Directives Nationales de Prévention et de Prise en Charge du Cancer du Col de l’Utérus

Objectives

Burundi’s 2019 national directives establish a standardised national framework for preventing and controlling cervical cancer across public, private and associative health facilities, aligned with reproductive, maternal, neonatal, child and adolescent health priorities in the National Health Policy 2016–2025. They seek to reduce cervical-cancer morbidity and mortality through primary prevention, screening and early treatment of precancerous lesions, and accessible tertiary and palliative care for invasive disease.[1][2]

• Strengthen primary prevention through human papillomavirus vaccination for girls aged 9–14 years, culturally appropriate education, behaviour change, condom promotion and communication that engages girls, boys, women, men and communities.[3][4][5]
• Increase screening among women aged 25–50 years, beginning at HIV diagnosis for women living with HIV, with five-yearly screening after a negative result for HIV-negative women and three-yearly screening for women living with HIV.[6][7]
• Achieve screening coverage of at least 80% of the target population, estimated at 1,511,547 women, equivalent to 1,209,238 women aged 25–49 in 2019.[7]
• Detect and treat eligible cervical intraepithelial neoplasia grade 2 or 3 lesions before progression to invasive cancer, using reductions in incidence and mortality as measures of screening effectiveness.[8]
• Provide secondary prevention through visual inspection with acetic acid, also referred to as IVA, and prompt treatment of eligible lesions, principally through cryotherapy in a single-visit screen-and-treat model where possible.[9][7]
• Ensure tertiary management of invasive cervical cancer through specialist diagnosis, surgery, radiotherapy, chemotherapy and palliative care, while improving prognosis, survival, quality of life and support for women and their families.[10][11]
• Advance advocacy, communication and social mobilisation to raise awareness, reduce risk factors, increase service use, empower communities and sustain political and financial support.[12][13]
• Strengthen enabling systems, including infrastructure, equipment, consumables, logistics, referral, health information, monitoring, research, workforce capacity and supervision.[14][11][15]

Implementation

The directives use an integrated, tiered delivery model linking community mobilisation, vaccination, screening, immediate or referred treatment, specialist care and follow-up. Implementation is led by the Ministry of Public Health and the Fight against AIDS and coordinated with the National Cancer Control Committee, decentralised health authorities, facilities, communities and implementing partners.[16][17]

• Coordinate national policy, implementation strategies, training materials, research, surveillance, adaptation of scientific recommendations and support to provincial, district and facility levels through the Ministry of Public Health and the Fight against AIDS.[16]
• Guide cancer prevention, screening, diagnosis and treatment interventions through the National Cancer Control Committee, including integration of cervical-cancer prevention and care.[16]
• Plan, coordinate, monitor and evaluate services within provinces and districts, while ensuring their availability, accessibility and use.[16]
• Deliver standardised promotional, preventive and curative services through peripheral facilities, supported by community health workers and other community actors who create demand for prevention and screening.[16][12]
• Integrate screening into family-planning, gynaecology, outpatient and HIV-care services, combining community outreach, facility education, counselling, campaigns and media communication.[18][19]
• Provide confidential, informed and voluntary screening, including counselling on risks, procedures, possible results, treatment and follow-up, and obtain permission for contact where results are not immediately available.[20][21]
• Use IVA with cryotherapy through trained nurses, midwives or doctors, including at basic health facilities, to provide immediate results and reduce loss to follow-up.[9][22]
• Apply cryotherapy only to eligible visible lesions and refer women with extensive lesions, suspected cancer, unsuitable results or complications for higher-level assessment and treatment.[7][23]
• Provide loop electrosurgical excision procedure, conisation, biopsy, colposcopy and laboratory diagnostics at appropriately equipped district, regional or national hospitals, with invasive disease managed by specialists.[24][17]
• Maintain referral and counter-referral systems, national referral forms and laboratory-result pathways so that results return to the original screening site and women receive ongoing care.[19][17]
• Procure equipment and consumables through established supply systems, assess facility readiness, anticipate service-site needs, and train technicians in routine equipment repair and maintenance.[25]
• Build provider capacity through nationally coordinated continuing training, approved curricula, qualified trainers, training of trainers, supervisory visits and incorporation of cervical-cancer content into medical and paramedical curricula.[15]
• Maintain client and treatment registers, collect facility data and monthly reports, integrate information into the national health information system and cancer registry, and use nationally standardised forms approved by the Ministry.[25][23]
• Report annual indicators including human papillomavirus vaccination coverage among girls aged 9–13 years, numbers screened by IVA, IVA-positive cases, women treated by cryotherapy or RAD, suspected and histopathologically confirmed cancers, and women receiving curative or palliative treatment.[23]
• Use measurable indicators and standardised data-collection tools to assess progress, support corrective action, guide management decisions and evaluate resource use and programme results.[25]

Monitoring & Evaluation

The guidelines establish a national monitoring and evaluation architecture for cervical cancer prevention and care, linking facility records, standardised forms, routine reports, the national health information system and cancer registries.[25][23]Monitoring is intended to measure progress towards programme goals and targets, guide corrective action and management decisions, promote efficient resource use, and assess whether interventions achieve expected results.[25]

• Use nationally standardised data-collection forms approved by the Ministry of Public Health and the Fight against AIDS, make them available in health facilities, collect essential service data systematically, and produce reports.[25]
• Establish cervical cancer screening and treatment registers that record client identification, screening, treatment and referral information, and integrate these data into the national health information system.[23]
• Maintain facility-level client registers and monthly reports, with facility providers responsible for collecting relevant service information.[23]
• Report annual national indicators covering human papillomavirus vaccination among girls aged 9 to 13 years; numbers screened using visual inspection with acetic acid, testing positive, treated by cryotherapy or RAD, suspected of cervical cancer, histopathologically confirmed, and receiving curative or palliative treatment.[23]
• Measure screening effectiveness through changes in cervical cancer incidence and mortality, and monitor coverage as the proportion of eligible women screened within a specified period.[8]
• Target screening of at least 80% of women at risk, as the guideline identifies this level of coverage as necessary for programme success.[8]
• Track follow-up, management and referral for women with positive or abnormal screening results, including the functioning of links between screening, diagnosis and treatment.[26]
• Use screening to monitor the longer-term progress of the human papillomavirus vaccination programme, since population-level effects on cervical cancer incidence will take decades to become apparent.[27]
• Maintain uniform nationwide data collection, individual clinical records, appointment details, positive-result registers and mechanisms to notify and trace women who miss follow-up appointments.[28][29]
• Apply quality assurance to cytology through review of negative smears or reanalysis of a random sample, with abnormal findings confirmed by the supervising anatomical pathologist.[30]

Referral and counter-referral records, national referral forms, laboratory submission forms and communication of results to originating screening sites support continuity of care and diagnostic follow-up across health-system levels.[19][6][17]Provincial and district health bureaux are responsible for planning, coordinating, monitoring and evaluating services within their jurisdictions, while the central ministry is expected to generate local evidence through research and surveillance.[16]

Accountability mechanisms described include provider training, supervision, competency requirements for procedures, regular assessment of visual-screening providers, and follow-up oversight by designated staff.[22][29][31][15]The source does not specify indicator definitions, reporting formats, data-quality audit procedures, evaluation schedules, named accountability sanctions or a comprehensive surveillance protocol beyond the arrangements described.[25][23]

Costing & Financing

The guidelines identify substantial operational resource requirements for cervical cancer prevention, screening, diagnosis, treatment and palliative care, but do not provide monetary budgets, allocations, financing sources, quantified funding gaps or formal economic assumptions.[11][25]Infrastructure, equipment, consumables, logistics, procurement, equipment maintenance and technician training are identified as necessary inputs for implementation.[11][25]

• Mobilise political and financial support through advocacy for cervical cancer prevention and care, with partners potentially providing technical and financial assistance throughout planning, implementation, monitoring and evaluation.[12][13]
• Plan screening-method selection around available funds, provider capacity, laboratories, specimen transport, health-system organisation, and the availability and cost of tests.[26]
• Prioritise affordable visual inspection with acetic acid and cryotherapy in resource-constrained settings, as these approaches require fewer resources than cytology, can be delivered in a single visit, and do not require complex equipment.[9]
• Recognise that visual inspection methods may have lower resource requirements because they can be performed without laboratory equipment, specimen transport or laboratory personnel.[22]
• Maintain laboratory capacity where cytology or human papillomavirus DNA testing is used, including trained personnel, specialised facilities, reliable sample transport, equipment and reagents.[32][33][34]
• Address the higher resource demands of cytology-based screening, which requires trained staff, equipped laboratories, specimen transport, information systems and client follow-up.[26]
• Recognise that liquid-based cytology costs more than conventional cytology, although it may improve efficiency and cost-effectiveness by reducing unsatisfactory samples and shortening interpretation time.[32]
• Recognise the feasibility constraints of combined cytology and human papillomavirus DNA testing, which is characterised as expensive and dependent on molecular laboratory capacity and reliable transport.[34]
• Procure equipment and consumables through routine supply systems, assess facility readiness using the equipment and essential-consumables assessment tool, and plan maintenance and supplies around anticipated service-delivery needs.[25]
• Account for the cost and limited accessibility of surgery and radiotherapy for many women in low-income settings, reinforcing the value of prevention, early detection and treatment of precancerous lesions.[35]

Human papillomavirus vaccination may be cost-effective where high-quality screening is not widely available, but vaccination should not divert financing from an effective screening programme.[5]Competing health needs, insufficient resources and limited political prioritisation are identified as barriers to expanding screening services.[26][20]No explicit resource-mobilisation targets, costing framework, budget calendar or financing-gap estimate is specified.[11][25]