Prospects and Challenges in the Introduction of Human Papillomavirus Vaccines in the Extended Middle East and North Africa Region

Determinants of human papillomavirus vaccine hesitancy among Lebanese parents

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV is responsible for cancer of cervix uteri. Despite its safety and immunogenicity, HPV vaccine hesitancy is one of the most challenging topics that pediatricians face.

METHODS

We aimed to describe the impact of knowledge, attitude, and practice towards vaccines in general, on practice related to HPV vaccination in Lebanon. A questionnaire addressed to parents of students (3-18 years of age) was distributed in 2 public and 2 private schools randomly selected from the greater Beirut area during the school year 2017-2018. Questionnaires covered knowledge, attitude, and practices of vaccination in general and HPV vaccine in particular.

RESULTS

Out of 400 distributed questionnaires, 306 (76.5%) were returned. Of the 185 parents aware of HPV vaccine, 60% hadn't given or were not planning to give the HPV vaccine to their children. Of parents not in favor of HPV vaccine, 7.5 thought that vaccines aren't necessary versus none among those in favor of HPV vaccine(p = 0.02). Thirteen percent of those not in favor of HPV vaccine thought that vaccines are not safe versus 2.7% in the group in favor (p = 0.02). An effect of gender on vaccine acceptance was noted: mothers vs fathers and daughters vs sons. Lack of recommendation by pediatricians and the thought that too little is known about the vaccine were the most selected reasons for parents not wanting to vaccinate their children against HPV, whereas cost and religious and cultural beliefs seemed to have no impact.

CONCLUSION

Most parents in our study did not vaccinate or weren't willing to vaccinate their children against HPV even when they were in favor of vaccines in general. Physician recommendation was shown to be one of the most important predictors of vaccination. Effort should be put into educating parents about the importance of the vaccine and its well-established safety and efficacy regardless of gender. Lebanese physicians should also be educated and empowered to recommend HPV vaccine more strongly and consistently.

Policy analysis of cervical cancer prevention in Iran based on the policy triangle model

BACKGROUND

Widespread use of screening in high-income countries has led to a significant reduction in cervical cancer mortality. Most low- and middle-income countries still have poorly organized screening programs. This study aimed at policy analysis of prevention and early detection of cervical cancer in Iran, a middle-income country.

MATERIALS AND METHOD

This qualitative retrospective study, extended by the health policy triangle model, was conducted from July 2020 to September 2021. A sample of this study consisted of 43 participants, including 16 key policy experts; nine 11 senior health system managers, 13 executives, and 3 clients selected purposefully. Data were collected through semi-structured interviews using the interview guide and analyzed using a framework analysis method based on the policy triangle model in MAXQDA2020.

RESULTS

Nine themes, 15 subthemes, and 36 codes were extracted based on the 4 dimensions of the model; stakeholder analysis challenges, including conflict of interest and decision-making challenges. Moreover, the most important policy process challenges indicated the weakness of monitoring and evaluation systems and weakness of using scientific principles in policy making. Weakness of organizational and intersectoral structure and weakness of executive management were obtained among the challenges in the context analysis. Finally, the most important challenges related to content analysis are weaknesses in applying scientific principles in policy making, including weaknesses in standard operating procedures, and low use of HTA capacity in developed guidelines.

CONCLUSION

A wide range of economic, social, and cultural problems can affect cervical cancer prevention policies. Several strategies are suggested to overcome these challenges, including allocating separate funds to cancer prevention programs, using structures to sustain prevention programs, designing, and using them to improve public awareness.

Cervical Cancer Awareness and Attitude Towards Cervical Cancer Screening and Human Papillomavirus Vaccines Among Urban Women of Karachi, Pakistan

Cervical cancer is the second most common cancer among women under 50 years of age in Pakistan. The current study was designed to assess the level of awareness through educational outreach presentations about cervical cancer, Papanicolaou (Pap) smear test, and human papillomavirus (HPV) vaccination in Karachi, Pakistan. Women from different urban hospitals were enrolled. Participants participated in a 45-minute presentation on cervical cancer awareness led by student pharmacists from Nazeer Hussain University, Karachi. A pre-and post-test was administered to assess the impact of the intervention. Descriptive statistics were used to summarize the findings, and a t-test was used for matched comparison, and a p-value <0.05 for statistical significance. A total of 150 women participated in the study. The study found that Pakistani women living in urban settings were less knowledgeable about the causes of cervical cancer and prevention. After the presentation, we observed a 45% increase in knowledge, and 31% of participants said they would obtain a Pap smear test in the next six months. Supervised pharmacy student-led presentations on cervical cancer educational awareness that significantly impacted women participants. Pharmacists can play a key role in reducing cervical cancer deaths through increased awareness, education, prevention, and immunization.

Costs and Resource Use Among Patients with Cervical Cancer, Cervical Intraepithelial Neoplasia, and Genital Warts in Algeria

Background: Cervical cancer rates in North Africa have risen in the last 10 years, suggesting that this region might benefit from cervical cancer screening and HPV vaccination programs. To assess the potential benefits of cervical cancer screening and HPV vaccination in North African countries, country-specific data on the prevalence and burden of HPV-related conditions are needed. Objectives: To describe the patterns and estimate the costs of management of cervical cancer, cervical intraepithelial neoplasia (CIN), and genital warts in Algeria. Methods: This was a descriptive analysis of questionnaire data obtained from a panel of 15 oncologists, gynecologists, and dermatologists (n=5 each). Data on diagnostic and treatment patterns, recurrence, and healthcare resource use (HCRU) were obtained. The costs (in Algerian dinars) associated with diagnosis, treatment, and recurrence were estimated. Results: Diagnosis of CIN was obtained by cytology tests or lesion biopsies; for cervical cancer, lesion biopsies, MRI, and CT scans were the most common diagnostic tests. For CIN, 70% of gynecologists and/or oncologists regularly or always used conization as a treatment. Treatments used regularly or always for cervical cancer included chemotherapy (80%), hysterectomy (70%), and radiation (70%). Annual HCRU per institution included 20 outpatient visits and 15 hospitalizations for CIN, and 50 outpatient visits and 11 hospitalizations for cervical cancer. For genital warts, diagnostic tests performed regularly or always included assays for hepatitis B, hepatitis C, HIV, and syphilis; cervical cytology; and colposcopy. Cryotherapy was the universal first-line treatment. Median per-patient costs associated with diagnosis, treatment, and recurrence were 6750, 19 750, and 77 750, respectively, for CIN; 53 750, 650 000, and 431 250, respectively, for cervical cancer; and 16 075, 15 500, and 9250, respectively, for genital warts. Discussion: These results give an estimate of the HCRU and cost of cervical cancer, CIN, and genital warts and highlight the need to assess more precisely the epidemiology of these diseases in Algeria. Conclusions: This study investigated the management of patients with cervical cancer, CIN, or genital warts in Algeria and provided the first estimates of diagnosis and treatment patterns, HCRU, and costs associated with these conditions. These resource use and cost estimates highlight the need to develop prevention strategies for HPV-related pathologies.

Does Social and Religious Background Matter? A Study of the Psychosocial Impact of Human Papillomavirus on Lebanese Women

OBJECTIVE

The human papillomavirus (HPV) has been associated with an important psychosocial impact. This impact has been poorly evaluated in developing countries, mostly because of the lack of instruments to quantify it. The HIP questionnaire aims to measure HPV-associated affective burden. Our team has previously translated this questionnaire to Arabic and used it to assess the impact of HPV on Lebanese women.

MATERIALS AND METHODS

While the HIP is a specific tool to evaluate the emotional impact of HPV, the Hospital Anxiety and Depression Scale questionnaire consists of 2 scales, anxiety and depression, and assess the psychological distress in nonpsychiatric patients. The HPV impact profile and Hospital Anxiety and Depression Scale questionnaires were administered to 118 Lebanese women with an HPV-related presentation, aiming to determine which aspect of these women's lives was mostly affected. The association with different sociodemographic factors was also assessed.

RESULTS

Feelings of "concerns and worries" were mostly strongly felt in our population except for women with genital warts who were more concerned with the risk of transmission and the impact on their partners. All women had predominant feelings of anxiety.Religion was a statistically significant influencing factor and employment a protective factor. Muslim women demonstrated significant adverse affects on HPV impact profile domains that included: "sexual impact," "self-image," "interaction with doctors," and "health control/life impact."

CONCLUSIONS

Different women perceive the diagnosis of HPV and HPV-related lesions differently. In this study, employment was found to play a protective role, but the biggest influencers were social and religious beliefs.

Healthcare resource utilization and costs associated with anogenital warts in Morocco

Background

Human papillomavirus (HPV), primarily genotypes 6 and 11, cause the majority of cases of anogenital warts (AGW). Although benign, AGW are associated with a substantial economic and psychosocial burden. Several vaccines have been developed to prevent HPV. The objective of this study was to describe the epidemiology and healthcare resource utilization of AGW in Morocco, as well as the associated costs of treatment from the public healthcare perspective.

Methods

This was a descriptive analysis of questionnaire data obtained via a Delphi panel. The panel consisted of 9 physicians practicing in public hospitals in Morocco (4 dermatologists and 5 obstetricians/gynecologists). The questionnaire collected data on physician and practice characteristics, diagnostic tests and procedures, treatments, and follow-up (including recurrence) of patients with AGW. Questionnaire items on which ≥ 70% of respondents agreed were considered as having consensus. Costs associated with diagnosis, treatment, and follow-up were calculated in Moroccan dirham (MAD) and converted to euros (€) based on official national price lists for public hospitals and the HCRU estimates from the questionnaire.

Results

The physician-estimated prevalence of AGW in Morocco was 1.6%-2.6% in women and 2.0%-5.3% in men. A mean (median) of 6.4 (4) patients per month per physician sought medical attention for AGW. Simple observation was the most common diagnostic method for AGW in both men and women, and excision was the most prescribed therapy (75%), requiring a mean of 2 visits. Recurrence occurred in approximately 27% of patients. The cost per case of managing AGW, including recurrence, was estimated at 2182–2872 MAD (€207–272) for women and 2170–2450 MAD (€206–233) for men. The total annual cost of medical consultations for AGW in Morocco ranged from 3,271,877 MAD to 4,253,703 MAD (€310,828–404,102).

Conclusions

Expert consensus indicates that AGW represent a significant burden to the Moroccan public healthcare system. These data can inform policy makers regarding this vaccine-preventable disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13027-021-00403-1.

Knowledge about cervical cancer and awareness about human papillomavirus vaccination among medical students in Jordan

Objectives

To assess the knowledge about cervical cancer and HPV infection and the awareness towards and perceived barriers of HPV vaccination amid medical students in Jordan.

Methods

The present study is a cross-sectional survey that was conducted for a period of three months in the College of Medicine at six different universities in Jordan. Third-year to sixth-year students from these medical colleges in Jordan were invited to participate in the study.

Results

There were 504 students that took part in the study with 42.3% being males and 57.7% females. The mean knowledge score of students in our survey was 21.4 ± 4.4 out of 34, which was categorized as a moderate level of knowledge regarding cervical cancer and HPV. Only 40.5% knew about the availability of the HPV vaccine in Jordan, and 65.9% accepted the idea that it is necessary to introduce the HPV vaccine for school girls in Jordan.

Conclusions

This study highlights that there is inadequate knowledge about cervical cancer and its screening among medical students in Jordan. Despite the limited awareness about the HPV vaccine among the study’s participants, there is a favorable opinion towards the introduction of the vaccine for school girls in Jordan. The data provide a benchmark on the level of knowledge about cervical cancer and awareness about HPV, which can be used to formulate an effective awareness program.

Awareness and knowledge of human papillomavirus vaccination and their influential factors among Chinese women: a systematic review

Objectives

To systematically review the knowledge attitudes and the influential factors on human papillomavirus (HPV) vaccination among Chinese women.

Methods

Published studies on knowledge and attitudes of HPV vaccination for preventing cervical cancer among Chinese female population were retrieved using the major Chinese and English databases. Meanwhile, handwork retrieval was also conducted and the references including in the literature were retrieved. The quality of the literature was rigorously evaluated and extracted independently by two researchers and the data were analyzed and described by review manager 5.3 (RevMan5.3) software.

Results

In all, 19 articles including 8 articles in Chinese and 11 in English were chosen. A total of 30,176 participants were included and the sample size ranged from 64 to 6,024. The overall awareness of HPV and HPV vaccine among Chinese women was at a low level. Chinese women generally showed poor knowledge about HPV and HPV vaccine. Acceptance of HPV vaccination among Chinese women was at a high level. Vaccination intentions were influenced by the theory of planned behavior (TPB) and measured by attitudes subjective norms and perceived behavioral control.

Conclusions

The health authorities may evaluate and develop TPB-based interventions to increase HPV vaccination intentions of Chinese women. HPV vaccination programs should focus on carrying out multi-level and targeted health education and developing effective public health strategies after balancing the cost and benefit of HPV vaccine program. Medical staff should play the positive role in promoting the use of HPV vaccines in China. Integration of policy and community perspectives and multi-level interventions are essential to maximize the public health benefits of HPV vaccination.

Knowledge, Attitude, and Barriers Towards Human Papillomavirus (HPV) Vaccination Among Youths of Karachi, Pakistan

Introduction Human papillomavirus (HPV) is the most common infection of the reproductive tract. The introduction of HPV vaccines by WHO aims to reduce the incidence of cervical cancer. Pakistan lacks an effective nationwide HPV vaccination program, thereby making HPV a major threat. In this study, we aimed to assess the knowledge of HPV vaccination in Pakistan and to determine the barriers against it. Methods A cross-sectional study was conducted in Karachi, Pakistan, between April and May 2019. A convenience sampling technique was implemented using a self-administered questionnaire, which was filled by individuals aged 18-26. The questionnaire assessed the knowledge regarding HPV and also evaluated the attitude and acceptability amongst these individuals towards the vaccine. Data were analyzed using Statistical Package for Social Sciences (SPSS), version 20.0. Results The majority of the participants belonged to the monthly household income range of 200,000 rupees and above, which was labeled as the high-income category (n=158, 39.5%). Out of the 18 people who were vaccinated, eight belonged to the aforementioned category. Of these 18, nearly two-thirds (n=11, 61.1%) had gotten vaccinated upon the recommendation of their doctor. A statistically significant difference was found only between those currently enrolled in universities and previously vaccinated for HPV (p=.047). Nearly half of the responders perceived the vaccine to be time-consuming (n=167, 41.8%) and overpriced (n=187, 46.8%). Conclusion The vaccination rate is low in Karachi, Pakistan. Concentrated efforts involving the healthcare system should be made to raise awareness regarding HPV and its vaccine thereby reducing barriers to HPV prevention.

The impact of teachings on sexuality in Islam on HPV vaccine acceptability in the Middle East and North Africa region

The human papilloma virus (HPV) vaccine is the recommended prevention strategy for viruses-related cancers, but its acceptability remains controversial, primarily because of the relationship between sexual activity and HPV infection. Countries in the Middle East and North Africa are conservative vis-à-vis sexual behaviors, where Islam shapes people's practices including sexual health, and imposes that sex be carried out within lawful context. Many sexually transmitted infections can be prevented if the rules of Islam are unfailingly applied by Muslims in that region. However, this is not guaranteed and a noticeable shift in the sexual behavior of the youth has been detected, including a drastic increase in unofficial sexual practices, which in the long-term increase HPV incidence and its related diseases. This study examines the available epidemiological data as well as the teachings in Islam's sacred texts and scholars' perspectives to describe the tensions that exist in Muslim cultures around sexuality. Understanding their influence and the function of these tensions can help illuminate the factors that contribute to barriers to accepting the vaccine.

Challenges in Cost-Effectiveness Analysis Modelling of HPV Vaccines in Low- and Middle-Income Countries: A Systematic Review and Practice Recommendations

BACKGROUND

Low- and middle-income countries (LMICs) face a number of challenges in implementing cervical cancer prevention programmes that do not apply in high-income countries.

OBJECTIVE

This review assessed how context-specific challenges of implementing cervical cancer prevention strategies in LMICs were accounted for in existing cost-effectiveness analysis (CEA) models of human papillomavirus (HPV) vaccination.

METHODS

The databases of MEDLINE, EMBASE, NHS Economic Evaluation Database, EconLit, Web of Science, and the Center for the Evaluation of Value and Risk in Health (CEA) Registry were searched for studies published from 2006 to 2015. A descriptive, narrative, and interpretative synthesis of data was undertaken.

RESULTS

Of the 33 studies included in the review, the majority acknowledged cost per vaccinated girl (CVG) (26 studies) and vaccine coverage rate (21 studies) as particular challenges for LMICs, while nine studies identified screening coverage rate as a challenge. Most of the studies estimated CVG as a composite of different cost items. However, the basis for the items within this composite cost was unclear. The majority used an assumption rather than an observed rate to represent screening and vaccination coverage rates. CVG, vaccine coverage and screening coverage were shown by some studies through sensitivity analyses to reverse the conclusions regarding cost-effectiveness, thereby significantly affecting policy recommendations.

CONCLUSIONS

While many studies recognized aspects of the particular challenges of HPV vaccination in LMICs, greater efforts need to be made in adapting models to account for these challenges. These include adapting costings of HPV vaccine delivery from other countries, learning from the outcomes of cervical cancer screening programmes in the same geographical region, and taking into account the country's previous experience with other vaccination programmes.

Cost-effectiveness of increasing cervical cancer screening coverage in the Middle East: An example from Lebanon

BACKGROUND

Most cervical cancer (CC) cases in Lebanon are detected at later stages and associated with high mortality. There is no national organized CC screening program so screening is opportunistic and limited to women who can pay out-of-pocket. Therefore, a small percentage of women receive repeated screenings while most are under-or never screened. We evaluated the cost-effectiveness of increasing screening coverage and extending intervals.

METHODS

We used an individual-based Monte Carlo model simulating HPV and CC natural history and screening. We calibrated the model to epidemiological data from Lebanon, including CC incidence and HPV type distribution. We evaluated cytology and HPV DNA screening for women aged 25-65years, varying coverage from 20 to 70% and frequency from 1 to 5years.

RESULTS

At 20% coverage, annual cytologic screening reduced lifetime CC risk by 14% and had an incremental cost-effectiveness ratio of I$80,670/year of life saved (YLS), far exceeding Lebanon's gross domestic product (GDP) per capita (I$17,460), a commonly cited cost-effectiveness threshold. By comparison, increasing cytologic screening coverage to 50% and extending screening intervals to 3 and 5years provided greater CC reduction (26.1% and 21.4, respectively) at lower costs compared to 20% coverage with annual screening. Screening every 5years with HPV DNA testing at 50% coverage provided greater CC reductions than cytology at the same frequency (23.4%) and was cost-effective assuming a cost of I$18 per HPV test administered (I$12,210/YLS); HPV DNA testing every 4years at 50% coverage was also cost-effective at the same cost per test (I$16,340). Increasing coverage of annual cytology was not found to be cost-effective.

CONCLUSION

Current practice of repeated cytology in a small percentage of women is inefficient. Increasing coverage to 50% with extended screening intervals provides greater health benefits at a reasonable cost and can more equitably distribute health gains. Novel HPV DNA strategies offer greater CC reductions and may be more cost-effective than cytology.

Social mobilisation, consent and acceptability: a review of human papillomavirus vaccination procedures in low and middle-income countries

BACKGROUND

Social mobilisation during new vaccine introductions encourages acceptance, uptake and adherence to multi-dose schedules. Effective communication is considered especially important for human papillomavirus (HPV) vaccine, which targets girls of an often-novel age group. This study synthesised experiences and lessons learnt around social mobilisation, consent, and acceptability during 55 HPV vaccine demonstration projects and 8 national programmes in 37 low and middle-income countries (LMICs) between January 2007 and January 2015.

METHODS

A qualitative study design included: (i) a systematic review, in which 1,301 abstracts from five databases were screened and 41 publications included; (ii) soliciting 124 unpublished documents from governments and partner institutions; and (iii) conducting 27 key informant interviews. Data were extracted and analysed thematically. Additionally, first-dose coverage rates were categorised as above 90 %, 90-70 %, and below 70 %, and cross-tabulated with mobilisation timing, message content, materials and methods of delivery, and consent procedures.

RESULTS

All but one delivery experience achieved over 70 % first-dose coverage; 60 % achieved over 90 %. Key informants emphasized the benefits of starting social mobilisation early and actively addressing rumours as they emerged. Interactive communication with parents appeared to achieve higher first-dose coverage than non-interactive messaging. Written parental consent (i.e., opt-in), though frequently used, resulted in lower reported coverage than implied consent (i.e., opt-out). Protection against cervical cancer was the primary reason for vaccine acceptability, whereas fear of adverse effects, exposure to rumours, lack of project/programme awareness, and schoolgirl absenteeism were major reasons for non-vaccination.

CONCLUSIONS

Despite some challenges in obtaining parental consent and addressing rumours, experiences indicated effective social mobilisation and high HPV vaccine acceptability in LMICs. Social mobilisation, consent, and acceptability lessons were consistent across world regions and HPV vaccination projects/programmes. These can be used to guide HPV vaccination communication strategies without additional formative research.

Prevalence, Genotype Distribution and Risk Factors for Cervical Human Papillomavirus Infection in the Grand Tunis Region, Tunisia

Implementation of Human Papillomavirus (HPV) vaccination should be considered a key cervical cancer prevention strategy in Tunisia, where Pap smear screening is not efficient. This study aims to estimate the prevalence and to identify risk factors associated with HPV infection among women from Grand Tunis, Tunisia. We conducted a cross-sectional study, between December 2012 and May 2013. Eligible women for this study were those aged 18–65 years, sexually active, who sought medical attention at their primary health care centre or clinic in Grand Tunis, Tunisia and who gave written consent. A liquid-based Pap smear sample was obtained from all women using a cervical brush. Only women with betaglobin positive test were further analysed for HPV detection and typing. A nested-PCR of the L1 region was performed followed by reverse line blot hybridization to facilitate the specific detection of 31 HPV genotypes. Multiple logistic regression modeling was used for the analysis of associations between variables with some considered possible confounders after checking for interactions. A total of 391 women were enrolled in this study and 325 out of the 391 cervical samples were positive for the betaglobin test. Overall HPV prevalence was 13.2% [9.8%−17.5%], with the following most prevalent HPV genotypes: HPV6 (40%), HPV40 (14%), HPV16 (12%), HPV52 (9%), HPV31 and HPV59 (7%), followed by HPV68 (4%). Mean age of HPV positive women was 40.7±0.92 years. Independently associated risk factors of HPV infection were smoking (OR:2.8 [0.8–9.6]), low income (OR:9.6 [1.4–63.4), bad housing type (OR:2.5 [1–6.8]), partner with multiple sexual relationship (OR:4.5 [0.9–22.9]) and single women (widowed, divorced, separated, never married) (OR:6.9 [1.1–42.2]). This study provides the first national-based estimate of HPV prevalence in Tunisia. Our findings contribute to the evidence on the current burden of HPV infection, the critical role of sexual behaviour and socioeconomic status and call for increased support for the screening program in Tunisia to prevent cervical cancer. These results allow us to evaluate the cost-effectiveness of vaccine program implementation in Tunisia in future.

Mothers' willingness to pay for HPV vaccines in Anambra state, Nigeria: a cross sectional contingent valuation study

BACKGROUND

Human papilloma virus (HPV) vaccination in Nigeria will require substantial financing due to high cost of HPV vaccine and inexistence of structures to support adolescent vaccination. Alternative sources are needed to sustain the government funded HPV vaccination programme. This study assessed Nigerian mothers' willingness-to-pay (WTP) for HPV vaccine. We also compared the difference between the average WTP and estimated costs of vaccinating a pre-adolescent girl (CVG).

METHODS

We conducted a quantitative, cross-sectional, survey-based study in which 50 questionnaires were distributed to each of 10 secondary schools located in two rural and one urban city in Anambra state. The questionnaires were then randomly distributed to girls aged 9-12 years of age to give to their mothers. Contingent valuation approach using the payment card technique was used to estimate the average maximum WTP among the survey participants. Correlates of WTP for HPV vaccination were obtained using multivariate logistic regression. Estimated CVG was obtained by adapting cost of HPV vaccine delivery in Tanzania to the Nigerian setting.

RESULTS

A total of 438 questionnaires (88 %) were returned. The average WTP was US$ 11.68. This is opposed to estimated delivery cost of US$ 18.16 and US$ 19.26 for urban and rural populations respectively at vaccine price offered by the Vaccine Alliance (Gavi) and US$ 35.16 and US$ 36.26 for urban and rural populations respectively at the lowest obtainable public sector vaccine price. Demand for HPV vaccine was deemed high (91.6 %) and was significantly associated with respondents previously diagnosed of HPV infection.

CONCLUSION

Demand for HPV vaccine was high although short of estimated CVG. High demand for vaccine should be capitalized upon to increase vaccine uptake. Education on cervical cancer and provider-initiated vaccination should be promoted to increase vaccine uptake. Co-payment could be a feasible financing strategy in the event of national HPV vaccination.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Distribution of Carcinogenic Human Papillomavirus Genotypes and Association to Cervical Lesions among Women in Fez (Morocco)

OBJECTIVES

To determine the distribution of cervical high-risk human papillomavirus genotypes and their association to cellular abnormalities in women from Fez and its neighborhood.

METHODS

Women attending the Hassan II University Hospital for cervical pap smears were recruited after an informed consent. Interviews and two cervical samples were performed for each woman. Cervical samples were used for cytological analysis and HPV DNA detection. HPV was typed using a method based on multiplex PCR with fluorescently labeled specific primers followed by capillary electrophoresis. The study was approved by the ethics committee of the Faculty of Medicine and Pharmacy of Fez.

RESULTS

The HPV prevalence in the studied population was 43.1% and the most prevalent types were HPV 53 (23 cases); HPV 16 (20 cases); HPV 35 (18 cases); HPV 51 (10 cases) and HPV 56 (7 cases). From the 619 confirmed pap smears, 20% were abnormal. The cytological abnormalities were significantly associated to HPV infection, women age, number of pregnancies and parity (p < 0.05).

CONCLUSION

More attention should be given to HPV in Morocco because it represents an important public health concern. The distribution of carcinogenic HPV types in the studied population is different from the data in other regions but epidemiological studies in other Moroccan regions are required.