Factors influencing cervical cancer re-screening in a semi-rural health district of Cameroon: a cohort study.

BACKGROUND: Screening participation at recommended intervals is a crucial component of cervical cancer prevention effectiveness. However, little is known regarding the rate of re-screening in a Sub-Saharan context. This study aimed to estimate the re-screening rate of women in a semi-rural after an initial HPV-based screening and identify factors that influence adherence. METHODS: This cohort study at the Annex Regional Hospital of Dschang enrolled women screened for cervical cancer over 5 years ago and due for re-screening. Women who initially tested HPV-positive (n = 132) and a random sample of HPV-negative women (n = 220) participated in a telephone survey between October 2021 and March 2022 to assess re-screening participation and reasons. Sociodemographic factors were collected, and associations with rescreening were evaluated. RESULTS: A total of 352 participants aged under 50 years (mean age 37.4 years) were contacted, and 203 (58.0%) completed the survey. The proportion of women who complied with the screening recommendation was 34.0% (95% CI 27.5% - 40.5%), The weighted re-screening proportion was 28.4%. Age, marital status, education level, type of employment, and place of residence were not associated with the rate of re-screening. Main reported barriers to re-screening were lack of information (39.0%), forgetfulness (39.0%), and impression of being in good health (30.0%). Women who remembered the recommended screening interval were 2 to 3 times more likely to undergo re-screening (aOR (adjusted odds ratio) = 2.3 [1.2-4.4], p = 0.013). Human papilloma virus- positive status at the initial screening was also associated with the re-screening((aOR) (95% CI): 3.4 (1.8-6.5). CONCLUSION: Following an initial Human Papilloma Virus-based screening campaign in the West Region of Cameroon, one third of women adhered to re-screening within the recommended timeframe. Existing screening strategies would benefit from developing better information approaches to reinforce the importance of repeated cervical cancer screening.

Telecytologic diagnosis of cervical smears for triage of self-sampled human papillomavirus-positive women in a resource-limited setting: concept development before implementation.

INTRODUCTION: Cytology is an option for triaging human papillomavirus (HPV)-positive women. The interpretation of cytologic slides requires expertise and financial resources that are not always available in resource-limited settings. A solution could be offered by manual preparation and digitization of slides on site for real-time remote cytologic diagnosis by specialists. In the present study, we evaluated the operational feasibility and cost of manual preparation and digitization of thin-layer slides and the diagnostic accuracy of screening with virtual microscopy. MATERIALS AND METHODS: Operational feasibility was evaluated on 30 cervical samples obtained during colposcopy. The simplicity of the process and cellularity and quality of digitized thin-layer slides were evaluated. The diagnostic accuracy of digital versus glass slides to detect cervical intraepithelial neoplasia grade 2 or worse was assessed using a cohort of 264 HPV-positive Cameroonian women aged 30 to 49 years. The histologic results served as the reference standard. RESULTS: Manual preparation was found to be feasible and economically viable. The quality characteristics of the digital slides were satisfactory, and the mean cellularity was 6078 squamous cells per slide. When using the atypical squamous cells of undetermined significance or worse threshold for positivity, the diagnostic performance of screening digital slides was not significantly different statistically compared with the same set of slides screened using a light microscope (P = 0.26). CONCLUSIONS: We have developed an innovative triage concept for HPV-positive women. A quality-ensured telecytologic diagnosis could be an effective solution in areas with a shortage of specialists, applying a same day "test-triage-treat" approach. Our results warrant further on-site clinical validation in a large prospective screening trial.

Investigation of Dengue Infection in Asymptomatic Individuals during a Recent Outbreak in La Réunion.

The number of dengue cases has increased dramatically over the past 20 years and is an important concern, particularly as the trends toward urbanization continue. While the majority of dengue cases are thought to be asymptomatic, it is unknown to what extent these contribute to transmission. A better understanding of their importance would help to guide control efforts. In 2019, a dengue outbreak in La Reunion resulted in more than 18,000 confirmed cases. Between October 2019 and August 2020, 19 clusters were investigated in the south, west, and east of the island, enabling the recruitment of 605 participants from 368 households within a 200 m radius of the home of the index cases (ICs). No active asymptomatic infections confirmed by RT-PCR were detected. Only 15% were possible asymptomatic dengue infections detected by the presence of anti-dengue IgM antibodies. Only 5.3% of the participants had a recent dengue infection confirmed by RT-PCR. Although the resurgence of dengue in La Réunion is very recent (2016), the rate of anti-dengue IgG positivity, a marker of past infections, was already high at 43% in this study. Dengue transmission was focal in time and space, as most cases were detected within a 100-m radius of the ICs, and within a time interval of less than 7 days between infections detected in a same cluster. No particular demographic or socio-cultural characteristics were associated with dengue infections. On the other hand, environmental risk factors such as type of housing or presence of rubbish in the streets were associated with dengue infections.

Transformation Zone Assessment Using Visual Inspection With Acetic Acid Before and After Thermal Ablation: Implications for Follow-Up.

PURPOSE: Thermal ablation (TA) has become the conventional method for treatment of precancerous cervical lesions in low-resource settings. After TA, both the squamocolumnar junction (SCJ) and the transformation zone (TZ) may be subject to change. Our aim was to evaluate SCJ and TZ variability after TA. METHODS: Study data were collected in a large prospective trial of a cervical cancer screening campaign in Cameroon. For each patient, two sets of cervical photos (native and with acetic acid) were taken before and 6-12 months after TA. The SCJ and TZ were evaluated independently by three observers according to the WHO nomenclature. When discordances were observed between the type of TZ and SCJ selected by each observer, a corrected TZ was established on the basis of the SCJ categorization. Interobserver agreement for TZ interpretation was evaluated using Cohen's kappa coefficient for agreement between two observers and Fleiss' kappa between three observers. RESULTS: Fifty consecutive participants were included in the analysis. Seventy-six percent were interpreted as TZ1-2, and 24% as TZ3 before TA. In 56% of cases, the entire SCJ could not be entirely visualized after TA, thus being recategorized as TZ3. Interobserver agreement was fair for diagnosis before TA (Kappa coefficient, 0.34; 95% CI, 0.27 to 0.45) and moderate for diagnosis after TA (Kappa coefficient, 0.40; 95% CI, 0.30 to 0.50). After TA, 36% progressed from TZ1-2 to TZ3, with a moderate interobserver agreement (Kappa coefficient, 0.44; 95% CI, 0.40 to 0.54). CONCLUSION: We observed a shift of the SCJ into the endocervical canal after TA. A significant proportion of participants had TZ 3 after treatment, raising the question of visual inspection with acetic acid's applicability as a first-line follow-up examination method after TA.

Prevalence and predictors of psychological distress before, during, and after a COVID-19 pandemic wave in Switzerland, 2021.

There are concerns about acute and long-term mental health effects of the COVID-19 pandemic. This study examined the prevalence and predictors of psychological distress before, during, and after a pandemic wave in Switzerland, 2021. Prevalence of psychological distress was estimated in adults aged 35-96 years using the General Health Questionnaire-12 administered in June 2021 (Specchio-COVID19 cohort, N = 3965), and compared to values from 2003 to 2006 (CoLaus|PsyCoLaus cohort, N = 5667). Anxiety and depression were assessed from February to June 2021 using the Generalised Anxiety Disorder scale-2 and the Patient Health Questionnaire-2, respectively. Prevalence of psychological distress in June 2021, after the pandemic wave (16.0% [95% CI, 14.6%-17.4%]) was comparable to pre-pandemic levels (15.1% [14.0%-16.2%]). Anxiety and depression were highest at the start of the pandemic wave in February 2021, and declined from February to June with the relaxation of measures. Predictors of psychological distress included being younger, female, a single parent, unemployed, a change in working hours or job loss in the past 6 months, greater perceived severity and contagiousness of COVID-19, and self-reported post COVID-19. By June 2021, following a pandemic wave, prevalence of psychological distress in Switzerland was closer to pre-pandemic levels. These findings highlight the need for additional mental health support during times of stricter government policies relating to COVID-19; yet they also suggest that individuals can adapt relatively quickly to the changing context.

Inter- and intra-observer agreement in the assessment of the cervical transformation zone (TZ) by visual inspection with acetic acid (VIA) and its implications for a screen and treat approach: a reliability study.

BACKGROUND: In low-resource countries, interpretation of the transformation zone (TZ) using the classification of the International Federation for Cervical Pathology and Colposcopy (IFCPC), adopted by the World Health Organization, is critical for determining if visual inspection with acetic acid (VIA) screening and thermal ablation treatment are possible. We aim to assess inter- and intra-observer agreement in TZ interpretation. METHODS: We performed a prospective multi-observer reliability study. One hundred cervical digital images of Human papillomavirus positive women (30-49 years) were consecutively selected from a Cameroonian cervical cancer screening trial. Images of the native cervix and after VIA were obtained. The images were evaluated for the TZ type at two time points (rounds one and two) by five VIA experts from four countries (Côte d'Ivoire, Cameroon, Peru, and Zambia) according to the IFCPC classification (TZ1 = ectocervical fully visible; TZ2 = endocervical fully visible; TZ3 = not fully visible). Intra- and inter-observer agreement were measured by Fleiss' kappa. RESULTS: Overall, 37.0% of images were interpreted as TZ1, 36.4% as TZ2, and 26.6% as TZ3. Global inter-observer reliability indicated fair agreement in both rounds (kappa 0.313 and 0.288). The inter-observer agreement was moderate for TZ1 interpretation (0.460), slight for TZ2 (0.153), and fair for TZ3 (0.329). Intra-observer analysis showed fair agreement for two observers (0.356 and 0.345), moderate agreement for two other (0.562 and 0.549), and one with substantial agreement (0.728). CONCLUSION: Interpretation of the TZ using the IFCPC classification, adopted by the World Health Organization, is critical for determining if VIA screening and thermal ablation treatment are possible. However, the low inter- and intra-observer agreement suggest that the reliability of the referred classification is limited in the context of VIA. It's integration in treatment recommendations should be used with caution since TZ3 interpretation could lead to an important referral rate for further evaluation. Trial registration Cantonal Ethics Board of Geneva, Switzerland: N°2017-0110. Cameroonian National Ethics Committee for Human Health Research N°2018/07/1083/CE/CNERSH/SP.

Utility of extended HPV genotyping for the triage of self-sampled HPV-positive women in a screen-and-treat strategy for cervical cancer prevention in Cameroon: a prospective study of diagnostic accuracy.

OBJECTIVE: To explore the utility of extended Human Papillomavirus (HPV) genotyping to detect cervical intraepithelial neoplasia grade 2 or more (CIN2+) in a 'screen-and-treat' strategy for HPV-positive women in low-resource settings. DESIGN: Prospective study of diagnostic accuracy. SETTING: The study took place in West Cameroon between September 2018 and March 2020. PARTICIPANTS: 2014 women were recruited. Asymptomatic, non-pregnant women aged 30-49 years without history of CIN treatment, anogenital cancer or hysterectomy were eligible. INTERVENTIONS: Participants performed self-sampling for HPV testing with GeneXpert followed by visual inspection with acetic acid and Lugol's iodine (VIA) triage before treatment if required. MAIN OUTCOME MEASURES: Liquid-based cytology, biopsies and endocervical brushing were performed in HPV-positive women as quality control. We assessed the detection rate of CIN2+ by HPV genotyping (two pools of genotypes obtained from the Xpert system, pool_1 (HPV 16, 18, 45) and pool_2 (HPV 16, 18, 45, 31, 33, 35, 52, 58)), VIA and cytology. RESULTS: 382 (18.2%) women were HPV-positive among which 11.5% (n=44) were CIN2+. Of those 44 participants, 41 were triaged positive by extended genotyping, versus 35 by VIA and 33 by cytology. Overall, triage positivity was of 68.4% for extended genotyping, 59.3% for VIA and 14.8% for cytology, with false positive rates of 83.4%, 84.1% and 37.7%, respectively. Extended genotyping had a higher sensitivity for CIN2+ detection (93.2%, CI: 81.3 to 98.6) than VIA (79.5%, CI: 64.7 to 90.2, p=0.034) and cytology (75.0%, CI: 59.7 to 86.8, p=0.005). No significant difference was observed in the overtreatment rate in triaged women by extended genotyping or VIA (9.9%, CI: 8.6 to 11.3, and 8.8%, CI: 7.7 to 10.1), with a ratio of 6.0 and 6.3 women treated per CIN2+ diagnosed. CONCLUSION: Triage of HPV-positive women with extended HPV genotyping improves CIN2+ detection compared with VIA with a minor loss of specificity and could be used to optimize the management of HPV-positive women. TRIAL REGISTRATION NUMBER: NCT03757299.

Socio-economic determinants of SARS-CoV-2 infection: Results from a population-based cross-sectional serosurvey in Geneva, Switzerland.

Background: SARS-CoV-2 infection and its health consequences have disproportionally affected disadvantaged socio-economic groups globally. This study aimed to analyze the association between socio-economic conditions and having developed antibodies for-SARS-CoV-2 in a population-based sample in the canton of Geneva, Switzerland. Methods: Data was obtained from a population-based serosurvey of adults in Geneva and their household members, between November and December, 2020, toward the end of the second pandemic wave in the canton. Participants were tested for antibodies for-SARS-CoV-2. Socio-economic conditions representing different dimensions were self-reported. Mixed effects logistic regressions were conducted for each predictor to test its association with seropositive status as the main outcome. Results: Two thousand eight hundred and eighty-nine adults completed the study questionnaire and were included in the final analysis. Retired participants and those living in suburban areas had lower odds of a seropositive result when compared to employed participants (OR: 0.42, 95% CI: 0.20-0.87) and those living in urban areas (OR: 0.67, 95% CI: 0.46-0.97), respectively. People facing financial hardship for less than a year had higher odds of a seropositive result compared to those who had never faced them (OR: 2.23, 95% CI: 1.01-4.95). Educational level, occupational position, and household income were not associated with being seropositive, nor were ethnicity or country of birth. Discussion: While conventional measures of socio-economic position did not seem to be related to the risk of being infected in this sample, this study sheds lights on the importance of examining the broader social determinants of health when evaluating the differential impact of the pandemic within the population.

Determinants of adolescents' Health-Related Quality of Life and psychological distress during the COVID-19 pandemic.

BACKGROUND: We examined the determinants of adolescents' Health-Related Quality of Life (HRQoL) and psychological distress (self-reported and parent-reported) during the COVID-19 pandemic, using a random sample of the population of Geneva, Switzerland. METHODS: Data was drawn from participants aged 14-17 years, who participated with their families to a serosurvey conducted in November and December 2020. Adolescents' HRQoL was evaluated using the validated adolescent-reported KIDSCREEN-10 and parent-reported KINDL® scales. Psychological distress was assessed with self-reported sadness and loneliness, and using the KINDL® emotional well-being scale. Using generalized estimating equations, we examined the role of socio-demographic, family and behavioural characteristics in influencing adolescents' mental health status and wellbeing. RESULTS: Among 240 adolescents, 11% had a low HRQoL, 35% reported sadness and 23% reported loneliness. Based on parents' perception, 12% of the adolescents had a low HRQoL and 16% a low emotional well-being. Being a girl (aOR = 3.20; 95%CI: 1.67-6.16), increased time on social media (aOR = 2.07; 95%CI: 1.08-3.97), parents' average to poor mood (aOR = 2.62; 95%CI: 1.10-6.23) and average to poor household financial situation (aOR = 2.31; IC95%: 1.01-6.10) were associated with an increased risk of sadness. Mismatches between adolescents' and their parents' perception of HRQoL were more likely for girls (aOR = 2.88; 95%CI: 1.54-5.41) and in households with lower family well-being (aOR = 0.91; 95%CI: 0.86-0.96). CONCLUSIONS: A meaningful proportion of adolescents experienced low well-being during the second wave of COVID-19, and average well-being was lower than pre-pandemic estimates. Adolescents living in underprivileged or distressed families seemed particularly affected. Monitoring is necessary to evaluate the long-term effects of the pandemic on adolescents.

"My motivation was to save": a qualitative study exploring factors influencing motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon.

BACKGROUND: Cervical cancer is a major public health issue among women in Cameroon and uptake of screening programs remains a challenge in many low- and middle-income countries. Community healthcare workers can play an important role in promoting cervical cancer services. This study aimed to explore factors affecting the motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. METHODS: A qualitative approach including 11 in-depth individual interviews with community healthcare workers was used. The interviews were audio-recorded, transcribed and coded using thematic analysis assisted by ATLAS.ti software. RESULTS: Four women and seven men aged between 21 and 77 years old were interviewed. Community healthcare workers had high motivation. Factors affecting motivation were divided into individual and environmental level, based on a theoretical framework. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. CONCLUSIONS: Key interventions to improve motivation among community healthcare workers include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport. TRIAL REGISTRATION: Geneva Cantonal Ethics Committee on Human Research (No. 2017-01110) and the Cameroonian National Ethics Committee for Human Health Research (No. 2018/07/1083/CE/CNERSH/SP).

Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.

Addition of digital VIA/VILI to conventional naked-eye examination for triage of HPV-positive women: A study conducted in a low-resource setting.

BACKGROUND: World Health Organization guidelines for cervical cancer screening recommend HPV testing followed by visual inspection with acetic acid (VIA) for triage if HPV positive. In order to improve visual assessment and identification of cervical intraepithelial neoplasia grade 2 and worse (CIN2+), providers may use visual aids such as digital cameras. OBJECTIVES: To determine whether combined examination by naked-eye and digital VIA (D-VIA) and VILI (D-VILI) improves detection of CIN2+ as compared to the conventional evaluation. MATERIALS AND METHODS: Women (30-49 years) living in Dschang (West Cameroon) were prospectively invited to a cervical cancer screening campaign. Primary HPV-based screening was followed by VIA/VILI and D-VIA/VILI if HPV-positive. Health care providers independently defined diagnosis (pathological or non-pathological) based on naked-eye VIA/VILI and D-VIA/VILI. Decision to treat was based on combined examination (VIA/VILI and D-VIA/VILI). Cervical biopsy and endocervical curettage were performed in all HPV-positive participants and considered as reference standard. Diagnostic performance of individual and combined naked-eye VIA/VILI and D-VIA/VILI was evaluated. A sample size of 1,500 women was calculated assuming a prevalence of 20% HPV positivity and 10% CIN2+ in HPV-positive women. RESULTS: Due to the COVID-19 pandemic, the study had to terminate prematurely. A total of 1,081 women with a median age of 40 (IQR 35.5-45) were recruited. HPV positivity was 17.4% (n = 188) and 26 (14.4%) had CIN2+. Naked-eye VIA and D-VIA sensitivities were 80.8% (95% CI 60.6-93.4) and 92.0% (95% CI 74.0-99.0), and specificities were 31.2% (95% CI 24-39.1) and 31.6% (95% CI 24.4-39.6), respectively. The combination of both methods yielded a sensitivity of 92.3% (95% CI 74.9-99.1) and specificity of 23.2% (95% CI 16.8-30.7). A trend towards improved sensitivity was observed, but did not reach statistical significance. CONCLUSION: Addition of D-VIA/VILI to conventional naked-eye examination may be associated with improved CIN2+ identification. Further studies including a larger sample size are needed to confirm these results.

Training, Supervision, and Competence Assessment of Cameroonian Health Care Providers Using HPV Self-Sampling, Triage by Visual Inspection, and Treatment by Thermal Ablation in a Single Visit.

Background: Developing human resource capacity and efficient deployment of skilled personnel are essential for cervical cancer screening program implementation in resource-limited countries. Our aim was to provide a context-specific training framework, supervision, and effectiveness evaluation of health care providers in a cervical cancer screening program. Methods: A 5-year cervical cancer screening program was implemented in Dschang, West Cameroon. Women were invited to perform human papillomavirus self-sampling (Self-HPV), followed by triage using visual inspection with acetic acid (VIA) and thermal ablation if needed. Health care providers were trained in four key learning phases to perform counseling, screening, and treatment process in a single visit. Training included (i) a 3-day basic course, (ii) 3-day advanced practical training, (iii) 2 weeks of supervision, and (iv) bi-monthly supervision by a mentor. The diagnostic performance of health care providers was compared between two time periods, period I (September 2018 to April 2019) and period II (May 2019 to January 2020), for an overall 17-month study period. Results: Fourteen health care providers were recruited for the training course and 12 of them completed the training objectives. Follow-up and evaluations were conducted for three health care providers working in the screening unit at Dschang District Hospital. During the study period, 1,609 women performed Self-HPV, among which 759 were screened during period I and 850 during period II. HPV positivity was 18.2 and 17.1%, and VIA positivity was 45.7 and 71.0% in period I and II, respectively. VIA sensitivity was 60.0% (95% confidence interval [CI] 26.2-87.8) and 80.8% (95% CI 60.6-93.4) in period I and II, respectively (p = 0.390). VIA specificity decreased between period I (57.4, 95% CI 48.1-66.3) and II (30.8, 95% CI 22.6-40.0) (p < 0.001). Health care providers demonstrated substantial agreement with their mentor in their diagnoses during both periods (period I: Cohen's kappa coefficient [k] = 0.73, 95% CI 0.62-0.85, and period II: k = 0.62 0.47-0.76; p = 0.0549). Discussion: Training, supervision, and a focus on effectiveness in cervical cancer screening are interventions that contribute to improving frontline provider competencies and maintaining a high quality of health care service delivery.

ABCD criteria to improve visual inspection with acetic acid (VIA) triage in HPV-positive women: a prospective study of diagnostic accuracy.

OBJECTIVES: A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting. DESIGN: Prospective study of diagnostic accuracy. SETTING: Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon. PARTICIPANTS: Asymptomatic non-pregnant women aged 30-49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35-45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial. INTERVENTIONS: HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards). PRIMARY OUTCOME MEASURE: Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values. RESULTS: ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day. CONCLUSIONS: ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context. TRIAL REGISTRATION NUMBER: NCT03757299.

Recruitment strategies to promote uptake of cervical cancer screening in the West Region of Cameroon.

OBJECTIVES: The World Health Organization's (WHO) global strategy for cervical cancer elimination has set the target of 70% of women screened in all countries by 2030. Community sensitization through media is often used, but community health workers' (CHW) involvement may contribute to improving screening coverage. We aimed to assess effectiveness and costs of two cervical cancer screening recruitment strategies conducted in a low-resource setting. METHODS: The study was conducted in the West Region of Cameroon, in the Health District of Dschang, a community of 300,000 inhabitants. From September 2018 to February 2020, we recruited and screened women for cervical cancer in a single-visit prevention campaign at Dschang District Hospital. During the first 9 months, recruitment was only based on Community Information Channels (CIC) (e.g.. street banners). From the tenth month, participation of CHW was added in the community after training for cervical cancer prevention counselling. Population recruitment was compared between the two strategies by assessing the number of recruited women and direct costs (CHW costs included recruitment, teaching, certification, identification badge, flyers, transport, and incentives). The intervention's cost-effectiveness was expressed using an incremental cost-effectiveness ratio (ICER). RESULTS AND DISCUSSION: During the period under study, 1940 women were recruited, HPV positive rate was 18.6% (n = 361) and 39 cases of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) were diagnosed. Among included participants, 69.9% (n = 1356) of women were recruited through CIC as compared to 30.1% (n = 584) by CHW. The cost per screened woman and CIN2+ diagnosed was higher in the CHW group. The ICER was 6.45 USD or 16.612021Int'l$ per screened woman recruited by CHW. Recruitment in rural areas increased from 12.1 to 61.4% of all women included between CIC-led and CHW-led interventions. These outcomes highlight the importance of training, preparing, and deploying CHW to screen hard-to-reach women, considering that up to 45% of Cameroon's population lives in rural areas. CONCLUSION: CHW offer an important complement to CIC for expanding coverage in a sub-Saharan African region such as the West Region of Cameroon. CHW play a central role in building awareness and motivation for cervical cancer screening in rural settings.

Forgoing healthcare during the COVID-19 pandemic in Geneva, Switzerland - A cross-sectional population-based study.

BACKGROUND: Health systems around the world continue to navigate through operational challenges surfaced by the coronavirus disease 2019 (COVID-19) pandemic; these have implications for access to healthcare. In this study, we estimate the prevalence and reasons for forgoing healthcare during the pandemic in Geneva, Switzerland; a country with a universal and mandatory private health insurance coverage. METHODS: Participants from a randomly selected population-based sample of the adult population living in the Canton of Geneva completed an online socio-demographic and lifestyle questionnaire between November 2020 and January 2021. The prevalence and reasons for forgoing healthcare since the beginning of the COVID-19 pandemic were examined descriptively, and logistic regression models were used to assess determinants for forgoing healthcare. RESULTS: The study included 5397 participants, among which 8.0% reported having forgone healthcare since the beginning of the COVID-19 pandemic; participants with a disadvantaged financial situation (OR = 2.04; 95% CI: 1.56-2.65), and those reporting an average (OR = 2.54; 95% CI: 1.94-3.31) or poor health (OR = 4.40; 95% CI: 2.39-7.67) were more likely to forgo healthcare. The most common reasons to forgo healthcare were appointment cancellations by healthcare providers (53.9%), fear of infection (35.3%), and personal organizational issues (11.1%). CONCLUSION: Our paper highlights the effects of the COVID-19 pandemic on access to healthcare and identifies population sub-groups at-risk for forgoing healthcare. These results necessitate public health efforts to ensure equitable and accessible healthcare as the COVID-19 pandemic continues.

Acceptability and safety of thermal ablation to prevent cervical cancer in sub-Saharan Africa.

BACKGROUND: The World Health Organization recommends thermal ablation as an alternative to cryotherapy to treat women with precancerous lesions in low-resource settings. However, limited data are available on women's experience and adverse events (AEs) of the procedure in the context of Sub-Saharan Africa. The objective of this study was to evaluate the acceptability and safety of thermal ablation in women screened positive for precancerous cervical lesions. METHODS: Asymptomatic women aged 30-49 years old living in the Dschang Health District were invited to participate in a cervical cancer screening campaign termed "3 T-Approach" (for Test-Triage and Treat). Recruited women were asked to perform HPV self-sampling followed by triage with visual assessment and treatment with thermal ablation if required. After treatment and 4-6 weeks later, interviews were conducted to assess women's experience on anxiety, discomfort, and pain during thermal ablation. AEs were recorded on pre-defined electronic forms 4-6 weeks after treatment to assess the procedure's safety. RESULTS: Between September 2018 and December 2020, 399 HPV-positive women (18.7% of women screened) were recruited, 236 (59.1%) had a positive visual assessment, 234 were treated by thermal ablation and 198 (84.6%) received therapy in the same visit. Treatment was not considered as painful (score ≤ 4/10) by 209 (90.9%) patients while 5 (2.5%) reported high pain (score 8-10/10). During post-treatment interviews 4-6 weeks later, most reported AEs were graded mild or moderate (grade I-II). The most frequent symptoms reported as mild AEs (grade 1-2) were vaginal watery discharge (75.5%), vaginal bloody-stained discharge (21.5%) and malodourous discharge (14.5%). None of the participants experienced serious AEs (grade 3-4) or AEs requiring admission to hospital or emergency consultation. The vast majority of women (99.6%) would agree to repeat the procedure if necessary and (99.6%) would recommend it to friends or family. CONCLUSION: Thermal ablation is widely accepted by women and appears as a safe procedure. It may contribute to improving the link between screening and treatment in a single visit and to optimizing cervical cancer control in low-resource settings. TRIAL REGISTRATION: The study was registered on clinicaltrials.gov ( NCT03757299 ) in November 2018 (28/11/2018).

Specchio-COVID19 cohort study: a longitudinal follow-up of SARS-CoV-2 serosurvey participants in the canton of Geneva, Switzerland.

INTRODUCTION: The COVID-19 pandemic has affected billions of people around the world both directly through the infection itself and indirectly through its economic, social and sanitary impact. Collecting data over time is essential for the understanding of the disease spread, the incidence of COVID-19-like symptoms, the level and dynamics of immunity, as well as the long-term impact of the pandemic. The objective of the study was to set up a longitudinal follow-up of adult participants of serosurveys carried out in the canton of Geneva, Switzerland, during the COVID-19 pandemic. This follow-up aims at monitoring COVID-19 related symptoms and SARS-CoV-2 seroconversion, as well as the overall impact of the pandemic on several dimensions of health and on socioeconomic factors over a period of at least 2 years. METHODS AND ANALYSIS: Serosurvey participants were invited to create an account on the dedicated digital platform Specchio-COVID19 (https://www.specchio-covid19.ch/). On registration, an initial questionnaire assessed sociodemographic and lifestyle characteristics (including housing conditions, physical activity, diet, alcohol and tobacco consumption), anthropometry, general health and experience related to COVID-19 (symptoms, COVID-19 test results, quarantines, hospitalisations). Weekly, participants were invited to fill in a short questionnaire with updates on self-reported COVID-19-compatible symptoms, SARS-CoV-2 infection testing and vaccination. A more detailed questionnaire about mental health, well-being, risk perception and changes in working conditions was proposed monthly. Supplementary questionnaires were proposed at regular intervals to assess more in depth the impact of the pandemic on physical and mental health, vaccination adherence, healthcare consumption and changes in health behaviours. At baseline, serology testing allowed to assess the spread of SARS-CoV-2 infection among the general population and subgroups of workers. Additionally, seropositive participants and a sample of randomly selected participants were invited for serologic testing at regular intervals in order to monitor both the seropersistance of anti-SARS-CoV-2 antibodies and the seroprevalence of anti-SARS-CoV-2 antibodies in the population of the canton of Geneva. ETHICS AND DISSEMINATION: The study was approved by the Cantonal Research Ethics Commission of Geneva, Switzerland (CCER Project ID 2020-00881). Results will be disseminated in a variety of ways, via the Specchio-COVID-19 platform, social media posts, press releases and through regular scientific dissemination methods (open-access articles, conferences).

Seroprevalence of anti-SARS-CoV-2 IgG antibodies, risk factors for infection and associated symptoms in Geneva, Switzerland: a population-based study.

Aims: To assess SARS-CoV-2 seroprevalence over the first epidemic wave in the canton of Geneva, Switzerland, as well as risk factors for infection and symptoms associated with IgG seropositivity. Methods: Between April and June 2020, former participants of a representative survey of the 20-74-year-old population of canton Geneva were invited to participate in the study, along with household members aged over 5 years. Blood samples were tested for anti-SARS-CoV-2 immunoglobulin G. Questionnaires were self-administered. We estimated seroprevalence with a Bayesian model accounting for test performance and sampling design. Results: We included 8344 participants, with an overall adjusted seroprevalence of 7.8% (95% credible interval 6.8-8.9). Seroprevalence was highest among 18-49 year-olds (9.5%), and lowest in 5-9-year-old children (4.3%) and individuals >65 years (4.7-5.4%). Odds of seropositivity were significantly reduced for female retirees and unemployed men compared to employed individuals, and smokers compared to non-smokers. We found no significant association between occupation, level of education, neighborhood income and the risk of being seropositive. The symptom most strongly associated with seropositivity was anosmia/dysgeusia. Conclusions: Anti-SARS-CoV-2 population seroprevalence remained low after the first wave in Geneva. Socioeconomic factors were not associated with seropositivity in this sample. The elderly, young children and smokers were less frequently seropositive, although it is not clear how biology and behaviours shape these differences.

COVID-19 vaccination acceptance in the canton of Geneva: a cross-sectional population-based study.

OBJECTIVE: This study aimed to assess acceptance of COVID-19 vaccination as well as its sociodemographic and clinical determinants, 3 months after the launch of the vaccination programme in Geneva, Switzerland. METHODS: In March 2021, an online questionnaire was proposed to adults included in a longitudinal cohort study of previous SARS-CoV-2 serosurveys carried out in the canton of Geneva, which included former participants of a population-based health survey as well as individuals randomly sampled from population registries, and their household members. Questions were asked about COVID-19 vaccination acceptance, reasons for acceptance or refusal and attitudes to vaccination in general. Data on demographic (age, sex, education, income, professional status, living conditions) and health-related characteristics (having a chronic disease, COVID-19 diagnosis, smoking status) were assessed at inclusion in the cohort (December 2020). The overall vaccination acceptance was standardised according to the age, sex, and education distribution in the Geneva population. RESULTS: Overall, 4067 participants (completion rate of 77.4%) responded to the survey between 17 March and 1 April 2021. The mean age of respondents was 53.3 years and 56.0% were women. At the time of the survey, 17.2% of respondents had already been vaccinated with at least one dose or had made an appointment to get vaccinated, and an additional 58.5% intended or rather intended to get vaccinated. The overall acceptance of COVID-19 vaccination standardised to the age, sex and education distribution of the population of Geneva was 71.8%, with a higher acceptance among men than women, older adults compared with younger adults, high-income individuals compared with those with a low income, and participants living in urban and semi-urban areas compared with rural areas. Acceptance was lower among individuals having completed apprenticeships and secondary education than those with tertiary education. The most common reasons reported by participants intending to get vaccinated were the desire to "get back to normal", to protect themselves, their community and/or society,and their relatives or friends against the risk of infection by SARS-CoV-2, as well as the desire to travel. Less than half (45.6%) of participants having children were willing or rather willing to have their children vaccinated against COVID-19 if it were recommended by public health authorities. CONCLUSION: Although our study found a 71.8% weighted acceptance of COVID-19 vaccination, there were noticeable sociodemographic disparities in vaccination acceptance. These data will be useful for public health measures targeting hesitant populations when developing health communication strategies.

Study protocol for a two-site clinical trial to validate a smartphone-based artificial intelligence classifier identifying cervical precancer and cancer in HPV-positive women in Cameroon.

INTRODUCTION: Cervical cancer remains a major public health challenge in low- and middle-income countries (LMICs) due to financial and logistical issues. WHO recommendation for cervical cancer screening in LMICs includes HPV testing as primary screening followed by visual inspection with acetic acid (VIA) and treatment. However, VIA is a subjective procedure dependent on the healthcare provider's experience. Its accuracy can be improved by computer-aided detection techniques. Our aim is to assess the performance of a smartphone-based Automated VIA Classifier (AVC) relying on Artificial Intelligence to discriminate precancerous and cancerous lesions from normal cervical tissue. METHODS: The AVC study will be nested in an ongoing cervical cancer screening program called "3T-study" (for Test, Triage and Treat), including HPV self-sampling followed by VIA triage and treatment if needed. After application of acetic acid on the cervix, precancerous and cancerous cells whiten more rapidly than non-cancerous ones and their whiteness persists stronger overtime. The AVC relies on this key feature to determine whether the cervix is suspect for precancer or cancer. In order to train and validate the AVC, 6000 women aged 30 to 49 years meeting the inclusion criteria will be recruited on a voluntary basis, with an estimated 100 CIN2+, calculated using a confidence level of 95% and an estimated sensitivity of 90% +/-7% precision on either side. Diagnostic test performance of AVC test and two current standard tests (VIA and cytology) used routinely for triage will be evaluated and compared. Histopathological examination will serve as reference standard. Participants' and providers' acceptability of the technology will also be assessed. The study protocol was registered under ClinicalTrials.gov (number NCT04859530). EXPECTED RESULTS: The study will determine whether AVC test can be an effective method for cervical cancer screening in LMICs.