Pierre Marie Tebeu

Awareness of HPV and cervical cancer prevention among Cameroonian healthcare workers

BackgroundCervical cancer, although largely preventable, remains the most common cause of cancer mortality among women in low-resource countries.The objective of this study was to assess knowledge and awareness of cervical cancer prevention among Cameroonian healthcare workers.MethodsA cross-sectional self-administered questionnaire in 5 parts with 46 items regarding cervical cancer etiology and prevention was addressed to healthcare workers in six hospitals of Yaoundé, Cameroon. The investigators enlisted heads of nursing and midwifery to distribute questionnaires to their staff, recruited doctors individually, in hospitals and during conferences and distributed questionnaires to students in Yaoundé University Hospital and Medical School. Eight hundred and fifty questionnaires were distributed, 401 collected. Data were analyzed with SPSS version 16.0. Chi-square tests were used and P-values < 0.05 were considered significant.ResultsMean age of respondents was 38 years (range 20-71 years). Most participants were aware that cervical cancer is a major public health concern (86%), were able to identify the most important etiological factors (58%) and believed that screening may prevent cervical cancer (90%) and may be performed by Pap test (84%). However, less than half considered VIA or HPV tests screening tests (38 and 47%, respectively). Knowledge about cancer etiology and screening was lowest among nurse/midwives.ConclusionKnowledge of cervical cancer and prevention by screening showed several gaps and important misconceptions regarding screening methods.Creating awareness among healthcare workers on risk factors and current methods for cervical cancer screening is a necessary step towards implementing effective prevention programs.

Risk factors for obstetric fistula in the Far North Province of Cameroon

To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.

Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

Objective To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol’s iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa. Design Systematic review and meta-analysis of diagnostic test accuracy studies. Data sources Systematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014. Review methods Inclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+). Results 15 studies of moderate quality were included (n=61 381 for VIA, n=46 435 for VILI, n=11 322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P≥0.23) and versus VILI (both P≥0.16). Accuracy of VIA and VILI increased with sample size and time period. Conclusions For primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region.

Effectiveness of a two-stage strategy with HPV testing followed by visual inspection with acetic acid for cervical cancer screening in a low-income setting.

The World Health Organization recently advocated a two‐stage strategy with human papillomavirus (HPV) testing followed by visual inspection of the cervix with acetic acid (VIA) as a suitable option for cervical cancer screening. However, its accuracy has never been directly assessed in the context of primary screening. To evaluate effectiveness of HPV testing on self‐obtained specimens (self‐HPV) followed by VIA (sequential testing) in a low‐income setting, we recruited 540 women aged between 30 and 65 years in two Cameroonian periurban areas. Eligible women were counseled about cervical cancer and how to perform self‐sampling. HPV positive and a random sample of HPV‐negative women were called back for VIA and biopsy. Disease was defined by interpretation of cervical intraepithelial neoplasia Grade 2 or worse (CIN2+). Performances of VIA, self‐HPV and sequential testing were determined after adjustment for verification bias. HPV prevalence was 27.0%. VIA positivity was 12.9% and disease prevalence was 5%. Sensitivity and specificity of VIA for CIN2+ were 36.4% [95% confidence interval (CI): 15.2–64.6%] and 90.4% (95% CI: 85.4–93.7%), respectively. Sensitivity of self‐HPV [100.0% (95% CI: 79.6–100.0%)] was 66% higher than that of sequential testing [33.3% (95% CI: 15.2–58.3%)]. Meanwhile, specificity of self‐HPV [74.5% (95% CI: 70.6–78.1%)] was 22% lower than that of sequential testing [96.7% (95% CI: 94.8–97.9%)]. A two‐stage screening strategy with self‐HPV followed by VIA improves specificity of cervical cancer screening, but at the cost of an important loss of sensitivity. Ways to improve VIA performance or other tools are needed to increase positive predictive value of HPV testing.

Connaissance, attitude et perception vis-à-vis des fistules obstétricales par les femmes camerounaises. Une enquête clinique conduite à Maroua, capitale de la province de l'extrême Nord du Cameroun

INTRODUCTION This study seeks to identify what the women who live in Maroua Cameroon know and think about obstetric fistula. POPULATION AND METHOD It is a single hospital, cross-sectional, descriptive and comparative study. Ninety-nine women in the maternity service of the Maroua Provincial Hospital were interrogated on obstetric fistula between May and July 2005, by enquirers who were trained health agents using a questionnaire which required both closed and open answers. RESULTS The women who had no previous knowledge of it were generally the illiterate (41.7% compared to 18.8%). More than a third of the women who had an idea of the fistula do not know that there is a surgical treatment for it. Whether they had the previous information on fistula or received it from us, one-tenth of the women suggested that suicide was the solution to fistula where as one-third of the women suggested that a patient suffering from fistula should be isolated. CONCLUSION AND INTERPRETATION Illiteracy contributes significantly to the lack of knowledge of this affection. The population has a poor perception and a strong negative attitude towards obstetric fistula as they see isolation or suicide as the solution to it.

Risk factors for obstetric vesicovaginal fistula at University Teaching Hospital, Yaoundé, Cameroon

eclampsia. However, some authors have documented an increased risk of developing pregnancy-induced hypertension in employed women because of the stress these patients are under; however, these authors did not evaluate the effect of employment on the risk of convulsion [6]. Prenatal care and bed rest have been recommended as possible preventive measures or a way of delaying the onset of convulsions in pre-eclamptic women who come under this category [5]. Prenatal care awareness is invariably linked to the level of education of pregnant women. In a less educated region like the Far North of Cameroon—where the level of illiteracy is 67% among women aged 15–49 years, as reported in the 2004 Demographic and Health Survey—it is not surprising that 48.7% of the patients in the present study with these high-risk pregnancies had no formal education. In conclusion, teenage pregnancy, nulliparity, and low educational status were identified as risk factors for convulsion in women with pre-eclampsia. Further research is needed to explore the risk factors that are likely to have high predictive values for eclampsia. Identification of these factors, good prenatal surveillance, and institution of proper management will decrease feto-maternal morbidity and mortality associated with hypertensive disorders in pregnancy. Conflict of interest

Risk factors for eclampsia among patients with pregnancy-related hypertension at Maroua Regional Hospital, Cameroon

[1] Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62(8):540–7. [2] National Department of Health. A Monograph of the Management of Postpartum Haemorrhage. South Africa: National Department of Health; 2010. Available at: http://www.doh.gov.za/docs/policy/2011/haemorrhage.pdf. [3] Ikeda T, Sameshima H, Kawaguchi H, Yamauchi N, Ikenoue T. Tourniquet technique prevents profuse blood loss in placenta accreta cesarean section. J Obstet Gynecol Res 2005;31(1):27–31. [4] Verkuyl DA. Fast and easy provisional treatment of severe postpartum haemorrhage. BJOG 2007;114(7):908–9. Table 1 Details of 13 patients who had a tourniquet applied to control postpartum hemorrhage.

Emergency obstetric hysterectomy at University Hospital, Yaoundé, Cameroon

day of the week (weekdays or weekends) [4] that maternal deaths occurred. Although it is difficult to draw definite conclusions on the linkages between the hospital shifts and the maternal deaths, the low numbers of doctors and midwives available on any given day of the week might be an area to be reviewed by hospital managers. There is however the need for further qualitative research to draw these linkages and implement recommendations to avert maternal deaths.

Prognostic value of repeated surgery on obstetric vesico-vaginal fistula outcome: A Cameroonian experience

Abstract Objective To analyze the outcome of repeat repair of vesico-vaginal fistula following a failure. Methods This was a cross-sectional analytic study in two different obstetric fistula surgery units at the Regional Hospital of Maroua-Cameroon and the University Teaching Hospital of Yaounde-Cameroon. The study period covered from January 2005 to December 2007 for the regional Hospital and from January 2008 to December 2011 for the University Teaching Hospital. During these periods, the first author was medical consultant in these institutions. Among the overall 81 operations analyzed, we had 31 repeat operations and 50 operations at first attempt. The chi -square test was used to compare the distribution of the various variables in the two study populations. Results Among the overall 81 operations analyzed, we had 31 repeat operations (37%) and 50 operations (63%) at first attempt. The success rates of closure of the fistula deteriorate with the number of attempts and vary from 88.2% at the first attempt, 76.9% at the second attempt, to 64.7% as from the third attempt. The result in terms of closing with continence also varies with the order of attempt with respective rates of 72.5%, 69.2% and 41.1% at the first, second and third attempts. Conclusion The result in terms of closing with continence of obstetric fistula surgery decreases with the number of surgical attempts.

Postpartum hemorrhage at Yaoundé University Hospital, Cameroon

Postpartum hemorrhage (PPH) is one of the leading causes of pregnancy-related mortality, accounting for up to 38% of maternal deaths [1,2]. The case fatality rate ranges from 1%–5% in many studies [1–3]. A retrospective cross-sectional study was conducted at the University Hospital Center, Yaoundé, Cameroon after receiving Ethical Committee approval. The files of patients seen between January 1, 2005 and December 31, 2009 were included in the study and reviewed. Informed consent from the patients was not required. A total of 10 302 deliveries were registered, including 419 cases of PPH. Of the PPH cases, 76 (18.1%) were excluded: 73 files were not found, 2 files were wet and therefore illegible, and 1 file was empty. A total of 343 files from women who had experienced early PPH— defined as PPH occurring within the first 24 hours following delivery— were identified. For every case of PHH, 2 consecutive patients without PPH who delivered after the PPH patient were selected as controls (686 women). Data were collected on sociodemographic characteristics, clinical and obstetric history, management, and maternal outcome in both groups of patients. Epi Info version 3.5.1 (CDC, Atlanta, GA, USA) was used for data analysis. Odds ratios and 95% confidence intervals were used to assess the effect of potential risk factors on the occurrence of PPH. Pb0.05 was considered statistically significant. Of 10 302 births recorded, there were 419 (4.1%) cases of PPH. This prevalence is similar to that reported by others [3]. The etiology of PPH included atony (49.9%), retained placenta (39.2%), vaginal and perineal tear (6.9%), cervical tear (5.5%), uterine rupture (1.5%), placenta accreta (1.2%), stillbirth (1.2%), and endometritis (0.9%). The mean age of the patients was 27.3±5.8 years (Table 1). Of those with PPH, 124 (36.2%) had prolonged labor (over 12 hours), 18 (5.2%) had had a previous cesarean delivery, 8 (2.3%) had uterine fibroids, 10 (2.9%) had placental abruption, and 3 (0.9%) had experienced previous PPH. Risk of PPH was higher in patients who had a stillbirth delivery (Pb0.01), fever during labor (Pb0.01), multiple pregnancy (Pb0.01), labor induction (Pb0.01), instrumental vaginal delivery (P=0.04), prolonged labor (over 12 hours) (Pb0.01), history of uterine fibroids (P=0.01), history of placental abruption (Pb0.01), history of cesarean delivery (Pb0.01), and history of polyhydramnios (P=0.01) (Table 2). After adjusting for confounding factors, several independent risk factors for PPH were identified: history of uterine fibroids (adjusted odds ratio [aOR] 6.29; 95% CI, 1.6–25.3; Pb0.01); history of cesarean delivery (aOR 2.31; 95% CI, 1.2–4.3; Pb0.01); parity of 4 and above (aOR 2.03; 95% CI, 1.3–3.2, Pb0.01); prolonged labor (aOR 1.74; 95% CI,1.1– 2.8; P=0.01); twin delivery (aOR 3.18; 95% CI,1.7–5.8; Pb0.01); and fever during labor (aOR 4.89; 95% CI, 1.3–18.5); Pb0.01) (Table 2). Similar risk factors were reported by other authors [3,4]. Endouterine evacuation was performed immediately after diagnosis in 289 (84.3%) PPH cases by either a midwife or gynecologist. Surgical management included 4 (1.2%) cases of hysterectomy, 4 (1.2%) cases of manual removal of complete retained placenta, and 1 (0.3%) case of hypogastric artery ligation. Among the 343 patients with PPH, there were 5 maternal deaths, giving a case fatality rate of 1.5%. This is higher than the level recommended by the UN for low-resource countries of below 1% [4]. The 5 maternal deaths comprised 4 cases of disseminated intravascular coagulation and 1 case of hypovolemic shock after abdominal hysterectomy. Unsatisfactory medical management of PPH must justify a surgical procedure. Uterine compression, uterine suture, bilateral ligation of hypogastric arteries, and hysterectomy as treatment options have been used successfully and reported by others [5]. The present findings highlight the pressing need for research on clinical audit and the availability of quality emergency obstetric care in this setting.