From Dr. Andrew Dykens
RPCV and Rotarian
Building Cervical Cancer Prevention Services in Sénégal
We are very proud to share the news that the Rotary Global Grant 1752614 titled “Building Cervical Cancer Prevention Services in Sénégal” is well underway! The Sénégal National Ministry of Health and Social Action officially launched the project through opening ceremonies on the morning of February 3, 2020 in Tambacounda Sénégal.
The invitees to this initial training included the medical directors, directors of primary health care, directors of community education, and directors of reproductive health at the regional and district levels for Kédougou and Tambacounda, including the following districts: Kédougou, Salémata, Saraya, Tambacounda, Bakel, Dianké, Goudiry, Kidira, Koumpentoum, and Maka. There were a total of 50 participants in the first two days of the training. Fifteen midwives continued throughout the full five days of the training.
The first two days consisted of didactic sessions. These sessions included the following topics: normal anatomy, histology and pathology, screening algorithm and referral, a review of cervical cancer screening techniques, visual inspection of the cervix with acetic acid (VIA), cryotherapy and thermocoagulation methodology, quality assurance, information and education, and teaching methodology, among other topics. The remaining three days of the training were the practical screen and treat sessions during which the midwives were able to perfect their technical skills in both VIA and thermocoagulation. Positive cases were treated in real time, and the midwives were able to practice data entry in the registry system that will help to ensure timely tracking and follow-up of positive cases.
This project is the natural progression of prior work within an ongoing partnership between Senegal, the University of Illinois at Chicago, and Peace Corps Senegal. This meaningful engagement by Rotary is helping to scale up training in clinical capacity in line with prior pilot projects. Since 2010 the University of Illinois at Chicago has worked closely with Peace Corps Senegal. Over 50 Peace Corps Volunteers have contributed to the ongoing work of building cervical cancer prevention services in this rural area. PCVs were instrumental in the theoretical planning of this current project and were helpful in working through logistics in preparation of this initial training. In addition a Returned Peace Corps Volunteer, Ellen Hendrix, is acting as the project manager. Her engagement as a Volunteer in Senegal in contributing to the partnership and her current work is critical to the future success of the project.
The following paragraphs provide background information on the state of cervical cancer in Sénégal and context of the two regions where we are introducing this project.
In 2018, 569,847 cervical cancer diagnoses and 311,365 deaths were projected globally, making it the fourth most common and lethal cancer among women globally.1 The most recent data from the Global Burden of Disease Study 2017 forecasts between 293,020 and 341,190 deaths in 2040, depending on the health scenario.2 Early detection and treatment have resulted in declining incidence and mortality rates in higher resource countries. However, low- and middle-income countries (LMICs) continue to experience significant increases in these measures, with the highest regional incidence and mortality in Africa.1 Sénégal currently ranks 17th in the world for cervical cancer incidence1 due to low accessibility and utilization of cervical cancer screening services.3 In Sénégal, the cervical cancer screening rate is very low at 6.9% for women ages 18 to 69.3,4 Screening rates are even lower in rural regions of the country, with an estimated participation rate of 1.9% for rural women ages 40 to 49.4 These low rates are attributable to the absence of available screening and treatment programs for rural Senegalese women.5
Kédougou
The Kédougou region is located in the southeastern corner of Sénégal, bordering Mali and Guinea. This far Southeastern region of Kédougou (16,800 km²) has an estimated population of 178,269 in 2018, representing about 1% of the population of Sénégal.6 In this region, the French literacy rate was estimated to be 30.2% in 2013, with lower levels in rural areas. The school attendance rate is 44%7 and there is a considerable shortage of healthcare workforce in the region. In 2018 there were 11 physicians (including a single gynecologist), 48 midwives, 32 registered nurses, 6 technicians, and 1 social worker providing care for the entire region.7,8 Through prior efforts, many of the midwives in this region have been previously trained in the VIA cervical cancer screening technique. However, there are now many new midwives in the region and this training will ensure that all midwives are properly trained and bring everyone up to date on the national guidelines.
Tambacounda
The Tambacounda region is located just Northwest of Kédougou. This region is 42,706 km² and has an estimated population of 841,518 in 2019, representing about 5.2% of Sénégal.9 The enrollment rate for secondary education is 21.2% (23.7% for boys and 18.6% for girls). In 2016 there were 37 physicians, 190 registered nurses, and 74 midwives providing care for the entire region.10 Very few midwives in this region have been previously trained in VIA; thus, our project will seek to implement this service across all health posts, making cervical cancer screening available to all women region wide for the first time ever.
We are currently in the process of planning the next steps. During the course of the training we asked that each health district team construct an action plan for integrating this health service into their routine activities. All health districts were able to complete this step within one week of the training, and we are currently in the process of reviewing the action plans. Next steps also include upcoming trainings which will take place at the health center in each of the involved health districts (3 in Kédougou and 7 in Tambacounda). One training will build clinical competence for all midwives and some nurses through each district to ensure that there is at least one person at each health post that is proficient in the screening technique. We are projecting that we will train a total of 255 individuals in VIA. In addition, we will be training each Bajuna Gox (village aunts) who will take on the responsibility of educating communities to ensure robust uptake of the newly implemented cervical cancer screening service. We are projecting that we will train a total of 647 individuals in community education. We will be tracking all screenings that take place to ensure there is a clear plan in place for referral, treatment, and follow-up of positive screens.
We are also making progress with patient management and clinical capacity building. We have purchased materials and supplies to support the screenings that will take place in the two regions. We will be supplying specula, acetic acid, and thermocoagulators in the two regions as well as tablets which will remain at district health centers to assist in follow up of positive screens. Patient registry and referral books received a national review and have been printed. A final planning activity includes the translation of our educational materials into multiple local languages to make them as accessible as possible for clinicians in these two regions. Along with community partners, Peace Corps Volunteers will be instrumental in helping to carry out the community education activities alongside women’s groups and community health workers.
In a random act of kindness, our medical equipment distributor in Sénégal decided to increase the volume of acetic acid at no additional cost to the project. This simple act is evidence of the ways communities come together in times of need to support one another, and we are grateful. Despite these uncertain times, we are encouraged by the continued support from Peace Corps and Rotary International. We are looking forward to a highly successful and sustained project in the months ahead!
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin [Internet]. 2018 Nov;68(6):394–424. Available from: http://dx.doi.org/10.3322/caac.21492
2. GBD 2017 SDG Collaborators. Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017. Lancet [Internet]. 2018 Nov 10;392(10159):2091–138. Available from: http://dx.doi.org/10.1016/S0140-6736(18)32281-5
3. Dykens JA, Linn AM, Irwin T, Peters KE, Pyra M, Traoré F, et al. Implementing visual cervical cancer screening in Senegal: a cross-sectional study of risk factors and prevalence highlighting service utilization barriers. Int J Womens Health [Internet]. 2017 Jan 27;9:59–67. Available from: http://dx.doi.org/10.2147/IJWH.S115454
4. Forman D, de Martel C, Lacey CJ, Soerjomataram I, Lortet-Tieulent J, Bruni L, et al. Global burden of human papillomavirus and related diseases. Vaccine [Internet]. 2012 Nov 20;30 Suppl 5:F12–23. Available from: http://dx.doi.org/10.1016/j.vaccine.2012.07.055
6. Beye AS, Ndir B, Dieng M, Thioune A, Magassouba N, Cissoko FA. Regional Economic and Social Situation of Kedougou in 2014 [Internet]. Kédougou Regional Service of Statistics and Deomgraphics, National Statistics and Demographics Agency of Senegal; 2014. Available from: http://www.ansd.sn/ressources/ses/SES-Kedougou-2014.pdf
7. Ndir B, Sene PIS, Ndiaye S, Diouf M. The Population of Senegal in 2017 [Internet]. National Statistics and Demographics Agency, Demographic and Social Statistics Division; 2017. Available from: http://www.ansd.sn/ressources/publications/Rapport_population_2017_05042018.pdf
8. Sénégal: Continuous Survey on the Provision of Health Care Services (ECPSS) [Internet]. Rockville, Maryland, USA: Agence Nationale de la Statistique et de la Démographie (ANSD) [Sénégal] and ICF; 2017. Available from: http://www.ansd.sn/ressources/rapports/Rapport%20Final%20ECPSS%202017.pdf
9. Tambacounda [Internet]. Agence National de la Statistique et de la Demographie. [cited 2020 Feb 14]. Available from: http://www.ansd.sn/index.php?option=com_regions&view=region&id=3&Itemid=1223
10. Diop AN, Dieng M. SITUATION ECONOMIQUE ET SOCIALE REGIONALE 2016 [Internet]. Service Régional de la Statistique et de la Démographie de Tambacounda; 2019 Sep. Available from: http://www.ansd.sn/ressources/ses/SES-Tamba-2016.pdf