12 GLOBAL HEALTH CHALLENGES

Women as Agents of Positive Change in Biosecurity –Roundtable Discussion at the 6th Annual International Symposium on Biosecurity and Biosafety: Future Trends and Solutions, 4-6 Nov 2016, co-chaired by Ambassador Bonnie Jenkins and Dr. Dana PerkinsPH

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FALL 2016 | CGHD.ORG 13

Global Health Security

The Role of Training and

Quality Assurance in Improving Cervical Cancer Screening in Low-Resource

SettingsARIEL BEERY

Co-founder and Chief Executive Officer of MobileODT,

With 528,000 new cases each year and over 250,000 deaths [1], cervical cancer is the fourth most

common cause of death from cancer in women globally and a leading cause of death from cancer for women in low-resource settings (LRS).

FALL 2016 | CGHD.ORG 1514 GLOBAL HEALTH CHALLENGES

• Improving diagnostic decisions, by connecting clinics and hospitals to medical consultants;

• Further developing capacity for healthcare providers to provide accurate and appropriate diagnosis through remote consultation and supervision, which improves the practitioners’ confidence and accuracy;

• Improving the experience of the clinical encounter through technology-based sensitization by enabling a patient to see her cervix and educating her on cervical cancer (Image 1); and

• Digitally capturing data more accurately for robust monitoring and evaluation

Additionally, since the EVA System is based on a mobile platform, and most health providers even in LRS are well-versed in the use of smartphones, the System is easy to use and quick to implement and scale (Image 2). With the EVA System, cervical cancer screening programs can quickly and cost effectively implement quality assurance for comprehensive oversight[8] and for continued training of the frontline health workforce.[9]

Ensuring Quality Using the EVA System:One program that has benefited from the EVA System

already is Grounds for Health (GFH), a Vermont-based NGO whose clinics have been using the EVA System in Nicaragua, Peru, and Ethiopia. GFH trains healthcare providers in VIA and works with local staff to provide on-

site supportive supervision. Delivering consistent, effective services is a top priority for GFH, yet supervision and quality-assurance for screeners is resource-intensive, and the distance between clinics makes it nearly impossible to provide continual consultation and ongoing training to the health providers at all facilities.

For this reason, GFH approached MobileODT in 2015 to introduce the EVA System to their facilities as a training tool for their local staff, with the aim of increasing the capacity of all health providers and of ensuring quality of screening across health facilities.  

By incorporating the EVA System into their program over the past year, local GFH staff have been able to capture cervical images and diagnostic decisions at the point of care, and share the data with clinical consultants around the globe to allow for remote supervision and quality assurance.

The team meets on a monthly basis to discuss particular cases for review, using the EVA System’s online web-portal. The field staff opens the portal while in the field, the clinical experts in Vermont open the web-portal from the US, and together the clinical team review cases captured that month and discuss best practices for diagnosis and treatment. This process of ongoing communication allows for ongoing capacity-building of the field staff and ensures the quality of the screening services provided to women.

Conclusion:The key to early treatment of cervical cancer is early

diagnosis, and a critical component of accurate, early diagnosis is highly trained health providers. In LRS settings, technology such as the EVA System can play a key role in the success of screening programs by providing a platform for ongoing

Deaths due to cervical cancer are largely preventable and can tragically strike during the middle of a woman’s most productive years, and when she has young children and growing families who depend on her.

It is widely believed that increasing access to regular cervical cancer screening in LRS would reduce mortality from the disease [2]; if pre-cancerous growths from a viral infection from HPV are caught in their first five years, treatment can be administered at a low-cost in virtually any setting. However, lack of infrastructure and shortage of experts make standard cervical cancer screening (Pap and HPV testing) inaccessible to many women. An alternative screening approach developed to address these challenges is Visual Inspection with Acetic Acid (VIA), a method in which a nurse or midwife applies a diluted acetic acid solution (3%-5% white vinegar) to a patient’s cervix and visualizes it from outside the vaginal canal with the naked eye.[3]. Pre-cancerous and cancerous lesions turn white after a few minutes of applying the acetic acid, and can be identified by trained healthcare providers. The low cost of the test (approximately $6 per test) and relative ease of implementation of VIA programs make it an appealing option for many cervical cancer screening programs, particularly when coupled with onsite treatment of suspicious lesions with cryotherapy ($28 per application ) [4]. For this reason, the World Health Organization has recommended VIA for low-resource settings in which Pap- or HPV-based screening programs are unfeasible [5].

Today VIA is practiced by health providers in over 70 countries around the world, and has been studied and debated extensively as a low-cost screening alternative. Nevertheless, while VIA expands access to screening, VIA programs face several challenges mainly resulting from the difficulty of providing quality clinical supervision to nurses and midwives performing the examination. VIA suffers from a positive predictive value (PPV) of only 17percent: approximately five of six positive diagnoses are false [6]. This leads to misdiagnosis, costing under-resourced health systems money in cases of over-diagnosis, and to untimely death in cases of under-diagnosis.

Training on VIA ranges from 4-10 days, after which diagnosis is dependent on the health provider’s assessment. Misdiagnosis is usually a challenge with newly trained providers who need close mentoring. In addition, lack of tools for monitoring and evaluation (M&E) make it difficult for the larger program to know which nurses need further instruction to provide the highest level of care. The limited supervision and broad reach of the clinics sometimes leads to inconsistencies in the standard of care provided to women. Quality assurance is therefore key to ensuring the reduction in cervical cancer death rates. The authors of a well-designed and executed study in South Africa even stated that “Quality assurance [using digital cervicography, a method whereby images of the cervix are captured during the examination and transmitted for review] should form the

cornerstone of any VIA program to improve sensitivity in detecting CIN 2+ lesions.”[7]

Digital Cervicography for Quality Assurance in Screening Programs:

Quality assurance (QA) is a process in which a reviewer looks at patient cases from a health provider and determines whether she or he is in agreement with the provider’s diagnosis and treatment for the patient. QA should be conducted on a regular basis by organizations as part of both supervision and monitoring and evaluation to ensure that the health services provided are high quality. Following a review session, reviewers can generate a report. There are three main objectives to reporting:

• Develop a holistic picture of how the organization is performing in terms of the quality of services provided to patients

• Identify patients that should be brought back into care due to under-diagnosis

• Identify providers that are underperforming and should receive additional training or supervision

However, QA supervision is resource-intensive and is consequently limited in most cervical cancer screening programs in LRS.

The Enhanced Visual Assessment (EVA) System, developed by MobileODT, has been specifically designed to facilitate QA and the ongoing supervision and training of health providers in LRS through digital cervicography. In digital cervicography (DC), the provider photographs the cervix following VIA using a high-magnification camera. With the EVA System, QA programs for VIA can be quickly and cost effectively implemented using DC as the modality of comprehensive oversight and continued training of the frontline workforce.

The EVA System is compact and composed of three main elements: a handheld medical device with polarized magnification lens and rechargeable light-source (the Scope), a mobile phone based application for patient data capture and image documentation (the App), and an online web-portal for quality control and monitoring and evaluation (the Portal) (Figure 1).

Using the EVA System, advanced practitioners are able to review and consult remotely with nurses at other facilities. The technology provides an opportunity for consultation and expert opinion by connecting clinicians in any setting to advanced clinical consultants, thereby improving diagnosis and building local capacity at a lower cost.

By implementing the EVA System, programs are able to ensure the highest standards of care for every woman, regardless of her socio-economic background through the following:

Figure 1. The EVA System app, scope and online web-portal.

FALL 2016 | CGHD.ORG 1716 GLOBAL HEALTH CHALLENGES

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supportive supervision of health providers and the existence of quality assurance checks.  By facilitating communication between health providers across settings, technologies such as the EVA System develop a health system partnership on a

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Image 1. Nurses educating patients on cervical cancer using the EVA System to show patients an image of their cervix.

Image 2. Training of nurses on the EVA System at a screening camp for World Cancer Day in Nyeri, Kenya, February 2016

global scale that makes high-quality cervical cancer screening accessible to women at all settings, to prevent unnecessary deaths from cervical cancer. GHD

REFERENCES1. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality, and Prevalence Worldwide in 2012. In Proceedings of the IARC 2014, Brussels,

Belgium, 19–21 March 2014.2. Denny, L. Cervical cancer prevention: New opportunities for primary and secondary prevention in the 21st century. Int. J. Gynecol.

Obstet. 2012, 119, S80–S84.3. Sankaranarayanan, R.; Wesley, R.; Somanathan, T.; Dhakad, N.; Shyamalakumary, B.; Sreedevi Amma, N.; Maxwell Parkin, D.; Nair, M.K.

Visual Inspection of the Uterine Cervix after the Application of Acetic Acid in the Detection of Cervical Carcinoma and Its Precursors. Cancer 1998, 83, 2150–2156.

4. Quentin, W.; Adu-Sarkodie, Y.; Terris-Prestholt, F.; Legood, R.; Opoku, B.K.; Mayaud, P. Costs of cervical cancer screening and treatment using visual inspection with acetic acid (VIA) and cryotherapy in Ghana: The importance of scale. Trop. Med. Int. Health 2011, 16, 379–389.

5. World Health Organization. Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention; World Health Organization: Geneva, Switzerland, 2013.

6. Sankaranarayanan, R.; Wesley, R.; Somanathan, T.; Dhakad, N.; Shyamalakumary, B.; Sreedevi Amma, N.; Maxwell Parkin, D.; Nair, M.K. Visual Inspection of the Uterine Cervix after the Application of Acetic Acid in the Detection of Cervical Carcinoma and Its Precursors. Cancer 1998, 83, 2150–2156.

7. Firnhaber, Cynthia, et al. “Evaluation of a cervicography-based program to ensure quality of visual inspection of the cervix in HIV-infected women in Johannesburg, South Africa.” Journal of lower genital tract disease 19.1 (2015): 7-11.

8. Firnhaber, Cynthia, et al. “Evaluation of a cervicography-based program to ensure quality of visual inspection of the cervix in HIV-infected women in Johannesburg, South Africa.” Journal of lower genital tract disease 19.1 (2015): 7-11.

9. Soutter, W. P., et al. “Cervicography in a colposcopy clinic.” Journal of Obstetrics and Gynaecology 11.3 (1991): 218-220.