implementing quality-assured Pap smear screening have stimulated the search for feasible and effective alternative screening strategies to reduce the burden of cervical neoplasia in such settings. Where applied successfully, as occurred in Scandinavian and other countries in the 1950s and beyond, there was a substantial reduction in the incidence of and mortality from cervical cancer following Pap smear programmes. However, requirements for traditional cytology screening programmes are prohibitively expensive and complex for initiation in the less developed countries of sub-Saharan Africa (SSA).

The lack of adequate infrastructure and human resources in health care services is a major impediment for implementing prevention strategies based on screening and human papillomavirus (HPV) vaccination in SSA. It is well recognised that creating appropriate infrastructure for cervical cancer prevention within the public health services is key to the success of prevention programmes. The lack of cervical cancer prevention programmes have resulted in a high burden of cervical cancer in SSA [2] and an increasing incidence of cervical cancer has been observed in some SSA countries such as Uganda [3]. SSA has the largest burden of human immunodeficiency virus (HIV) infection and the elevated risk of HPV infection among HIV-infected women further contributes to the high burden of cervical neoplasia in SSA. Thus, creating and improving infrastructure for cervical cancer prevention requires urgent attention from government authorities. The infrastructure requirements for implementing an integrated approach, based on HPV vaccination and screening in SSA, is briefly discussed in this paper.

Section snippets

Primary prevention of cervical cancer through vaccination

The aim of primary prevention is to prevent the initiation of cervical carcinogenesis and thus avoid occurrence of cervical cancer. Knowledge of the causes and co-factors that increase the risk of disease is vital for effective primary prevention strategies. It has been well-established that persistent infection with one of the oncogenic HPV types is the necessary cause for cervical cancer [4], [5]. HIV-infected women appear to be at a higher risk of persistent infection with HPV [6]. The

Cervical cancer prevention through secondary prevention

Secondary prevention of cervical cancer is based on the detection and effective treatment of cancer precursors through screening, leading to a reduction in the incidence of and mortality from invasive cancer. Effective cervical cancer prevention, especially in low-resource settings, should be focused on reaching women for screening at the time of the peak risk of treatable precancerous conditions due to persistent HPV infection and before the average age at which invasive cancers occur [16].

Infrastructure requirements for management of invasive cancer

Screening for cervical neoplasia, by whatever method, in a previously unscreened population will result in the diagnosis of invasive cervical cancer in both early and advanced stages and these will require proper staging and adequate treatment. It is unfortunate that adequate infrastructure is lacking in most SSA countries to manage invasive cancer. Staging will require assessment of the vagina, parametrium, urinary bladder and rectum by a combination of clinical and endoscopic procedures.

Conclusions

Reducing the high burden of cervical cancer substantially in less-developed countries has become a real possibility and achievable goal with the availability of HPV vaccination and feasible and effective alternatives to cytology screening. Political commitment, creative sources of financing and good planning in developing and augmentation of infrastructure and human resources for an integrated approach of vaccination, screening and treatment of women with cervical lesions is critically

Acknowledgements

The authors wish to thank Mrs. Evelyn Bayle, Ms. Sandrine Montigny, Ms. Karine Racinoux and Mrs. Krittika Guinot, IARC, for their help in the preparation of this manuscript.
Disclosed potential conflict of interest

RS, RA, GS-L: Have disclosed no potential conflicts of interest.

LD: Has received honoraria for appearing on various speaker fora for GlaxoSmithKline and Merck and Co. and sponsorship for research studies.

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