By Rebecca Harshbarger
Sunday, April 26, 2009
Ugandan health officials are mulling the results of two pilot projects involving the HPV vaccine that test different ways to reach the nation's girls. One project adds the vaccine to existing public health programs; the other is based in schools.
KAMPALA, Uganda (WOMENSENEWS)--In wealthier countries, screening programs to detect cervical cancer in its early stages, when it's more easily treated, are part of routine health care.
But in cash-strapped countries, such as Uganda, women are rarely screened and only go for treatment during the disease's advanced stages, when symptoms are apparent and the chances of saving a woman's life are diminished.
Health activist Claire Judith Achieng is working to bring screenings to rural women, but she said her own mother is an example of how difficult the job can be.
"In my village, my mom told me we lost this prominent woman to stomach cancer," said Achieng, who has conducted numerous workshops in central Uganda about cancer screening. "I told her, 'Mom, it's time you go for screening.' And she said, 'but what if it said I had it?'"
"I'm an activist, and I can't even get my mom to go to a screening," said Achieng.
About 473,000 cases of cervical cancer are diagnosed annually, according to the National Cervix Cancer Coalition, based in West Hills, Calif., with 85 percent of those cases in low-income countries.
The Ugandan Ministry of Health estimates that 85 percent of the nation's women who develop cervical cancer are diagnosed when it is already at an advanced stage.
Uganda has little capacity to treat these women. According to the Ugandan Ministry of Health, the country of 30 million has an estimated 140 obstetricians and gynecologists and 3,400 midwives. Uganda has only one radiotherapy machine to treat cancer patients, according to the director of Mulago Hospital, as the other radiotherapy machine broke down last October.
In the past couple of years public health researchers have been intensifying efforts to attract urban women to community-based health clinics for screenings, with good results so far. Drawing upon research they have done in urban areas, the Health Ministry is working on developing screening services in rural communities.
At the same time, public health officials and advocates are beginning to express optimism about stopping the disease before it has a chance to start through vaccination programs.
In a demonstration project in two Ugandan districts that started last year, the country's Health Ministry began to inoculate 9- and 10-year-old girls against human papillomavirus (HPV), a common precursor to cervical cancer. The program was supported by PATH, a Seattle-based nonprofit health advocacy organization, which has received millions of dollars in grants from the Bill and Melinda Gates Foundation for vaccines and fighting HIV-AIDS and neglected diseases.
HPV is the most common sexually transmitted infection in the world. The Atlanta-based Centers for Disease Control and Prevention recommends that girls receive vaccination against this virus between the ages of 9 and 26, preferably before they become sexually active.
Ugandan health officials picked two districts that they considered to be average by health standards, one in the central part of the country and one in western Uganda.
In the first central district, called Nakasongola, health workers who normally deliver vaccinations and de-worming medicine were also given vaccines for HPV to inoculate 9- and 10-year-old girls. This translated into few additional costs, since health workers didn't have to significantly change their routine. However, some health workers said it was difficult to locate all the 9- and 10-year-old girls in the district.
In Ibanda, the western district, the government's strategy was school-based.
All girls in "primary 5" or fifth grade were vaccinated. Health workers reported that using the existing school networks made it easier for follow-ups, which are key since the vaccine requires three doses in order to be effective.
The time span to administer the treatment can vary with the drug's brand, but usually the injections must be given over a six-month period. GlaxoSmithKline, a London-based pharmaceutical giant that makes a vaccine for HPV, donated the immunizations for the project.
Parents had numerous concerns about the safety of the vaccine, but Emmanuel Mugisha, the country manager for PATH, said many fears were allayed by an extensive awareness campaign that the Health Ministry conducted in the two districts.
"Before we began vaccinations, we ran programs on television and radio talk shows, handed out education materials, showed films, held community meetings and involved political leaders to talk to the general public," said Mugisha.
In its advanced stages, cervical cancer can cause women to bleed between menstrual periods, emit a foul-smelling discharge and suffer lower abdominal pain. Eventually, the bleeding can become severe and cause death, or the cancer spreads to other parts of the body.
Preventive efforts are hindered by the silent quality of the disease in its early stages. Women can go many years, while the disease is progressing, without any symptoms. This lack of visibility lowers the incentive to travel long distances for screenings, particularly when both time and money are scarce.
So while the vaccination program is considered important here, the push for screenings is also critical.
Many women are still afraid to even enter a gynecologist's office, said Achieng. The idea of undressing for a doctor and having the cervix examined makes many women feel extremely uncomfortable.
Some activists are hoping that a do-it-yourself testing kit will come along soon, based on a simple new test that has been gaining ground with clinicians. The test can be performed with a small mirror, vinegar and a bright light, in the privacy of a woman's own home.
In the United States, about 1-in-4 female teens have received a HPV vaccination, according to federal health officials.
More than a hundred variations of HPV have been discovered, but not all types increase the risk for cervical cancer. The two vaccines administered by a growing number of governments around the world are effective in protecting women from about 70 percent of all HPV types found worldwide, including the ones that can lead to cervical cancer.
PATH is conducting three similar demonstration projects in Peru, India and Vietnam. The demonstration project in Peru was held in 2007, Vietnam's project began in 2008 and is ongoing and the one in India will begin in 2009.
Rebecca Harshbarger is a journalist based in Kampala, Uganda.
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