By Alexis NIZIGIYIMANA MD
Globally, WHO reported that cervical cancer affects over half a million women each year, and kills a quarter of a million. One woman dies of cervical cancer every two minutes, making it one of the greatest threats to women’s health(1). It is predominant among women aged 15 years and older reaching the peak between 45 and 65 years old, which ranked it the second most common female cancer in the 15±44year group (2). According to the 2014 Africa Cervical Cancer Multi-Indicator Incidence and Mortality Scorecard, out of the 20 countries globally with the highest incidence of cervical cancer, 16 are African countries (3).
There are proven approaches to reduce these disparities, including HPV vaccination to prevent cervical cancer. However, in many countries, and in many lower-resource areas within countries, implementation of HPV vaccination is limited, as is the availability of, and access to early detection programmes, cancer surgery, essential cancer medicines, radiotherapy, palliative care, as well as to support for those who survive, sometimes called “survivorship care”(4). In Burundi, Cervical cancer accounted for an annual estimated incidence of 1429 ICC cases and 108 deaths, corresponding to an annually age-standardized incidence and mortality rates of 49.3 and 39.3 per 100,000 women respectively (2). However, cervical cancer is preventable and curable, at low cost and low risk, when all adolescent girls were immunized against human papillomavirus (HPV), and screening to facilitate the timely detection of early precursor lesions in asymptomatic women is available together with appropriate diagnosis, treatment, and follow-up(5). In Burundi, the limited access to effective prevention measures as well as early detection and treatment services significantly reduces patients’ chances of survival (2). This paper is aiming at exploring the health system gaps responsible for the poor delivery of the cervical cancer prevention program in Burundi. Cervical cancer prevention policy
The cervical cancer prevention has received a little attention disproportionately to its global burden. Some asserts that the lack of local-level cervical cancer indicators in much of sub-Saharan Africa due to limitations in systematic reporting, cancer registries, and information collection, which may be difficult to raise cervical cancer as a priority issue if national actors are not aware of the scale of the problem in their home country(6).they also argue that the little attention attached to cervical cancer may be due to in part because of underrepresentation of women or structural bias against women’s health in national and global circles, while others framed cervical either as an NCD, which leads to it having to compete with a number of other health issues with this category or a women’s rights and women’s health, which moves it outside the epidemiological burden of cervical cancer to link it to a broader social priority of gender equality. However, these efforts seem to have provided limited changes in the conceptualization of cervical cancer on the global health agenda (6). Nevertheless, the International organization including GAVI, Foundations, United High-Level Meeting, African First ladies have continuously advocated to raise cervical cancer at a global level,and other support cervical cancer prevention programs (6).In recognition of this, the WHO Director-General made a global call for action on 19th May 2018 towards the elimination of cervical cancer (7). However, Burundi does not yet have any operational policy and cancer registry neither on cancer controls in general nor on cervical cancer, but the Ministry of Health (MOH) in Burundi, through its non-communicable diseases control programme “PNILMCNT” (Programme National Intégré de Lutte Contre fewer Maladies Chroniques non Transmissibles), has recently developed cancer national strategic plan 2016–2020, including cervical cancer control (2).
Cervical cancer screening and diagnosis
The cervical cancer is preventable through screening that allows for early detection and subsequent treatment of precancerous lesions caused by sexually transmitted infection with human papillomavirus (HPV). While most HPV infections clear spontaneously within 1 to 2 years, a persistent infection with one of approximately 15 oncogenic HPV genotypes may progress to pre-cancer which, if untreated, may become invasive cancer (8).
Since the last clinical guidelines for screening were developed, an increasing number of studies have been published that support the high sensitivity of human papillomavirus (HPV) DNA testing, relative to cytologic evaluation of cervical cells with a Pap test (cytology), for detecting high-grade cervical intraepithelial neoplasia (CIN) (8).
Despite these above evidence-based cervical cancer prevention, Burundi has no national organized cervical cancer screening strategy in Burundi. Pap smear can only be done at the teaching hospital in Bujumbura, Roi Khaled, when gynecologists propose it to their clients and the latter are able to afford this service. Therefore, very few women are screened and few have heard about cervical cancer prevention. The only functional pathology laboratory in the country is hampered by frequent stock out of reagents, very old equipment, and insufficient personnel as there are only 2 pathologists and 3 cytotechnicians with only bench training (2). This could be explained by the financial resources constraint, while in 2015, 60.1% of allocated resources to the Ministry of Public Health consisted of foreign aid, contributions of donor Governments only represented 17% of health allocations in 2016, according to the Financial Laws of the Government of Burundi (11) .
HPV vaccine and treatment
Cervical cancer is largely preventable through public health interventions (HPV vaccination and screening with treatment of pre-cancerous lesions), and HPV vaccination of girls is among the few cancer-related so-called “Best Buys” or “very cost-effective strategies” according to the World Health Organization’s Global Action Plan for the Prevention and Control of Non communicable Diseases (2013-2020)(9).
Conversely, the price for three doses of HPV vaccine was estimated to be about $13·50 through GAVI Alliance procurement, $39 at the lowest non-GAVI public sector indicative price, and more than $300 in high-income countries (8). Burundi has no HPV vaccination program, but recently GAVI has been conducting a pilot HPV vaccine program in two health district of Burundi in 2017(10). Nevertheless ,regarding the price of HPV vaccine, the financial constraints could prevent
the government to scale up the cervical cancer prevention program across the country, as it is ranked fifth from bottom (184 of 188 countries) on UNDP’s Human Development index with most human development indicators being shockingly low, which ranks it to 132nd out of 157 countries in terms of progress toward meeting the Sustainable Development Goals (11). Also, the cervical cancer prevention could compete with other health issues as the government is facing a double burden of diseases (communicable and non-communicable diseases respectively 68% and 32% of total deaths)(12).
Concerning the access to cervical cancer treatment, the Burundian health system is still facing not only the lack of radiotherapy, chemotherapy and the palliative care but also the lack of oncologists across the country; the only treatment available is surgery(2).
Cervical cancer is the leading cause of women’s death worldwide, and the second cause of mortality among women in Burundi. This case study revealed gaps that faced the Burundian health system in tackling cervical cancer. We call upon the government to urgently develop a cervical cancer prevention program including HPV vaccination program, cervical cancer screening equipment, an educational program for health care providers on cervical cancer prevention. We also launch a call to the international community such as GAVI, IUCC, and others to support the government to implement the WHO recommendation for the cervical cancer program. And lastly, a vibrant call goes towards the Burundian women to do regular cervical cancer screening, where is possible.
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