title: Use of thermo-coagulation as an alternative treatment modality in a 'screen-and-treat' programme of cervical screening in rural Malawi.
abstract: The incidence of cervical cancer in Malawi is the highest in the world and projected to increase in the absence of interventions. Although government policy supports screening using visual inspection with acetic acid (VIA), screening provision is limited due to lack of infrastructure, trained personnel, and the cost and availability of gas for cryotherapy. Recently, thermo-coagulation has been acknowledged as a safe and acceptable procedure suitable for low-resource settings. We introduced thermo-coagulation for treatment of VIA-positive lesions as an alternative to cryotherapy within a cervical screening service based on VIA, coupled with appropriate, sustainable pathways of care for women with high-grade lesions and cancers. Detailed planning was undertaken for VIA clinics, and approvals were obtained from the Ministry of Health, Regional and Village Chiefs. Educational resources were developed. Thermo-coagulators were introduced into hospital and health centre settings, with theoretical and practical training in safe use and maintenance of equipment. A total of 7,088 previously unscreened women attended VIA clinics between October 2013 and March 2015. Screening clinics were held daily in the hospital and weekly in the health centres. Overall, VIA positivity was 6.1%. Almost 90% received same day treatment in the hospital setting, and 3- to 6-month cure rates of more than 90% are observed. Thermo-coagulation proved feasible and acceptable in this setting. Effective implementation requires comprehensive training and provider support, ongoing competency assessment, quality assurance and improvement audit. Thermo-coagulation offers an effective alternative to cryotherapy and encouraged VIA screening of many more women.
authors.affiliation: Usher Institute for Population Health Sciences and Informatics, Teviot Place, University of Edinburgh, EH8 9AG, United Kingdom.
authors.forename: Christine
authors.identifier: 0000-0003-4868-0554
authors.initials: C
authors.lastname: Campbell
authors.affiliation: Nkhoma CCAP Hospital, PO Box 48, Nkhoma, Malawi.
authors.forename: Savel
authors.initials: S
authors.lastname: Kafwafwa
authors.affiliation: Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom.
authors.forename: Hilary
authors.initials: H
authors.lastname: Brown
authors.affiliation: Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom.
authors.forename: Graeme
authors.initials: G
authors.lastname: Walker
authors.affiliation: Nkhoma CCAP Hospital, PO Box 48, Nkhoma, Malawi.
authors.forename: Belito
authors.initials: B
authors.lastname: Madetsa
authors.affiliation: Department of Gynaecology, Stobhill Hospital, Glasgow, G21 3UW, United Kingdom.
authors.forename: Miriam
authors.initials: M
authors.lastname: Deeny
authors.affiliation: Nkhoma CCAP Hospital, PO Box 48, Nkhoma, Malawi.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Kabota
authors.affiliation: Nkhoma CCAP Hospital, PO Box 48, Nkhoma, Malawi.
authors.forename: David
authors.initials: D
authors.lastname: Morton
authors.affiliation: Nkhoma CCAP Hospital, PO Box 48, Nkhoma, Malawi.
authors.forename: Reynier
authors.initials: R
authors.lastname: Ter Haar
authors.affiliation: Global Health Academy, University of Edinburgh, 1 George Square, Edinburgh, EH8 9JZ, United Kingdom.
authors.forename: Liz
authors.initials: L
authors.lastname: Grant
authors.affiliation: Global Health Academy, University of Edinburgh, 1 George Square, Edinburgh, EH8 9JZ, United Kingdom.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Cubie
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D055088:Early Detection of Cancer / Q000379:methods; D004564:Electrocoagulation / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008403:Mass Screening; D008875:Middle Aged; D012307:Risk Factors; D012424:Rural Population; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D055815:Young Adult
keywords: VIA; ablative treatment; cervical screening; thermo-coagulation; ‘screen and treat’