Contents

Sl. Topics Page

No
Abbreviations 2
Executive Summary 4
1 Introduction 6
2 Vision and Objectives 8
3 Cervical cancer control strategies 9
3.1 Overview 9
3.2 Convergence between different health programmes 13
4 Primary Prevention: Introduction of HPV Vaccine in to National 15
Immunization Programme
4.1 Introduction 15
4.2 Key strategic directions for introduction of HPV vaccine into 19
national immunization programmes
5 Secondary Prevention: Population-Based Cancer Cervix Screening 22
5.1 Introduction 22
5.2 Key strategic directions for cancer cervix screening 29
6 Facilitating cervical cancer treatment and palliative care 31
6.1 Introduction 31
6.2 Organize facilities for staging and diagnostic work-up 32
7 Augmenting Cervical Cancer related Palliative Care 33
7.1 Introduction 33
7.2 Organizing palliative care services 33
7.3 Key strategic directions for improvement of palliative care services 34
8 Health education, awareness and community mobilization 35
8.1 Introduction 35
8.2 Key strategic directions for community mobilizations include 36
9 Monitoring, Evaluation and Cancer Registry 37
10 Advocacy 38
11 Conclusion 39
12 Annex i-x

1
Abbreviations
AHI : Assistant Health Inspector
AEFI : Adverse Event Following Immunization
ASRs : Age-Standardized Rates
BCC : Behavioural Change Communication
BSMMU : Bangabandhu Sheikh Mujib Medical University
CBHC : Community Based Health Care
CBE : Clinical Breast Examination
CC : Community Clinic
CS : Civil Surgeon
CHCP : Community Health Care Provider
CES : Coverage Evaluation Survey
CIN : Cervical Intraepithelial Neoplasia
DDFP : Deputy Director - Family Planning
DGFP : Director General of Family Planning
DGHS : Director General of Health Services
DGNM : Director General of Nursing & Midwives
DH : District Hospital
DHIS2 : Data Health Information System Version-2
DNA : Deoxyribo Nucleic Acid
EPI : Expanded Program on Immunization
FIGO : International Federation of Gynaecology and Obstetrics
FPI : Family Planning Inspector
FWA : Family Welfare Assistant
FWV : Family Welfare Visitors
GAVI : Global Alliance for Vaccines and Immunization
GAVI HSS : GAVI Health System Strengthening Support
GOB : Government of Bangladesh
HA : Health Assistant
HI : Health Inspector
HMIS : Health Management Information System
HPNSDP : Health Population and Nutrition Sector Development Program
HPNSP : Health Population and Nutrition Sector Program
HPV : Human Papillomavirus
HSIL : High-grade Squamous Intraepithelial Lesion
HRHPV : High and Intermediate Risk HPV
HSM : Hospital Service Management
ICC : Invasive Cervical Carcinoma
LBC : Liquid-Based Cytology
LEEP : Loop Electrosurgical Excision Procedure
LSIL : Low-grade Squamous Intraepithelial Lesion
MCH : Medical College Hospital
MCRAH : Maternal Child Reproductive and Adolescent Health
MDG : Millennium Development Goal
MIS : Management Information System
MO : Medical Officer
MOH&FW : Ministry of Health and Family Welfare

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MNC&AH : Maternal Newborn Child and Adolescent Health
MT-EPI : Medical Technologist-EPI
NCCBCST : National Centre for Cervical and Breast Cancer Screening and Training
NCDC : Non-Communicable Disease Control
NCIP : National Committee on Immunization Practice
NICRH : National Institute of Cancer Research & Hospital
NIP : National Immunization Programme
PATH : Program for Appropriate Technology in Health
PIP : Programme Implementation Plan
PHC : Primary Health Care
SACMO : Sub-assistant Community Medical Officers
SCC : Squamous Cell Carcinoma
SDG : The Sustainable Development Goals
SSN : Senior Staff Nurse
STD : Sexually Transmitted Diseases
UCI : Universal Child Immunization Initiative
UH&FWC : Union Health & Family Welfare Center
UHC : Upazila Health Complex
UHFPO : Upazila Health and Family Planning Officer
UICC : Union for International Cancer Control
UNFPA : United Nations Populations Fund
UNICEF : United Nations International Children’s Emergency Fund
VIA : Visual Inspection of Cervix with Acetic Acid
VILI : Visual Inspection after Application of Lugol’s Iodine
WHO : World Health Organization

3
Executive Summary

The overall objective of the strategy of prevention and control of cervical cancer in
Bangladesh is to develop broad guidelines for Government of Bangladesh (GOB) to
strengthen the National Cervical Cancer Control Programme by introducing vaccination
programme for adolescent girls against the Human Papillomavirus (HPV) through Expanded
Program on Immunization (EPI) and implementing population based organized cervical
cancer screening and treatment through public delivery system.

Cervical cancer is the 2 nd most common cancer among women in Bangladesh, and every
year 11,956 new cases of cervical cancer are detected and 6582 women die of the disease.
It is preceded by precancerous changes within cervical cells by the infection from HPV. GOB
initiated HPV demonstration program at Gazipur in August, 2015 and vaccination is in progress
since 16th April, 2016. GOB will scale up HPV vaccination programme to girls of grade V at
school and 10 years at community and a school-based vaccination programme will be
implemented. Ministry of Health and Family Welfare (MOH&FW), in collaboration with
development partners, will mobilize sufficient resources to expand immunization services once
the HPV vaccine demonstration programme is successfully completed.

Since the year 2005, GOB gradually developed opportunistic cervical cancer screening
facilities at all districts and since the year 2012 GOB is expanding the programme to the upazila
level. The programme adopted Visual Inspection of Cervix with Acetic Acid (VIA) method for
cervical cancer screening for the women 30 years and above at around 400 centres. In this
National Strategy, GOB has planned to implement organized population-based cancer
screening programme through the public health delivery system following a uniform guideline
to achieve a reasonable coverage of 40% of the target population and will develop efficient
linkage between screening and treatment of the positive cases. All ever married women
between 30 – 60 years of age will be offered screening at an interval of 5 years. VIA-based
screening will be continued for cervical cancer screening. All screen-positive women should
be counseled, further evaluated by colposcope/mini-colposcope and treated at appropriate
facilities. All colposcopy suspected cervical pre-cancers shall be treated following “see and
treat strategy” during the same visit. Adequate human resources for service delivery need to be
developed and deployed. Initiation and strengthening of various services within the existing
health infrastructure, adequate supply and maintenance of equipment and uninterrupted supply

4
of consumables should be ensured. The cancer cervix screening programme will be part of
Primary Health Care (PHC), Reproductive Health, Non-communicable Disease Control
(NCDC) programme, Hospital Service Management (HSM) and Management Information
System (MIS) of DGHS and DGFP. A mass screening policy will be taken along with
developing population based screening programme. Appropriate referral, electronic data
management system for screening and management within the health system will be organized.
Institution Heads and Gynaecology consultants of primary, secondary and tertiary level should
be responsible for implementation of services, coordination between various levels of service
delivery, and quality assurance. Detection of early cervical cancer, facilities for staging and
diagnostic workup, appropriate treatment based on stage of the disease will be ensured.
Gynaecologists, gynaecologic oncologists should be made available at all tertiary care centers
for surgical management of early-stage cancers. Radiation therapy and chemotherapy facilities
should be made available at selected tertiary care hospitals, including dedicated oncology
centers. The capacity of health systems should be improved to ensure the treatment of cancer
patients on time. An appropriate evaluation and treatment services for pre-invasive and
invasive cervical cancers such as colposcopy, thermo-coagulation, LEEP (Loop
Electrosurgical Excision Procedure), radical surgery, radiation-therapy/chemo-therapy, alone
or in combination should be established.

The concept of palliative care to policy-makers, health-care planners, administrators, and the
general people should be promoted. An inter-professional team including doctor, nurse, social
worker, counselor need to be developed to deliver the palliative care services. Availability of
essential drugs for the management of pain and other symptoms including access to an adequate
and uninterrupted supply of oral morphine at all facilities should be ensured.

GOB through several meetings designed and developed this cervical cancer control strategy
(2017 – 2022) according to the needs of the country, community, outreach and facility-based
clinical services. This strategy discusses the determinants of a successful and organized HPV
vaccination and cancer cervical screening programme. It recommends that adolescent
vaccination and cervical cancer screening services will be organized as a functional continuity
across different levels of health care delivery from community to primary health care centers
and to referral hospitals. Augmentation of cancer treatment services and improving palliative
care are also crucial components of cervical cancer control that are discussed in the strategy.

5
1. Introduction
Cervical cancer is one of the most common cancers in women across the globe, with an
estimated prevalence of 1,547,161 cases worldwide in 2012. 1Almost 80% of cervical
cancers occur in the developing countries. In Bangladesh, cervical cancer is the 2 nd most
common cancer among women, with age-standardized rates (ASRs) for incidence and
mortality much higher than the global average statistics (Incidence rates: 19.3 vs.
14.0/100,000 women; Mortality rates: 11.5 vs. 6.8/100,000 women). It is estimated that
every year 11,956 new cases of cervical cancer are detected in Bangladesh and 6582 women
die of the disease (Figure 1) 2. Cervical cancer is caused by the sexually transmitted HPV,
which is one of the most common viral infection of the reproductive tract. Survival of cervical
cancer patients is strongly determined by stage at diagnosis. Due to the late stage at diagnosis
and inadequate management facilities, mortality rates from cancer cervix are very high in
Bangladesh. The overall 5-year relative survival for early and localized cancers is 73.2%,
but can be as low as 7.4% for advanced stage disease.3

Bangladesh has high burden of cervical cancer due to the high prevalence of risk factors
like early marriage, early initiation of sexual activity, multiparity, sexually transmitted
diseases (STDs) and low socio-economic condition. All the tertiary level hospitals and
institutes of this country are burdened with a large load of cervical cancer patients with
high mortality rates. Treatment of cancer cervix is expensive and requires radical operative
procedures and/or radiotherapy and prolonged hospital stay. In Bangladesh, facilities for
radical surgery and radiotherapy are available only in few government institutions. In the
private sector the treatment facilities are available in limited centers and are expensive.
Cervical cancer can be prevented and controlled through a combined strategy: by vaccination
of adolescent girls against the human papillomavirus (HPV) and implementing population
based organized cervical cancer screening and treatment. Since the year 2004 Government of
Bangladesh (GOB) gradually developed cervical cancer screening facilities at all districts of
Bangladesh through technical assistance of Bangabandhu Sheikh Mujib Medical University
(BSMMU) and United Nations Populations Fund (UNFPA). Since 2012, GOB is expanding
the programme towards upazila level for spreading screening services towards grass root level.
The programme adopted VIA method for cervical cancer screening for the women 30 years
and above at around 400 centres. Though the centres screened more than a million of women,
the centres are providing opportunistic screening only. Hence development of organized

6
population based screening programme designed to detect and treat pre-cancerous conditions
is crucial for reduction of cervical cancer incidence in Bangladesh.

Figure1. Estimated age-standardized incidence and mortality rates of cancers in women of

Bangladesh [Source: GLOBOCAN 2012]

Expanded Programme on Immunization (EPI) is one of the important components of the

Programme Implementation Plan (PIP) of GOB. As commitment of the GOB to the Global
Universal Child Immunization Initiative (UCI), in 2009, a National Committee on
Immunization Practice (NCIP) was established to consider and assess feasibility of
introduction of new and underused vaccines in the national EPI Programme. The NCIP in 9
September 2013 recommended implementation of HPV Demonstration programme. GOB has
started HPV demonstration program at Gazipur in August, 2015 and vaccination started on16th
April 2016. Therefore GOB is in a promising position to develop cervical cancer prevention

7
control strategies through a combined strategy of vaccination of adolescent girls against the
HPV and implementing population based organized cervical cancer screening and treatment.

During planning for the preventive strategies, it is also essential to establish appropriate
evaluation and treatment services for pre-invasive and invasive cervical cancers such as
Colposcopy, Thermo-coagulation, LEEP, Radical surgery, Radiotherapy alone or as combined
chemo radiation. Bangladesh like some other countries in the South-East Asia Region has very
much inadequate management facilities for invasive cervical cancers and this issue needs
special attention. An efficient strategy to deliver palliative care to provide relief from the
physical and psychological sufferings of advanced cancer should be planned at different levels
of the health facilities and community by trained team of clinicians, nurses and health workers.
GOB should design and implement cervical cancer control programmes according to the needs
of the country, community, outreach and facility-based clinical services.

2. Vision and Objectives

Vision
Cervical Cancer free Bangladesh.

Goal
The strategic goal is to improve cervical cancer prevention and control activities to reduce the
incidence, prevalence, morbidity and death from cervical cancer and to promote women’s good
health.

Objectives
The overall objective of the National Strategy for Cervical Cancer Prevention & Control is
to guide, develop, strengthen strategies to improve cervical cancer control activities; to
reduce the burden of morbidity, disability and death from cervical cancer and to promote
women’s good health.

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The specific objectives:

1. Introduce and scale up delivery of HPV vaccine to girls aged 9 to 13 years through a
coordinated multisectoral approach including EPI.
2. Implement and scale up organized cervical cancer screening programmes utilizing evidence
based, cost-effective interventions through public health service delivery system across
different levels of health care.
3. Strengthen health systems and quality assurance mechanism to ensure quality and equitable
access to cervical cancer screening services with particular attention to socioeconomically
disadvantaged population groups.
4. Augment management facilities for invasive cancer cervix as part of a comprehensive
cancer control programme.
5. Introduce palliative care services into all level of health system as part of a comprehensive
cancer control programme.
6. Encourage convergence with related health programmes to ensure a coordinated approach
for cervical cancer control within the health system.
7. Initiate and augment a structured advocacy and educational campaign for cervical cancer
control.
8. Establish a Monitoring & Evaluation framework for the cervical cancer control.
9. To contribute towards establishment of a National Cancer Registry comprising several
hospitals based and one population based cancer registry as a ready source of data for
further research.

3. Cervical cancer control strategies

3.1 Overview
Cervical cancer is preceded by precancerous changes within cervical cells which represent a
continuum of morphologic changes beginning with Cervical Intraepithelial Neoplasia 1(CIN
1, mild dysplasia) and progressing through CIN II (moderate dysplasia) and CIN III (severe
dysplasia) to invasive carcinoma. Cervical cancer is caused by the infection from HPV, a
double stranded DNA virus, a sexually transmitted infection.

Zur Hausen (1977) for the first time suggested the association between HPV and genital
cancer.4 But it received little attention from researchers and epidemiologists prior to 1988.
Afterwards, several studies established HPV infection as a STD and major risk factor for the

9
development of CIN and invasive cancer.5-10 A study in 1999 estimated that over 99% of
cervical cancers worldwide contained HPV DNA. 11 Studies revealed that cervical dysplasia
and cancer usually arises among women with persistent HPV infection. 12,13

The persistence and severity of the precancerous change influence the progress of the disease.
HPV infection initially causes CIN I, CIN II and CIN III according to severity. Unless treated,
some of the CIN lesions progresses to frank cancer. The likelihood of regression of CIN I,
CIN II and CIN III is 60%, 40%, 33% respectively and progression to Invasive Cervical
Carcinoma (ICC) is 1%, 5% and greater than 12% respectively. The time lag between
infection and development of ICC varies and is apparently on average more than 15 years .14

HPVs are classified into nearly 130 different genotypes and about 30 types of HPV that infect
the genital mucosa has been categorized into low, intermediate and high risk groups.5,8 “Low
risk” HPVs (6,11,42,43 and 44) were present in 20.2% of low grade squamous intraepithelial
lesions (LSIL) or CIN1 but absent in cancers. “Intermediate risk” HPVs (31,33,35,51,52, and
58) were detected in 23.8% of high-grade squamous intraepithelial lesions (HSIL) or
CIN2/CIN3 and 10.5% of invasive cancers. “High risk” (HPV 16) were associated with 47.1%
of both HSILs and invasive cancers. “High risk” HPV 18, 45, and 56 were found in 26.8% of
invasive cancers. Numerically, HPV 16 was also the most important single type, detected in
invasive cancers and HSIL and HPV 16 and 18 are implicated in 65% to 80% of all cervical
cancers.8 About 10-15 types of high and intermediate risk HPV (HRHPV) types were
responsible for more than 90% of invasive cancers and they were referred to as cancer-
associated HPVs.8,15 Besides cervical cancer, HPV can cause anal cancer, vaginal and vulvar
cancer, penile cancer and oro-pharyngeal cancer.

The virus can be transmitted through genitalia to genitalia, skin to skin or skin to genitalia
contact. Transmission via HPV-contaminated fomites (clothing, sheets, towels, objects, and
instruments) has also been suggested. Women are at highest risk of acquiring HPV infection
when they initiate their sexual life. Peak prevalence of ano-genital HPV infection is observed
between 20-25 years and the prevalence comes down drastically after 30 years of age since
most of the infected women clear the infection due to natural immunity. It takes nearly 1 to 2
years to clear the HPV infection and this infection by itself does not have any symptoms.
Symptoms appear only when the infection causes diseases like genital warts or cancer. The
virus enters through small breaks present in the epithelium near the squamo-columnar junction
and infects the cells of the basal layer of the squamous epithelium. The virus replicates within
the cells and the viral replication is synchronized with the cell division. Since most women can

10
clear the viral infection due to the natural immunity, they do not get cervical neoplasia. Only a
small number of women cannot clear the infection and the persistent HPV infection causes
neoplastic changes in the metaplastic epithelium at the transformation zone. The malignant
process starts if the viral genome gets integrated into the host genome.

CIN1 or low-grade squamous intraepithelial lesions (LSIL) regress spontaneously or remain

static. CIN2 and CIN3 lesions together referred to as high-grade squamous intraepithelial
lesions (HSIL), may progress to invasive cancer if they remain undetected and/ or untreated.
Hence, HSILs are known as true cervical cancer precursors.

It is well established that detection and treatment of CIN and early invasive cancers through
organized cervical cancer screening programmes can reduce mortality rates from the disease
in the screened population.
A comprehensive continuum of care for cervical cancer will require prevention at three stages:
primary prevention (through HPV vaccination); secondary prevention (through cervical cancer
screening and treatment of precancerous lesions) and tertiary prevention (through early
diagnosis and proper treatment of cervical cancer). Palliative care should be the last resort of
care for terminal cases.

Primary Prevention: Protecting adolescent girls through vaccination against the two most
carcinogenic HPV types is a safe and effective primary prevention strategy against cervical
cancer. Two commercially produced HPV vaccines are widely available in almost all countries
in the South-East Asia Region including Bangladesh. Assessment of the target population for
vaccination through schools is proved a viable option in Bangladesh.

Assessment of the target population for vaccination through schools is proved a viable option
in Bangladesh. Bangladesh has already achieved gender parity in primary and secondary school
enrolment. This attainment has occurred due to some specific public interventions focusing on
girl students, such as stipends and exemption of tuition fees for girls in rural areas and the
stipend scheme for girls at secondary level. The net enrolment ratio in 2011 was 98.7 percent
(Girls-99.4%, Boys-97.2%) which was 60.5 percent in 1990 (from Ministry of Primary and
Mass Education Report)16. A comprehensive national policy for HPV vaccination and cervical
cancer screening will be cost-effective and will contribute towards attainment of the The
Sustainable Development Goals (SDGs). As per this document, all girls of grade V and 10
years of age will be the target group of HPV vaccination. Service delivery models for HPV
vaccination in Bangladesh will be mainly school-based, with community-based and health

11
centre-based vaccination programs to improve reach the target population. It is important to
note that girls vaccinated with HPV should also be screened when they reach the target age
group, since 30% of cervical cancer is caused by HPV types that are not currently targeted by
available vaccines. EPI, Bangladesh will monitor the performance of the vaccination program
through vaccination coverage and disease surveillance.

Secondary Prevention: It is well established that detection and treatment of CIN and early
invasive cancers through organized cervical cancer screening programmes can reduce mortality
rates from the disease in the screened population. Several simple and low-cost screening
strategies have evolved over the past few years for implementation for population-based
screening programmes in different countries. In Bangladesh, Visual Inspection by Acetic Acid
(VIA) is the accepted test for cervical cancer screening. The target population for screening
will be women between 30-60 years of age; and the screening interval will be 5 years. All
screen-positive women will receive a colposcopy test and treated accordingly.

Tertiary Prevention: In Bangladesh, cases of cervical cancer present both during screening as
well as at different gynaecological outpatient departments. For proper treatment of cervical
cancer, histological confirmation of disease and staging needs to be done before the treatment
is initiated. Early detection of cervical cancer is crucial to improve prognosis of cases; and
facility capacity to provide staging and diagnostics need to be improved in addition to
organizing appropriate treatment.

Palliative Care: Palliative care is reserved for terminal cases of cervical cancer. It is a critical
need within the public health system, but in Bangladesh it is often ignored. Policy makers,
health care providers as well as the patient community need to be made aware raising regarding
the importance of palliative care. The country needs to set up proper training and facilities for
providing high quality palliative care.

Appropriate and timely treatment of invasive cervical cancer and introduction of palliative care
services for patients with advanced cancer should be strategies to reduce morbidities,
mortalities and, improved quality of lives. Cervical cancer prevention and strategies over the
lifespan of women is shown in Figure 2

12
Figure 2 Cervical cancer prevention and control strategies over the lifespan of women

3.2 Convergence between different health programmes

The service delivery for both HPV vaccination and cervical cancer screening components
utilizing the existing health infrastructure is shown in Table 1. GOB has integrated cervical
cancer screening programme within the government health infrastructure and major advantage
of programmatic convergence is utilization of a common health MIS.
Table 1. Key roles of different health-care levels and sharing of resources and
responsibilities, to deliver comprehensive cervical cancer control
Health Service Providers Services Offered
Facilities/Programme
Primary Level (CC, Community Health Care • HPV Vaccination
Union subcentre, Provider (CHCP), Health • Screening with VIA
UH&FWC, UHC) Assistant (HA), Assistant • Examination by mini-
Health Inspector(AHI), colposcope/ Colposcope
Health Inspector (HI) • Treatment of CIN by Thermo-
Family Welfare assistant coagulator/cryotherapy
(FWA), Family Planning • Behavioral Change
Inspector (FPI), Family Communication (BCC) and
Welfare Visitors (FWV), community mobilization
MT-EPI, SACMO, Senior • Capacity building of primary
Staff Nurses (SSNs), level health workers.
Midwives, Medical • Use of MIS & surveillance
Officer, Gynecologist system.
Secondary Level SSNs, Midwives, EPI • HPV vaccination,
(District Hospital, superintendent, Medical • Screening with VIA,
Technologists of • Colposcopy, biopsy &

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MCWC, private laboratory, Medical treatment of CIN by Thermo-
facilities) Officer, Pathologists, coagulator / LEEP,
Gynecologist, Surgeon • Histopathology,
• Capacity building for VIA
service provider, Capacity
building for pathologists,
health educators, counselors,
statistician.
• Manage referrals and send
back to primary level
• Coordination and follow up
with departments of
Gynaecology and Pathology
of the same hospital and
tertiary level hospital.
• Integrate services with
reproductive/adolescent
health and/or immunization
programme.
• Use of MIS & surveillance
system.
Tertiary Level SSNs, Midwives, • Treatment of pre-cancers by
(Institutes &Medical Pathologists, Thermo-coagulator / LEEP,
College Hospitals) Medical Oncologist, Diagnostic facilities,
Radiation Oncologist, Colposcopy and biopsy,
Gynecologist, Surgeon • Capacity building for VIA,
cytology, HPV test,
Colposcopy, treatment, and
histology; Treatment of
invasive cancers (operative,
radiotherapy, chemotherapy)
• Training of trainers, Use of
MIS & surveillance system.
National cancer DGHS, DGFP, DGNM, • Policy and guidelines
prevention and NICRH, NCCBCS&T of • Funding and resources
control programme BSMMU, MOHFW • Monitoring, evaluation &
quality assurance

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4. Primary prevention: Introduction of HPV Vaccine into
Expanded Program on Immunization (EPI)

4.1 Introduction

HPV vaccination is most effective if administered prior to sexual debut and exposure to HPV
infection. As per WHO recommendations, girls aged 9 to 13 years should be vaccinated against
HPV through effective, affordable and equitable delivery strategies. Vaccinating a single age
cohort within the target age range is a cost-effective approach. EPI of Bangladesh, selected one
district for HPV demonstration programme with school girls of Grade V and 10 years in the
community (out of school) as the target group for vaccination. As per WHO recommendation,
the girls below the age of 15 years need only two doses of the vaccine with an interval of six
months between the doses. Therefore EPI of Bangladesh has adopted two doses of the vaccine
with six months interval. High coverage of the target population and adherence to the dose
schedule are key factors for the success of the HPV vaccination programme. Bangladesh as
low income country already received support through the Gavi Alliance to initiate
demonstration programme at a subsidized cost. After completion of the demonstration
programme, Gavi Alliance may support for national scale up and sustainability of this
vaccination programme. If Gavi Alliance support is withdrawn, then GOB will consider to
continue the vaccination program.

The EPI in Bangladesh is one of the well-established and successful programmes which aim to
reduce child morbidity and mortality from vaccine preventable diseases. Following the launch
of the National Immunization Program in 1979, EPI Bangladesh has been recognized for its
sustained high vaccination coverage. The full valid vaccination coverage in the year 2015 was
82.5% (Bangladesh EPI Coverage Evaluation Survey, 2015)17. With the support of Gavi
Alliance, HPV Demonstration Program in Gazipur (2016-18) has been launched on 16th April’
2016. The target group included around 30689 girls of grade V and 10 years girls out of school
for the 1st year and the vaccination coverage was 87.2% (As per HPV Vaccination Coverage
Survey 2016).18 Total target for 1st dose for 2nd year in Gazipur district was 23,632 and 23,517
was vaccinated successfully. Total vaccination coverage was 99.52% & vaccine wastage rate
was 4.37% according to the data obtained from civil surgeon office, gazipur.

15
4.1.1 Service delivery models

In Bangladesh, EPI is implemented through various outreach centers and health center-based
activities. However to ensure high coverage of girls belonging to the target age group,
Bangladesh has included school based vaccination programme. The following service delivery
model is being adopted:

A. School based vaccination

A school-based delivery strategy has been adopted in the demonstration programme. In
Bangladesh as high proportion (98%) of adolescent girls attend school (Ministry of Primary
and Mass Education Report)16 and the school authorities have positive attitude to participate in
school health based programmes. High level commitment and good coordination between
Ministry of Health & Family Welfare, Ministry of Primary & Mass Education, Ministry of
Education, Local Government Division, Ministry of Women & Child Affairs, administrators
and teachers are required. The vaccination schedule has to be planned avoiding school holidays
and examination dates. Behavioural Change Communication (BCC) activities among parents
and parent–teachers association meetings will be done to improve awareness on cervical cancer
control and other health issues and facilitate to obtain verbal consent for HPV vaccination.

B. Community Based Vaccination

There should be a plan to find out the girls who are not in school. This can be executed through
outreach services on a monthly basis in rural wards and on the basis of EPI session plan in
urban wards. Service providers for vaccination at rural wards include Health Assistants (HAs),
Family Welfare Assistants (FWAs) and Community Health Care Providers (CHCPs).
Vaccination at urban wards will be the primary responsibility of the Local Government
Division through the appointed service provider of the City Corporation, Municipalities and
different NGOs.

C. Health Centre based Vaccination

The HPV vaccine will be administered through the primary and secondary health facilities
including outreach services like satellite session. Mechanisms are available to inform the girls
and their parents who have not received vaccination at school and community based facilities
to attend the health facilities on the days of vaccination.

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4.1.2 Procurement and logistics

Like other vaccine, In line with national and international targets, the MOHFW, in
collaboration with development partners, will mobilize necessary resources to extend
immunization services throughout the country. Every application for new vaccine introduction
will be carefully analyzed in terms of costs, financing gaps, and government co-financing
requirements. A decision to proceed with HPV Vaccine introductions will be accompanied by
a clearance from the Ministry of Finance in terms of financial sustainability. The vaccine
procurement policy, logistic plan to deliver the vaccines maintaining the cold chain and to
supply other logistics and the protocol for vaccination should be laid down prior to rolling out
the programme. Like any other vaccination programme, the programme managers are expected
to regulate vaccine procurement, supply chain, temperature monitoring, storage and transport
capacities, and report regularly on progress against targets, stock levels and wastage rates. The
logistics of the new vaccine delivery should be sustainable and synchronized with
immunization and other health interventions.

4.1.3 Capacity-building

Orientation training and supervision of existing staffs are integral part of HPV vaccine delivery
strategy. Capacity-building will be organized for health and family planning staffs at primary
and secondary level facilities. Teachers and parents will be oriented on HPV vaccination and
cervical cancer control.

Implementation/requirement plan along with budget will be developed. Strengthening the

capacity of cold chain logistics, logistics and distribution mechanism, surveillance, MIS
integrated with District Health Information System Version-2 (DHIS2) will be required.
Districts/Upazila level annual micro-plan with special emphasis to HPV vaccination will be
prepared. EPI training guidelines, training materials, record keeping and recording forms will
be revised to include the HPV vaccine. Advocacy meetings will be carried out with multi-
sectoral partners and community representatives at national, divisional, district and sub-district
levels. Communication materials (posters, leaflets etc.) will be produced. Effective
communication channels between the key stakeholders at the central and district levels will be
developed and maintained. Close collaboration of academic institutions will be required.

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4.1.4 Screening for cervical cancer and HPV vaccination

Cervical cancer screening will be continued during HPV vaccination. Women not having HPV
vaccination will need protection through screening. The vaccinated population will also need
screening in future, since nearly 30% of cancer cervix is caused by HPV types not targeted by
currently available vaccines. The vaccinated population may require less frequent screening as
they are at much lower risk, although the current recommendation is to follow the routine
schedule of screening as per individual country protocol. The data of vaccinated girls will be
preserved by MIS and they will have screening after the age of 30 years.

4.1.5 Monitoring and surveillance

EPI, Bangladesh will monitor the performance through vaccination coverage and disease
surveillance. It has well-established mechanism for reporting vaccine-related Adverse Events
Following Immunization (AEFI). This same reporting mechanism should be utilized for the
HPV vaccine. The health authorities should ensure that all reported serious adverse events are
appropriately investigated to establish causality.
Continuous monitoring and feedback on performance will be done to evaluate the quality of
programme performance. HPV vaccination coverage will be monitored by proportion of girls
in the target age group vaccinated and proportion of vaccinated girls receiving both the doses
of the vaccine. The vaccine database will be linked to the screening database through a common
HMIS, and the vaccinated women will be screened at 30 years of age. Several process
indicators should also be monitored, including the regular supply of vaccines, maintenance of
the cold chain and records. CIN and cervical cancer should be reported from all health facilities
(including primary, secondary and tertiary hospitals, private facilities and NGOs) on a monthly
basis to the HMIS according to the case definitions, procedures and guidelines of the DGHS.
All Divisions, Districts, City Corporations, UHCs, Municipalities and other Hospitals (public
and private) will identify a trained and designated surveillance focal person to conduct active
and passive surveillance for HPV infected/associated diseases, respond to disease events and
report to HMIS through DHIS2.
The MOHFW, in collaboration with technical partners and research institutes, will
collaborate/develop the laboratory capacity of the country in order to introduce case based
laboratory surveillance for HPV vaccine preventable diseases (for laboratory confirmation of
diagnosis, tracking epidemiology of diseases, and for evaluating vaccine efficacy and program

18
effectiveness). The HPV test facilities (appropriately equipped and staffed National Control
Laboratory) at divisional level to monitor vaccine effects should be developed.

4.2 Key strategic directions for introduction of HPV vaccine into national immunization
programme

GOB is going to introduce HPV vaccination programme into existing EPI. The following
strategic directions will be taken to augment the health system to introduce the HPV vaccine.

4.2.1 Strategic direction 1: Define the target population

1. The vaccine will be given only to girls until there is a new recommendation for vaccinating
boys.
2. All girls of Grade V and 10 years of age in the community (out of school) will be the target
group for vaccination every year.

4.2.2 Strategic direction 2: Arrange for sustainable financing

1. 1. In line with national and international targets, the MOH&FW, in collaboration with
development partners, will mobilize sufficient resources to extend immunization services
once the HPV vaccine demonstration programme is successfully completed.
2. Every application for new vaccine introduction will be carefully analyzed in terms of costs,
financing gaps, and government co-financing requirements.
3. A decision to proceed with new vaccine will always be accompanied by a clearance from
the Ministry of Finance in terms of financial sustainability
4. There should be no funding gap for resource requirements for vaccines and logistics. The
requirements of vaccines and logistics supply are expected to be financed from two
sources: Gavi and the GOB (through Pooled Funds). Together with co-financing Gavi-
supported vaccines, GOB directly contributes around 67% of the total Programme
financing. WHO and UNICEF will also be responsible for some portion of programme
financing, while other bilateral partners combined contribution will fulfil the financial
gaps if required.
5. The GOB will be continuously monitoring financial situation with financing EPI in
collaboration with development partners. GOB is committed for HPV immunization
through the HPNSDP.

19
4.2.3 Strategic direction 3: Select appropriate delivery and coverage strategy

1. A school-based vaccination programme will be implemented in Bangladesh as it has

provided more than 95% coverage during the vaccine demonstration project and a good
proportion of girls attend primary schools.

2. Vaccination at primary and secondary level health facilities and at community level will also
be done

3. A combination of both delivery strategies will be followed to vaccinate hard to reach

populations to improve coverage.

4. All girls to be vaccinated at the age of 10 years at the private facility should be reported to
the nearest GOB facility for incorporation in DHIS2.

5. Maintenance of the cold chain, uninterrupted supply of vaccines & logistics and high
coverage with all the doses of the vaccine should be ensured.

4.2.4 Strategic direction 4: Integrate immunization, surveillance and other related health
interventions

1. A programme officer/focal person at the national/regional level should be responsible for

planning and execution of services, coordination between different stakeholders and quality
assurance.

2. The opportunity of reaching adolescent girls through the HPV vaccination programme
should be utilized to deliver other health services targeted to the same population.

3. Regular programme evaluations should be conducted at local, district and national levels and
should be linked with routine immunization Coverage Evaluation Surveys (CES) and HMIS.

4. Capacity building of service providers for both vaccination and screening should be organized at
health facilities.

20
Table 2. Key strategic directions for introduction of HPV vaccine into
national immunization programme

All girls of Grade V and 10 years in the community

The target population (out of school) will be the target group for
1
vaccination every year
The MOH&FW, in collaboration with development

2 Sustainable financing partners, will mobilize sufficient resources to expand

immunization services

School-based vaccination will be the main delivery

3 Vaccine delivery and coverage strategy
strategy. 95% vaccine coverage will be ensured

Regular programme evaluations at local, district and

Integrate immunization, surveillance
4 and other related health interventions national levels should be conducted and should be
linked with routine immunization CES and HMIS

Service providers along with respective supervisors at

5 Capacity building
different health facility levels

21
5. Secondary Prevention:
Population-Based Cancer Cervix Screening
5.1 Introduction
An organized cancer screening programme should be population-based, managed through the
public health delivery system, follow a uniform guideline, achieve a reasonable coverage of
the target population and have efficient linkage between screening and treatment of the positive
cases. The essential components of an organized population-based screening programme are
shown in Figure 3.

Organized screening program includes

 Commitment and policy at national level

 Clearly defined program protocol

 Screening and treatment methodologies

 Frequency of screening

 Target age group for screening

 Operational aspects of program

 Mechanism of inviting target women systematically to ensure high participation

rate

 Linkage between screening, diagnosis and treatment

 Program monitoring, supervision and quality assurance plan

Figure 3. Different components of an organized population-based cervical cancer screening

programme

GOB through an orientation meeting in October, 2003 decided VIA as a feasible method for
cervical cancer screening and a pilot programme to evaluate the feasibility of screening with
VIA within the existing government health infrastructure was carried out in 16 districts in
2005.19-22 Service providers (Doctors, SSNs and FWVs) were trained at BSMMU, which was
the nodal center for training. VIA was offered to ever married women of 30 years and above
and VIA positive women were referred for colposcopy and treatment at the colposcopy clinic
of BSMMU, Rangpur and Chittagong Medical College Hospitals. After piloting GOB has
scaled up the programme to all the districts and is now expanding the programme to the upazila
level. In Bangladesh screening is practiced currently by around 400 centres at primary,

22
secondary and tertiary level hospitals. However this is predominantly an opportunistic
screening programme,20 and GOB need to develop organized population based screening
programme designed to detect and treat pre-cancerous conditions.

5.1.1 Defining the target population and frequency of screening

As cervical cancer is rare before 30 years of age and Bangladesh is a low resource country,
GOB has taken a policy for not to screen women prior to 30 years of age. Moreover, screening
women at a younger age detects many low-grade lesions that are self-limiting and do not
usually progress into cancer. The maximum possibility of detecting high-grade precursor
lesions (CIN2 and CIN3) is possible if screening is performed from 30 to 49 years age group.
GOB will adopt 30-60 years for cervical cancer screening. The screening will be performed
every five years. All efforts should be made to achieve at least 40% coverage of the target
population within next five years.

5.1.2 Screening test adopted in Bangladesh

Bangladesh adopted an affordable, accessible way of cervical cancer screening programme.
VIA is accepted as a method of screening as it is relatively simple, need minimum infrastructure
support and part of the result of the procedure is available immediately. GOB formally
launched the National Cervical and Breast Cancer Screening Program in 2006 by gradually
scaling up the pilot project towards the district level with support from BSMMU and UNFPA.
This screening programme has expanded upazila level since 2012 through strong government’s
contribution. A list of test characteristics, personnel requirements and limitations of different
screening is given in Annex 1.

5.1.3 Screening test facilities and providers

Bangladesh initiated cervical cancer screening facilities at the primary, secondary and tertiary
level health-care facilities. VIA is performed at Medical College Hospitals (MCHs), BSMMU,
District Hospitals (DHs), Maternal and Child Welfare Centres (MCWCs), selected Upazila
Health Complexes (UHCs), few NGO clinics by trained Family Welfare Visitors (FWVs),
Paramedics, SSNs, and Doctors.19-22
Work Flow at the Screening Centers is shown in annex II. In the next 5 years VIA services will
be expanded to remaining 250 UHCs.

23
5.1.4 Management of women with VIA positive cases
Screen positive cases are being referred to the colposcopy clinics of tertiary level health-care
facilities (BSMMU / MCHs), where evaluation and management are carried out.19-24 About
twenty government medical college hospitals and BSMMU are functioning as referral centre
through development of colposcopy clinics for evaluation and management of screen positive
cases. Workflow at the Colposcopy Clinic is shown in annex III. Cervical pre-cancers are
treated either by removing the entire abnormal area with Loop Electrosurgical Excision
Procedure (LEEP) or with Thermo-coagulation. Facilities for LEEP are available at BSMMU
and about 15 Government MCH and facilities of thermo-coagulation is available at 4 selected
MCHs almost free of cost.
Thermo-coagulation is safe, simple and effective technique to treat selected CIN lesions of
any grade. Nurses shall be trained to perform thermo-coagulation. In Bangladesh Thermo-
coagulation has been generously used recently at several tertiary health facilities and at health
camps of many UHCs. In Bangladesh minicolposcope is used to identify cervical pre-cancers
among VIA positive women at BSMMU, selected MCHs, DHs and selected UHCs before
treatment in health camps.23-24 At tertiary levels, DHs and UHCs “See and Treat” protocol
(Annex IV) are being adopted and logistics (colposcope/minicolposcope and Thermo-
coagulator) will be made available in a phase wise manner in all this centers.

All grade of cervical pre-cancers should be treated. Hysterectomy should not be practiced for
the treatment of CIN lesions. Follow-up of treated patients will be continued at the primary,
secondary or tertiary facilities by available methods. VIA, colposcopy and HPV DNA test can
be used during follow-up on an annual basis for three years. Women tested negative on three
consecutive rounds will be returned to the routine screening protocol applicable to the normal
population.
All invasive cancer cases will be referred to appropriate facilities for further management based
on International Federation of Gynaecology and Obstetrics (FIGO) clinical staging.

5.1.5 Strategies to improve compliance

To improve client’s compliance, program efficiency and cost effectiveness less visit
approaches is preferred. The following strategies will be adopted to improve compliance to
diagnosis and treatment.

24
 See-and-treat strategy: A colposcopy suspected cervical pre-cancer (all grades) shall be
treated during colposcopy without waiting for histology confirmation.
 GOB will develop and strengthen colposcopy clinics along with colposcope,
electrosurgical equipment and thermo-coagulator at all MCHs and DHs to establish ‘See-
and-treat strategy’.
 At primary (UHCs) level, VIA positive women will have examination by
colposcope/minicolposcope if facility is available and suspected pre-cancers will be treated
by thermo coagulator during the same sitting with verbal consent of the client or can be
referred to higher centre (DH or tertiary level) if necessary.
 Screen-positive women who need higher centre referral will be counseled to travel to
referral centers whenever necessary. A strong linkage between the screening centres at
primary and the referral facilities at secondary or tertiary level will be developed with help
of HMIS.
 Strengthening of static centres and special programme (screening and management camps)
can be organized for marginalized, remote, hard to reach populations.

5.1.6 Record-keeping and data management

Maintenance of records, storage of data related to various components of screening, and
periodic reports are essential for an organized screening programme. At BSMMU, MCHs,
District Hospitals, MCWCs and UHCs a simple paper-based record keeping system has already
been introduced for the clients receiving VIA and CBE test through registry and VIA+ve and
VIA-ve cards. At BSMMU and other referral centers, findings of referred patients are recorded
on the colposcopy registry and VIA+ve Cards.
For population based organized screening, GOB will develop an electronic data base for all
women 30years and above at upazila, district, city corporation and municipality level. GOB
should arrange training and resources for developing and maintenance this data base. This data
base will include women’s basic information, screening, colposcopy, treatment and follow up
records in the allocated spaces. Women will be referred to nearer VIA centre
(UHC/DH/MCWC/MCH/Institutes etc.) with a referral slip containing NID number by CHCP
and other field level health workers. After examination, VIA negative women will be provided
a VIA negative card and advised to come back for repeat test after 5 years. VIA positive women
will be given a VIA positive card and evaluated and treated if facilities are available at the same
centre or referred to the nearer colposcopy clinic (MCH/Institutes/DH/BSMMU). All data will

25
be entered in the electronic data base DHIS2 by SSN/doctors/FWVs/statisticians before or
during the same visit. The computerized data-base should be maintained at each screening
centre and all colposcopy centers. The template for Cervical cancer screening database is being
developed and will be maintained by the HMIS through DGHS (DHIS2) (Annex X). A
mechanism to check the compliance of screen-positive women to colposcopy and/or treatment
should be established by DGHS, DGFP and BSMMU/ national coordination centre.

5.1.7 Monitoring, evaluation and quality assurance of the programme

The impact indicators are reduction of cancer cervix incidence and reduction of death from
disease. It can be obtained through a population-based cancer registry or organized health
information system. Outcome/performance indicators will be monitored on a regular basis to
identify gaps and, based on this; modifications to programme strategies should be undertaken.
Common performance indicators are suggested as below:
 Coverage of the target population (Number of women in the target age group screened/
Total number of women in the target age group x 100).
 Screening test positivity (Number of women positive on screening test/Number of women
screened x 100).
 Compliance to colposcopy (Number of women undergoing colposcopy/Number of
women positive on screening test).
 Compliance to treatment (Number of women treated for CIN-II+ on colposcopy or
biopsy/Number of women detected to have CIN-II+ on colposcopy or biopsy x 100).
 Detection rates of CIN-II, or worse disease (Number of CIN-II or worse disease
detected/Total number of women screened).
 Positive predictive value of the test to detect CIN2 or worse disease (Number of CIN2
or worse disease detected/Total number of women positive on screening test).
For quality assurance, the responsible programme personnel (UH&FPO, Civil Surgeon/
Hospital Superintendent, Gynae consultant, Hospital Director/ Head of Gynae and Obs)
should review and analyze MIS data and implement corrective measures based on the
findings.

26
5.1.8 Research
Research will be encouraged to build the evidence based information on the programme to
determine best practices. Collaboration with Institutional researchers and other research
institutions like BSMMU, NICRH, ICDDRB, international organizations will be pursued to
answer critical clinical and community questions. Key focus areas for research include
promotion of operational research at all levels and link with national surveys to gather cervical
cancer data.

5.1.9 Training of service providers

A ‘National Centre for Cervical and Breast Cancer Screening and Training (NCCBCST) at
BSMMU, is being developed for rapid development of competency-based training for service
providers from different levels of health care and better coordination of the programme.
Decentralization of training centres will be performed at divisional level in a phase wise
manner. More trained manpower will be developed to improve the screening coverage and
Table 2 showed details of the conduction of the training programmes. Criteria of a designated
training centre are shown in Annex V.

During training each trainee should perform an adequate number of procedures under
observation of trainers. A format for evaluation of VIA trainees is given in Annex VI. After
the successful completion of training, the appropriate authority will certify the trainees. Only
certified providers should perform the tests. After training, the service providers need to be
supervised until they achieve a satisfactory level of competency. All VIA providers should
receive a short refresher training initially at every year and then at alternate year. VIA trained
service providers will receive other specialized trainings such as training on colposcopy and
Thermo-coagulator. At least three VIA trained service providers should be placed at each VIA
centre. VIA service providers and statisticians/statistic assistance from all level should be
trained for data management and follow-up.

Table 3. Guidelines for conducting training programmes for service providers related to
cancer cervix screening programmes
Health Health Durati
Health
professionals set-up to Competency to on of
Service professionals
who can be conduct be achieved trainin
to be trained
trainer training* g

27
VIA Trained doctors Doctors, SSN, Tertiary Test procedure, Two
and nurses FWV level, interpretation, weeks
Programme midwives, documentation,
managers paramedics record keeping,
pre- and post-test
counseling
Cytology and Trained Pathologists Tertiary Processing One
histology pathologists and and level specimens, week
Laboratory Laboratory Interpretation,
technicians technicians, reporting,
documentation,
laboratory
quality control
HPV Trained Laboratory Tertiary Processing of One
detection virologist, technicians, level samples week
microbiologists, Pathologists and conducting
technical tests,
persons interpretation,
reporting,
documentation,
laboratory
quality control
Colposcopy Trained doctors Doctors, Tertiary Performing the 10
and SSN (for level procedure, days
treatment colposcopy interpretation of
and/ colposcopic
or findings,
thermocoagul reporting,
ation documentation,
only) counseling
before and after
procedures
Awareness Trained doctors, All health Primary or Counseling 2
and nurses, social personnel secondary individually days
education workers, involved level and in groups,
programme use of the
managers education tools
and materials
Data Trainer from Statisticians, Secondary Computer 3 days
Management HMIS, DGHS, VIA and and training,
DGFP, Tertiary Colposcopy Tertiary Training on data
Centers, service level, management
Programme providers, DGHS
manager Programme
manager
Programme Public health Programme DGHS, Programme 2 days
management specialists, managers, Tertiary management,
programme health level, financing,
managers administrators Secondary monitoring,
, level evaluation and

28
 laboratory in quality
charge assurance
* Criteria of training center (Annex-V)

5.2 Key strategic directions for cancer cervix screening:

5.2.1 Strategic direction 1: Define the target population

All women between 30 – 60 years of age will be offered Screening.

5.2.2 Strategic direction 2: Define the frequency of screening

The screening interval will be 5 years.

5.2.3 Strategic direction 3: Suitable screening test

VIA-based screening will be followed in Bangladesh for cervical cancer screening.

5.2.4 Strategic direction 4: Ensure management of the screen-positive women

a) All screen-positive women should be counseled, further evaluated by colposcope/
minicolposcope and treated at appropriate facilities. All colposcopy suspected cervical
pre-cancer lesions shall be treated following “see and treat strategy”.
b) Colposcopy/minicolposcopy, Thermo-coagulation services should be organized at
selected primary, secondary level health care facilities. At the tertiary level, all services
should be available including LEEP.
c) Women should have easy access to treatment services to ensure high compliance.

5.2.5 Strategic direction 5: Organize capacity-building of human resources

a) Adequate human resources for service delivery will be developed.
b) Competency-based training of all service providers at designated training centers will
be ensured with proper resource persons and training materials.
c) Good quality training with appropriate post-training follow-up will be ensured.

5.2.6 Strategic direction 6: Strengthen the health infrastructure and ensure

convergence
a) Organize and strengthen the various services within the existing health infrastructure.
b) Ensure supply and maintenance of equipment and uninterrupted supply of
consumables.

29
c) Select the best possible option for integrating the services with existing programmes to
minimize additional resource requirements and achieve good coordination.
d) The cancer cervix screening programme will be part of Maternal Neonatal Child and
Adolescent Health (MNC&AH), Maternal Child Reproductive and Adolescent Health
(MCRAH), Community Based Health Care (CBHC), Non-Communicable Disease
Control (NCDC), Hospital Service Management and HMIS (DGHS and DGFP).
e) A mass screening policy will be taken along with developing population based
screening programme.
f) Appropriate referral system for screening and management within the existing health
system will be organized

5.2.7 Strategic direction 7: monitoring, evaluation and quality assurance

a) Facility managers such as Upazila Health & Family Planning Officers (UHFPOs), Civil
Surgeons (CSs), Deputy Directors of Family Planning (DDFPs), Hospital
Superintendents and Gynaecology Consultants of primary, secondary and tertiary level
health care facilities should be responsible for implementation of services, coordination
between various levels of service delivery and quality assurance.
b) The indicators to be used for monitoring and quality assurance of the programme, and
how they will be monitored periodically, will be clearly defined.

Table 4. Key strategic directions for cancer cervix screening:

1 The target population All Women between 30 – 60 years of age

2 Frequency of screening The screening interval for women will be 5 years
3 Screening test VIA-based screening will be followed in
Bangladesh. The opportunistic screening will be
converted to organized population based screening
4 Management of screen-positive  All screen-positive women should be evaluated
women by colposcope/minicolposcope
 Colposcopy suspected high-grade precursor
lesion shall be treated following “see and treat
strategy”

30
5 Capacity-building of human Ensure competency-based training and refresher
resource training
6 Strengthening the health Various services within the existing health
infrastructure and ensure infrastructure will be strengthened.
convergence
7 Set up a mechanism for Indicators to be used for monitoring and quality
monitoring, evaluation and quality assurance with active involvement of MIS (DHIS2)
assurance

6. Facilitating cervical cancer treatment

6.1 Introduction:

In Bangladesh, a significant number of cervical cancer cases are detected both during cervical
cancer screening and at different gynaecological outpatient departments. Further diagnostic
workup and stage wise treatment should be available in the facilities. These facilities should be
accessible and affordable to women and effective referral and linkage between the women and
facilities should be developed.

6.1.1 Cancer Cervix staging

Histological confirmation of disease as well as staging of the disease is essential prior to the
initiation of treatment for invasive cancer. Cervical cancers need to be staged, as per the FIGO
clinical staging guidelines. The basic evaluation methods recommended to determine the stage
of cancer cervix are: colposcopy, vaginal and rectal examination to inspect and palpate the
growth and its extensions, cystoscopy and proctoscopy, ultrasonography of the abdomen and
pelvis, x-ray examination of the lungs.

6.1.2 Treatment of Cancer Cervix

The treatment modality is decided based on the clinical stage of the disease, which also
determines the survival rate (Annex VII). Early cervical cancer should be treated by radical
hysterectomy with bilateral pelvic lymphadenectomy. Radiation therapy, with or without
concomitant chemotherapy, is equally effective, although morbidity is higher than surgical
management. More advanced cases should be treated by radiation therapy. The standard
radiation therapy for cervical cancer is a combination of external beam radiation therapy and
brachytherapy.

31
6.2 Organize facilities for staging and diagnostic work-up

6.2.1 Strategic direction 1: Ensure early detection of cervical cancer

1. All screen-detected cervical cancer patients will reach an appropriate health facility for
further management without appreciable delay.
2. Any woman presenting to the health facilities with symptoms suspicious of cervical cancer
should have appropriate referral and diagnostic work-up.

6.2.2 Strategic direction 2: Organize facilities for staging and diagnostic workup
1. Facilities for clinical staging and other diagnostic work-up for cervical cancer are to be made
available in the gynaecology department of all tertiary care centres.

6.2.3 Strategic direction 3: Arrange appropriate treatment based on stage of

disease
1. Gynaecologists, surgeons or gynaecologic oncologists should be made available at tertiary
care centers for surgical management of early-stage cancer
2. Radiation therapy and chemotherapy facilities should be made available in selected tertiary
care hospitals, including dedicated oncology centers.
3. The capacity of health systems should be improved to ensure the management of cancer
patients on time.

Table 5. Key strategic directions for cervical cancer treatment

• Ensure early detection of cervical cancer

• Organize facilities for staging and diagnostic work-up
• Arrange appropriate treatment based on stage of diseases

32
7. Augmenting cervical cancer related palliative care
7.1 Introduction
Palliative care is the active total care for a person with terminal illness who is near the end of
his or her life. Palliative care aims at improving a patient’s quality of life. This means treating
pain and other symptoms and, at the same time, offering social, emotional and spiritual support.
Palliative care facilities are much needed to reduce the suffering of patients with advanced
cervical cancer. A significant number of cases are detected in advanced stages where operative
and radiotherapy treatment is not possible and they should get palliative case.
Palliative care should have a primary health care approach and integrated into the health-care
system. This should facilitate palliative care education and improve access to essential and
affordable medicines such as morphine and other opioids.

7.2 Organizing palliative care services

Adequate facilities for palliative care should be made available at the tertiary, secondary and
primary health-care level. All physicians and nurses/paramedics must be aware of the basic
principles of palliative care. Medical and nursing undergraduate teaching must incorporate the
principles of basic palliative care into their curriculum. Opioid analgesics such as codeine and
oral morphine are absolutely necessary for the management of cancer pain and these drugs
must be available for pain relief.

1. Managing physical Sign and Symptoms

The women and the health care provider should identify the most common symptoms and signs
of advance cervical cancer like pelvic pain, excessive vaginal bleeding and discharge, decrease
or absence of urination. The women should be advised on how and where to get medication,
when to seek medical help and when to get admission to hospital.

2. Using Modern Medication to relieve pain

Most women with advanced cervical cancer will experience pain at some time during their
illness. It is important to strengthen follow-up and referral systems and ensure that women have
continuous access to medications.

33
3. Promoting good nutrition

Good nutrition helps a person with terminal illness to maintain her strength and allow her to
lead a comfortable life. So, it is important to explain to families that sick people need to
continue to eat nutritious food to keep up their strength.

4. Social, emotional and spiritual issues

Staying in regular contact with a sick woman and her family is a very good practice and this
demonstrate commitment to her physical and emotional wellbeing. Good communication skills
are essential to providing effective social, emotional, and spiritual support.

7.3 Key strategic directions for improvement of palliative care services

7.3.1 Strategic direction 1: Prepare the ground for palliative care services
promote the concept of palliative care to policy-makers, health-care planners and
administrators, and the general people.

7.3.2 Strategic direction 2: Organize the services at facility level

1. An inter-professional team including doctor, nurse, social worker, counselor need to be

developed to deliver the palliative care services.
2. All professionals working in palliative care for the first time will require training.

7.3.3 Strategic direction 3: Ensure availability of drugs, including morphine

1. Ensure the availability of essential drugs for the management of pain and other symptoms at
all facilities.
2. Access to an adequate and uninterrupted supply of oral morphine should be recognized as a
basic right of the patients who need them.

Table 6. Key strategic directions for palliative care services

• Prepare the ground for palliative care services

• Organize the services
• Ensure availability of drugs, including morphine

34
8. Health education, awareness and community mobilization

8.1 Introduction:
Health education and awareness are key components of a comprehensive cervical cancer
control and should be targeted towards high acceptance of the services by the community.
Some basic principles and suggestions are listed below.

1. Understanding the baseline knowledge and perceptions of the community is crucial to

developing communication materials and communication strategies.

2. Messages should be target-specific, culturally appropriate and address common myths,

misconceptions and fears related to a new vaccine or tests related to cancer.

3. The core messages should be consistent, irrespective of the community and setting, and as
per the recommendations of the national guideline and protocol for cervical cancer control.

4. The key counseling message – that the disease can be prevented by adopting a healthy
lifestyle, avoiding harmful practices and accepting the age-specific interventions (vaccination
or screening) – needs to be stressed during training and awareness-building.

5. Educating girls to complete the vaccination course after the first or second dose and
counselling screen-positive women to complete the diagnostic evaluation and treatment are
essential to maintain high compliance.

6. Involving boys and male family members in the group counselling sessions usually improves
acceptance of the programme. However, due consideration should be given to the fact that in
some communities girls or women may feel embarrassed discussing certain issues in the
presence of male family members.

7. A booklet in the local language containing answers to frequently-asked questions, along with
pictorial depictions related to cervical cancer prevention using simple words, can be a very
useful tool for educators.

Health education will be delivered at community or health facilities, or both. Health workers
and volunteers at community or primary health facilities are the first point of contact with the

35
community. They should be given a short orientation training so that they can inform and
motivate parents to send their daughters for vaccination and encourage women to undergo
screening. They will keep records of the vaccinated girls and screened women, and can remind
parents to complete the vaccination course or counsel screen-positive women to reach the next
level of health care for further evaluation and treatment. At health facilities, health education
and counseling can be done by trained health workers, midwives, nurses and doctors. The target
audience can be accessed in waiting areas, outpatient clinics and also through community
outreach initiatives.

The aim of health education will be to:

- Inform the community about cervical cancer, its causes and natural history,
- Increase awareness on signs and symptoms of overt cervical cancer,
- Reduce ignorance, fear, embarrassment and stigma related to cervical cancer,
- Inform the public of available services and where to get them.
- Empower communities with information to enhance decision making and promote
positive health seeking behavior
- Involvement of community leaders will be essential to provide valuable support for
outreach efforts and in adequate allocation of local resources for essential screening
and treatment services.
- Male family members and other community members must support women’s
decisions to seek screening and to go for treatment when it is needed.

8.2 Strategies to be used for community mobilization include:

1. Existing structures to enhance public awareness and support (e.g. health Assistant,
Community Health Care Providers, Community midwives, school health programs,
Parliamentary health committees, professional bodies, training institutions etc.) will be
used. Health education messages will be imparted through direct face-to-face meetings.
Local peer groups (teachers, politicians, religious leaders, etc.), youth groups, women
groups, and voluntary organizations etc. can also be involved in group counseling meetings.
2. It is necessary to create awareness about cervical cancer and involvement of the women’s
representatives of local government division for cervical cancer prevention & control
strategies.

3. A broad-based media campaign utilizing print and electronic media will be used to improve
the visibility of the programme and enhance participation rates.

36
4. Printed materials such as booklets, flipcharts and posters in the local language aided by
pictures, diagrams and charts should be used to propagate the messages

5. Depending on the facilities and resources available, billboards, slide shows, video, tv &
road drama shows and Street-plays will also be organized to develop awareness targeting
to schools, mass population and teachers

6. Government organizations including Department of Cancer Epidemiology of NICRH,

BSMMU, Non-governmental organizations, community-based organizations, and the
private sector health care agencies can play role in cervical cancer prevention. The HPV
vaccination, screening and treatment modalities of cervical cancer should be highlighted at
each monthly meeting of health centers. They will be critical in the promotion of
community involvement and in community mobilization for utilization of services

9. Monitoring, Evaluation and Cancer Registry

Monitoring and Evaluation: See the section 4.1.5

Cancer Registry:

Cancer registry is an organization for systematic collection, storage, analysis and interpretation
of data on persons with cancer. It is an essential part of any cancer control program. There are
two main types of cancer registry: hospital based cancer registry (HBCR) and population based
cancer registry (PBCR). Bangladesh needs to establish a population-based cancer registry to
provide epidemiological data on cancer incidence, prevalence and trends in the population (for
all cancers as well as cervical cancer).

37
10. Advocacy
The purpose of advocacy is to empower policy-makers to make informed decisions on
programme needs, implementation and service utilization. Advocacy is also essential to ensure
community participation and acceptance, and generate demand for the services from within the
community.

The targets for advocacy and communication efforts should include the
following:
• High-level decision-makers and advisors in relevant government sectors
• Development partners and members of civil society organizations
• Members of academic institutions and professional associations
• Administrators and managers at the health ministry and hospitals
• Health-care providers including physicians, nurses, midwives and school health
workers;
• Community leaders and public representatives
• Media representatives.

The advocacy document should include brief and focused country-specific messages and data
on cervical cancer incidence and deaths. It should also highlight the fact that the disease is
preventable through a comprehensive approach. A document that clearly identifies strategies
and service delivery guidelines based on the country’s needs, priorities and capabilities is
useful for the policy-makers.

Critical areas for advocacy include: the removal of policy barriers; allocation of sufficient
financial and human resources for the programme; investment in HPV vaccine; and systems
strengthening for implementation of the cervical cancer control program. Lobbying for
establishment of a budget line for the cervical cancer program will be undertaken.

To facilitate the advocacy process, tools will be developed to demonstrate the cost benefit
analysis and these will be shared in forums with the policy makers. Working with other
government sectors and nongovernmental agencies, the Ministry of Health will organize
activities and develop materials to increase public awareness of cervical cancer and its

38
prevention, to mobilize eligible women to utilize cervical cancer control services, and to
encourage communities to assist women with cervical cancer.

11. Conclusion:
An action plan will be prepared in the fastest time to implement this approved strategies,
through which the successful introduction of VIA screening technology and HPV vaccines into
programmes across the country is possible. Bangladesh government is determined to prevent
and control cervical cancer by successful implementation of this strategy.

39
References

1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin

DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality
Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France:International Agency
for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on
18/12/2013.
2. GLOBOCAN (2012) GLOBOCAN 2012: Population Fact Sheet –
BangladeshGLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence
Worldwide in 2012.
3. Sankaranarayanan R, Swaminathan R, Brenner H, Chen K, Chia KS, Chen JG, et al.
Cancer survival in Africa, Asia, and Central America: a population-based study.
Lancet Oncol. 2010 Feb;11(2):165-73.
4. ZurHausen H. Human papillomaviruses and their possible role in squamous cell
carcinomas. CurrTop MicrobiolImmunol 1977; 78:1-30.
5. Cuzick J, Terry G, Ho L, Hollingworth T and Anderson M. Type-specific human
papillomavirus DNA in abnormal smears as a predictor of high-grade cervical
intraepithelial neoplasia. Br J Cancer 1994; 69: 167-171.
6. Cox JT, Schiffman MH, Winzelberg AJ and Patterson JM. An evaluation of Human
papillomavirus testing as part of referral to colposcopy clinics. ObstetGynaecol 1992; 80:
389-395.
7. Koutsky LA, Holmes KK, Critchlow CW, Stevens CE, Galloway DA, Vernon D and
Kiviat NB. A cohort study of the risk of cervical intraepithelial neoplasia grade 2 or 3 in
relation to papillomavirus infection. N Engl J Med 1992; 327(18): 1273-1278.
8. Lorincz AT, Reid R, Jenson AB, Greenberg MD, Lancaster W, Kurman RJ. Human
papillomavirus infection of the cervix: relative risk associations of 15 common anogenital
types. ObstetGynecol 1992; 79(3): 328-337.
9. ZurHausen H. Viruses in human cancers. Science 1991; 254: 1167-1172.
10. Reeves WC, Brinton L A, Garcia M, Brenes MM, Herrero R, Gaitan E, Tenorio F, DE
Brinton RC and Rawls WE. Human papillomavirus infection and cervical cancer in Latin
America. N Engl J Med 1989; 320 (22): 1437-1441.
11. Walboomers JMM, Jacobs MV, Manos MM, Borch FX, Kummer A, Shah KV, Snijders
PJF, Peto J, Meijer CJLM and Munoz N. Human papillomavirus is a necessary cause of
invasive cervical cancer worldwide. J Pathol 1999; 189: 12-19.

40
12. Ho GYF, Burk RD, Klein S, Kadish AS, Chang CJ, Palan P, Basu J, Tachezy R, Lewis
R, Romney S. Persistent genital Human papillomavirus infection as a risk factor for
persistent cervical dysplasia. J Natl Cancer Inst 1995; 87: 1367-1371.
13. Hildesheim A, Schiffman MH, Gravitt PE, Glass AG, Greer CE, Zhang T, Scott DR,
Rush BB, Lawler P, Sherman ME, Kurman RJ and Manos MM. Persistence of type-
specific Human papillomavirus infection among cytologically normal women. The
Journal of Infectious Diseases 1994; 169: 235-240.
14. Östör AG. Natural history of cervical intraepithelial neoplasia: a critical review. Int J
GynecolPathol 1993; 12(2): 186-192.
15. Bosch FX, Manos MM, Muñoz N, Sherman M, Jansen AM, Peto J, Schiffman MH,
Moreno V, Kurman R, Shah KV. Prevalence of Human papillomavirus in cervical caner:
a worldwide perspective. J Natl Cancer Inst 1995; 87: 796-802.
16. Ministry of Primary and Mass Education; Available from: http://www.bd.undp.org,
accessed on 05/07/2017.
17. Bangladesh EPI Coverage Evaluation Survey, 2015.
18. HPV Coverage Survey, EPI, DGHS, 2016.

19. Nessa A, Rashid MH, Ferdous NE Chowdhury A (2013). Screening for and management
of high-grade cervical intraepithelial neoplasia in Bangladesh: A cross-sectional study
comparing two protocols. J ObstetGynaecol Res, 39, 564-71.
20. Ahmed T, Ashrafunnessa, Rahman J (2008). Development of a Visual Inspection
Programme for Cervical Cancer Prevention in Bangladesh. Elsevier Reproductive
Health Matters, 16, 78-85.
21. Basu P, Nessa A, Majid M, et al (2010). Evaluation of the National Cervical Cancer
Screening Programme of Bangladesh and the formulation of quality assurance
guidelines. J FamPlannReprodHlth Care, 36, 131-4.
22. Nessa A, Hussain MA, Rahman JN, Rashid MH, Muwonge R and Sankaranarayanan R
(2010). Screening for cervical neoplasia in Bangladesh using visual inspection with
acetic acid. Int J GynaecolObstet, 111, 115-8.
23. Holme F, Kapambwe S, Nessa A, Partha B, Murillo R, Jeronimo J. Scaling up proven
innovative cervical cancer screening strategies: Challenges and opportunities in
implementation at the population level in low and lower-middle income countries. Int J
Gynecol Obstet 2017;138 (Suppl. 1):63–68
24. Nessa A, Naud P, Esmy PO, Joshi S, Rema P, Wesley R, Kamal M, Sauvaget C,
Muwonge R, Sankaranarayanan R. Efficacy, Safety, and Acceptability of Thermal
Coagulation to Treat Cervical Intraepithelial Neoplasia: Pooled Data From Bangladesh,
Brazil and India. Clin Gynecol Obstet. 2017; 6(3-4): 58-64

41
 Annex I

Test characteristics, personnel requirements and limitations of different

screening:

Sensitiv Specificit Personnel for

Screening ity to y to Test processing
Major limitations
test detect detect provider and
CIN2+ CIN2+ interpretation
Doctors/nur Result not immediately
ses/midwiv available, laboratory
Cyto-
es/ necessary,
Convention Tcechnicians/
53% 96.3% Reproducti Highly trained
al cytology cytopathologis
ve health personnel,
ts
care Low to moderate
providers sensitivity
Doctors/nur
Result not immediately
ses/midwiv
Cyto- available, laboratory
Liquid- es/
Tcechnicians/ necessary,
based 79.1% 78.8% Reproducti
cytopathologis Highly trained
cytology ve health
t personnel,
care
expensive
providers
Doctor/nurs
e/midwife/
Result not immediately
Reproducti Laboratory
HPV DNA 96.1% 90.7% available laboratory
ve health technician
necessary expansive
care
provider
Doctor/nurs
Sensitivity moderate,
e/midwife/
high false-positives
Reproducti
VIA 80% 92% Not Necessary subjective, performance
ve health
variable and depands on
care
training providers
provider

i
 Annex II

Work Flow at the Screening Center

ii
 Annex III
Workflow at the Colposcopy Clinic:

iii
 Annexes IV

Management of screen-positive women based on colposcopy diagnosis

(“see-and-treat” approach) alone

Screening test positive

Colposcopy

Normal Suspected CIN Invasive Cancer

Assess if lesion is suitable for Thermo-coagulation

Treatment based
1. No endocervical extension
on stage
2. TZ – Type 1
3. Limited to three quadrants
4. No suspicion of cancer

Suitable for Not suitable for

Thermocoagulati Thermocoagulati Follow-up
Repeat screening on on
after 5 years for VIA

Thermocoagulation Cold knife

(Biopsy optional) conisation/LEEP

Follow-up at 12 months (screening test/colposcopy)

iv
 ANNEX V

Criteria of a designated training center:

Sl No Parameter Performances
1 Number of screening At least 4000 screening each year
Number of management of screen At least 1000 screen positive cases
2 positive cases (VIA, Paps, HPV test) should have colposcopic examination
each year
Treatment of pre-cancer At least 300 pre-cancers should be
treated each year ( at least 100 cases
3
treated by LEEP)

Histopathological Examination Must be performed within the

4
institute
Record keeping Must be upto the standard (VIA,
Colposcopy Register, Cards, system
5
for maintaining electronic database
connected to DHIS2 of DGHS MIS)
Equipment Colposcope, Thermocoagulator,
6 Electrosurgical equipment must be in
good working condition
Teaching and nursing staff Adequate teaching and nursing staff
7 must be present

v
 Annex VI

Score sheet for clinical supervision of via trainees

A. COUNSELING SKILLS ON VIA and CBE

Rate the performance of each step or task observed using the following rating scale:
1. Needs Improvement: Step or sequence not performed correctly
2. Competently Performed: Step or sequence partly performed.
3. Proficiently Performed: Step or task efficiently and precisely performed in the proper
sequence.

COUNSELING SKILLS ON VIA AND CBE

STEP/ACTIVITY CASES
COUNSELING
Initial Interview (Woman Reception Area)
1. Greet the woman respectfully.
2. Establish purpose of the visit and answer questions.
3. Provide general information about preventing cervical and
breast cancer by early detection.

4. Give the woman information about the pelvic examinations.

a. Explain how the VIA, breast and pelvic examination are done.

b. Explain what to expect during the clinic visit.

VIA and CBE-Specific Counseling (Examination Area)
1. Assure necessary privacy.
2. Obtain general information (name, address, etc.)

3. Ask the woman about her reproductive health history (Age at

first sexual contact? History of vaginal discharge, pelvic pain and
history of cancer in family; particularly breast cancer)

xvii

4. Give the woman additional information about VIA and CBE:

a. Explain the nature of cervical cancer and its relationship to

HPV infection.

b. Discuss the risk factors for cervical and breast disease

c. Describe how the VIA and CBE is done and the possible
findings.
d. Explain the management if the VIA is abnormal

vi
 e. Explain the management if the CBE is abnormal
5. Ask about her attitudes towards VIA and CBE.
6. Discuss the woman's needs, concerns and fears.
7. Help the woman begin to decide to have VIA test.
If woman chooses to have a VIA and CBE:
8. Ask the woman if she has any other questions about the VIA
and CBE.

9. Describe the VIA and CBE procedure and what she should
expect during the pelvic examination and afterward.

If the VIA and CBE is negative:

1. Discuss with the woman the results of the VIA test and what it
means to her reproductive health.
2. Tell her when to return for future screening.

3. Assure the woman she can return to the same clinic at any time
to receive advice or medical attention.
4. Provide follow up visit instructions.

xviii

B. CBE CLINICAL SKILLS

Rate the performance of each step or task observed using the following rating scale:
1. Needs Improvement: Step or sequence not performed correctly
2. Competently Performed: Step or sequence partly performed.
3. Proficiently Performed: Step or task efficiently and precisely performed in the proper
sequence.

CLINICAL SKILLS ON CBE

STEP/ACTIVITY CASES
INITIAL INTERVIEW (EXAMINATION AREA)
1. Greet the woman respectfully and with
kindness.
2. Tell the woman you are going to examine her
breasts.
3. Ask the woman to undress from her waist up.
Have her sit on the examining table with her arms at
her sides.
4. Wash hands thoroughly and dry them. If
necessary, put on new examination or high-level
disinfected surgical gloves on both hands.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
BREAST EXAMINATION
1. Look at the breasts and note any differences in:

vii
 • shape
• size
• nipple or skin puckering
• dimpling
Check for swelling, increased warmth or tenderness in
either breast.
xix
2. Look at the nipples and note size, shape and
direction in which they point.
Check for rashes or sores and nipple discharge.
3. Look at breasts while woman has hands over her
head and presses her hands on her hips. Check to see
if breasts hang evenly.
4. Have her lie down on the examining table.
5. Look at the left breast and note any differences
from the right breast.
6. Place pillow under woman's left shoulder and
place her arm over her head.
7. Palpate the entire breast using the spiral
technique. Note any lumps or tenderness.
8. Squeeze the nipple gently and note any
discharge.
9. Repeat these steps for the right breast. If
necessary, repeat this procedure with the woman
sitting up and with her arms at her sides.
10. Have the woman sit up and raise her arm. Palpate
the tail of the breast and check for enlarged lymph
nodes or tenderness.
11. Repeat this procedure for the right side.
12. After completing the examination, have
woman cover herself. Explain any abnormal findings
and what needs to be done. If the examination is
normal, tell the woman everything is normal and
healthy and when she should return for a repeat
examination.
13. Show the woman how to perform breast self-
examination.
SKILL/ACTIVITY PERFORMED SATISFACTORILY
xx

viii
 C. VIA CLINICAL SKILLS

Rate the performance of each step or task observed using the following rating scale:
1. Needs Improvement: Step or sequence not performed correctly
2. Competently Performed: Step or sequence partly performed.
3. Proficiently Performed: Step or task efficiently and precisely performed in the proper
sequence.

CLINICAL SKILLS ON VIA

STEP/ACTIVITY CASES
INITIAL INTERVIEW (EXAMINATION AREA)
1. Greet the woman respectfully and with kindness.
2. Explain why the VIA is recommended and describe the procedure.
3. Tell her what the findings might be and what follow up or treatment might be
necessary.
GETTING READY FOR VIA
1. Check that the instruments and supplies are available.
2. Ensure that the light source is available and ready to use.
3. Check that the woman has emptied her bladder.

4. Help her onto the examining table, help her to be undressed and drape her.

5. Wash hands thoroughly with soap and water and dry with clean, dry cloth or
air dry.
6. Put one pair of new examination disposable gloves on both hands. If available,
put a second glove on one hand.
7. Arrange instruments and supplies on high-level disinfected tray or container, if
not already done.

xxi

VISUAL INSPECTION WITH ACETIC ACID

1. Inspect external genitalia and check urethral opening for discharge.
2. Insert speculum and adjust it so that the entire cervix can be seen.
3. Fix the speculum blades in the open position so that the speculum will remain
in place with the cervix in view.
4. Adjust the light source so that you can see the cervix clearly.

5. Examine the cervix for cervicitis, ectropion, growth, Nabothian cysts or ulcers.

6. Identify the cervical os, squamocolumnar junction (SCJ) and transformation

zone.
7. Soak a clean swab in 5% acetic acid and apply it to cervix. Dispose of swab in
a leak proof container or plastic bag.
8. Wait at least 1 minute for the acetic acid to be absorbed and any acetowhite
change to appear.
9. Inspect the SCJ carefuly
a. Check whether cervix bleeds easily

ix
 b. Look for any raised and thickened white plaques or acetowhite epithelium

xxii

VISUAL INSPECTION WITH ACETIC ACID

11. As needed, reapply acetic acid or swab the cervix with a clean swab to remove
mucus, blood or debris. Dispose of swab in a leak proof container or plastic bag.

12. When visual inspection has been completed, use a fresh swab to remove any
remaining acetic acid from the cervix and vagina. Dispose of swab in a leak proof
container of plastic bag.
13. Remove the speculum.
a. If VIA test was negative, place in 0.5% chlorine solution for 10 minutes for
decontamination
b. If the VIA test was positive, place speculum on high-level disinfected tray
or container.
14. Perform the bimanual examination and rectovaginal examination (if
indicated).

POST-VIA TASKS
1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by
turning inside out.

a. If disposing of gloves, place them in leak proof container or plastic bag.

Gloves must be disposed of if rectovaginal examination performed.

b. If reusing surgical gloves, submerge in 0.5% chlorine solution for 10

minutes for decontamination.
2. Wash hands thoroughly with soap and water and dry with clean, dry cloth or
air dry.
3. Record the VIA test results and other findings in woman's record.
a. If acetowhite change is present, draw a map of
the cervix and the diseased area on the record.
4. Discuss the results of the VIA test and pelvic examination with the woman and
answer any questions.

a. If VIA test is negative, tell her when to return for repeat VIA testing.

b. If VIA test is positive or cancer is suspected,

discuss recommended next steps.
c. After counseling, provide treatment or refer.

Score sheet for Clinical Supervision of VIA Trainees (Contd.)

Comments:
Pre-VIA Counseling:
Pre-VIA Activities:
VIA Skill:

x
 Annex VII

Overall survival of cervical cancer patients by stage of disease

Cervical 5 – Year
Treatment Modalities
Cancer Stage Survival Rate
IA Conization/radical hysterectomy and pelvic lymphadenectomy 93%
Radical hysterectomy and pelvic lymphadenectomy/external beam
IB 80%
radiotherapy with brachytherapy
Radical hysterectomy and pelvic lymphadenectomy/external beam
IIA 63%
radiotherapy with brachytherapy
IIB External beam radiotherapy with brachytherapy 58%
IIIA External beam radiotherapy with brachytherapy 35%
IIIB External beam radiotherapy with brachytherapy 32%
IVA Individualized treatment with palliative intent 16%
IVB Individualized treatment with palliative intent 15%

Source: American joint committee on Cancer (AJCC) Cancer staging manual. Seventh Edition (2010).

xi
 Annex VIII

Demographic Data

1.1 Total population

1.2 Total Men

1.3 Total Women
1.4 Urban Population
1.5 Rural Population
1.6 Number of aged 30-60 years
1.7 Number of girls aged 9 years
1.8 Number of girls aged 10 years
1.9 Number of girls aged 11 years

1.10 Number of girls aged 12 years

If age breakup not available, number of girls

1.11
aged 10-14 years
Percentage of girls (specify age like 9-14
1.12 yrs) that completed primary school
education

Note: Indicate year and source

Remarks:

DEMOGRAPHIC DATA
1.1 Total population: 156.8 million
1.2 Total men: 78.6 million
1.3 Total women: 78.2 million
1.4 Urban population: 44.1 million
1.5 Rural population: 112.7 million
1.6 Number of women aged 30-59: 43,380,414 (15-49)
1.7 Number of girls aged 9: 1,529,000
1.8 Number of girls aged 10: 1,549,000
1.9 Number of girls aged 11: 1,558,000
1.10 Number of girls aged 12: 1,559,000
1.11 If age breakup not available, Number of girls aged 10-14 yrs
1.12. Percentage of girls (Specify age like 9-13yrs or 10-14 yrs) that completed primary
school education

xii
 Annex IX

Commonly used teaching materials for comprehensive control

of cancer cervix
Visual inspection after acetic acid application (VIA)
International Agency for Research on Cancer (IARC).A practical manual on visual
screening for cervical neoplasia (2003). Freely available at:
http://screening.iarc.fr/viavili.php?lang=l

International Agency for Research on Cancer (IRAC).A training course in visual

inspection with 5% acetic acid (VIA) (2005). Freely available at:
http://screening.iarc.fr/digitallearningserie.php

The Johns Hopkins Program for International Education in Gynecology and

Obstetrics (JHPIEGO).Cervical Cancer Prevention Guidelines for Low-resource
Settings (Guide for Participandts) (2005). Available as PDF for free. Hard copies
available for purchase. Contact: [email protected]

JHPIEGO.CervicalCancerPreventionGuidelinesfor Low-
resourceSettings(GuideforParticipants)(2005), Available as PDF for free, Hard copies
avarlable for purchase, contact: [email protected]

JHPIEGO.Cervical Cancer Prevention Guidelines for Low-resource Settings (Guide for

Trainers)(2005).Available PDF
forfree,Hardcopiesavailableforpurchase.contact:[email protected]

JHPIEGO.Atlas of Visual lnspection of the Cervix with Acetic Acid (VIA).Available

for purchase.
contact: [email protected]

JHPIEGO.VisuallnspectionforCervicalCancerPrevention:An InteractiveTraining
Tool.Available for purchase.contact: [email protected]

JHPIEGO.Visuallnspectionofthe CervixFlashCardSet.Availablefor
purchase.contact:[email protected]

Program for Appropriate Technology in Health (PATH): Course in visual Methods

for CervicalCancer screening: Vrsuallnspection with Acetic Acid and Lugol’slodine
(2004). Online previewavailable at: http://www.rho.org/training.htmThe complete CD-
ROM may be ordered. Contact:[email protected]

WHO. Comprehensive Cervical Cancer Control: A Guide to Essential Practice (2006).

PDF freelyavailable at:
http://www.who.int/reproductivehelth/publications/cancers/9241547006/en/index.html

xiii
Colposcopy
UICC UICC Cervical Cancer Curriculum. Demonstration available
at:http://uicc.org/resources/cervical-cancercurriculum to access additional modules and
materials, contact [email protected]

UICC, WHO, IARC, INCTR. Colposcopy and treatment of Cervical intraepithelial

Neoplasia: A Beginner’s Mannual (2004). PDF freely available at:
http://screening.iarc.fr/colpo.php?lang=l

Histology/cytology
UICC, WHO, IARC, INCTR.Histopatholgy of the Uterine Cervix, Digital Atlas –
Cytopatholgy of the Uterine Cervix.Digital Atlas (2004). PDF freely available at
http://screening.iarc.fr/atlashisto.php?lang=l

Staging
ASCO, ASCO Multidisciplinary Cancer Management Course. Contact:
[email protected]://www.asco.org/mcmc

LEEP/LEETZ
IARC Digital Learning Series: A course in LOOP Electrosurgical Excision Procedure
(2005). PDF freely available at: http://screening.iarc.fr/digitallearningsere.php

Planning and Programme Management

ACCP Planning and Implementing Cervical Cancer Programs: Manual for Program
Managers (2004) PDF freely available at
http://screening.iarc.fr/planningmanual.php?lang=l
PATH Planning Appropriate Cervical Cancer Programs (2000)
PDF freely available at: http://www.path.org/files/cxca-planning-approprog-

xiv
 Annex X

The Template for Cervical Cancer Screening Database from DHIS2

xv
3/28/2017 Tracker Capture

Tracker capture

Enrolling organisation unit Mirpur Upazila Health Complex

Program Cervical and Breast Cancer Screening Program

Enrollment Date

Profile

Registration no

Full name*

Husband's Name*

National ID (NID)

Date of Birth*

Phone number*

Present Address

Parmanant Address*

Occupation*

Education

Total Child ( Death+Alive )

Age of Marriage*

Age of first delivary

http://103.247.238.82:8080/dhismohfw/dhis-web-tracker-capture/index.html#/ 1/2

xvi
xvii