Human Papillomavirus Prevention InterventionFeasibility Study in Tanzania

Worldwide, Human papillomavirus (HPV) is one of the most common sexually transmitted viruses infecting humans. HPV infections may lead to the development of pre-cancer and if left untreated can lead to cancer; hence it has been established as the primary underlying cause of cervical cancer. In developed countries, it has been demonstrated that effective cytology (Pap test) screening can prevent up to 80% of cervical cancer. Although similar coverage can be attained in low-resource settings there are challenges at community and policy making levels. These include, lack of awareness, follow-up, quality control and assurance as well as human and financial resources. Vaccination before exposure to cancer-causing HPV is a particularly important intervention that has demonstrated potential for high health impacts in pilot settings. This report highlights the findings of a study that assessed the capacity, gaps and barriers for the implementation of HPV prevention interventions in Tanzania. Triangulation methods were employed using both quantitative and qualitative tools. Documents on policies and guidelines were reviewed to assess the current status of policies with regard to prevention. Assessment of the diagnosis and treatment options for cervical cancer to establish the gaps and opportunities for policy improvement were made. Information on incidence, prevalence and mortality from cervical cancer in the various regions in Tanzania were extrapolated from hospital records. These were supplemented by a literature review on HPV and cervical cancer at global level. Further literature review was done to gather information on sexual behaviour among youth in Tanzania and elsewhere in Africa. The training curriculum for nurse midwifery, assistant medical officer, medical officers and nursing officers was reviewed to identify gaps in knowledge, awareness and skills for cervical cancer prevention and management. Teachers responsible for training in the health institutes were interviewed to gain more insight into the curriculum regarding cancer. In-depth interviews were conducted with stakeholders to assess the opportunities, challenges and perceptions of intervention in the health system. Teachers were interviewed on their perceptions of the interventions and the possibility of using schools as vaccination delivery platforms. Focus group discussions (FGDs) were held with parents and guardians in rural and urban settings in Coast, Kilimanjaro and Lindi regions. This provided information on health needs, acceptability of interventions and strategies for advocacy. A questionnaire was administered to the head of sections among four referral hospitals (Ocean Road Cancer Institute (ORCI), Bugando Medical Centre (BMC), Kilimanjaro Christian Medical Centre (KCMC) and Peramiho Hospital) to gather information on human resources, training, equipment, drugs, and supplies specifically for cervical cancer prevention and control. A checklist adapted from the Alliance for Cervical Cancer Prevention (ACCP) was used to check for essential equipment, supplies and drugs for cervical cancer prevention and control. I. Non-communicable diseases (NCDs), including cervical cancer, have been recognized as an important public health problem in recent years and the government is committed to implement appropriate control measures, as noted in the most recent Health Strategic Plan which is a document for resource mobilization. A specific cervical cancer framework has been developed by various stakeholders led by the WHO country office as a basis for its strategic plan development. Furthermore a special reproductive cancer unit (cervical cancer, breast and prostate) has been established at the Ministry of Health and Social Welfare under the Reproductive and Child Health department. II. Cancer of the cervix is a critical public health problem as it was in 2007-2008 the leading form of cancer and accounted for more than 37% of all cancers diagnosed at the ORCI, the only dedicated cancer institute in the country. III. There is shortage of human resources and basic equipment necessary for cervical cancer screening, diagnosis and management in main hospitals. IV. There was heterogeneity of screening approaches among the five referral facilities surveyed. V. Tailored training courses for screening and management of cervical cancer have contributed to increased access of services in peripheral areas. However the approach was impaired by lack of essential equipments and thus efforts need to be made to increase availability. VI. The curriculum used by health institutes across Tanzania covers cervical cancer but the approach is very theoretical explanations with little practical ‘hands-on’ training in the diagnosis and management of cervical cancer. VII. Awareness about cervical cancer burden is low among stakeholders (community, policy makers and Non Governmental Organizations). Specifically those not dealing with cervical cancer directly. Most of them are not aware that there is an opportunity for prevention using vaccines. VIII. Promoting awareness is essential for appropriate cervical cancer management. The main channels of advocacy suggested include radio, community meetings and television. IX. There are key challenges regarding resources, particularly finance and human resources, and these have a bearing on sustaining such measures in the long run. X. There is an opportunity to integrate HPV vaccine within the Tanzanian health system infrastructure. The infrastructure for EPI is well established and well placed in the organogram of the ministry. However, the EPI cold chain facilities are currently fully utilized and there is a need to invest in storage infrastructure in case same facilities have to be used for HPV vaccine. XI. Primary schools were identified as the best channel for vaccination as there is high attendance in primary schools and the opportunity for special vaccination days. XII. The community members interviewed were positive regarding the introduction of HPV vaccine, as long as parents and the community were well informed.