IHPP June 8, 2007

Situation Analysis of Cervical

Cancer Screening in Thailand

Progress Report on Quantitative

Analysis IHPP

June 8, 2007

An Optimal Policy Strategy for Prevention and Control of

Cervical Cancer in Thailand

Proposed byInternational Health Policy Program

Funded by World Bank

Study objectives• To generate reliable and relevant

information to guide health policy choices about prevention and control of cervical cancer in Thailand

• To recommend an optimal policy strategy that is cost-effective in the reduction of disease burden of cervical cancer.

• To estimate short- and long-terms investments in human resources and infrastructure for appropriate delivery of the newly designed policy strategy for cervical cancer prevention and control.

Research Methodology

Input

Input

Input

Findings: effectiveness of the current practice

Work package 1: determination of the programme performance(survey and review of literature)

Findings: a mixed menu of cost-effective interventions for prevention and control of cervical cancer in Thailand

Work package 2: economic evaluation for an optimal policy strategy

Findings: better understanding the social, political and institutional factors and constraints for introduction of the new policy strategy

Work package 3: policy analysis for introduction of the new policy strategy for prevention and control of cervical cancer in Thailand

Findings: short- and long-term plans for human resources and infrastructures

Work package 4: estimation of human resource and infrastructures required for introduction of the new policy strategy

Jan-Apr 07

Mar-Jul 07

Apr-Sept 07

Aug-Dec 07

Work Package 1 Planned Activities

(Cervical Cancer Screening Program Performance)

Component

Approach Data source Place Time

1. Service coverage in population

Desk-based Secondary analysis

- Report on Pap/VIA delivery (district/provinces)- Sexual and Reproductive Health Survey (2006)- DOH reports (CPIS)- NCI reports (PapRegistry)

NHSONSODOHNCIPHO a

Jan-May

2.1 Human and physical resources 2.2 Service loads

- Secondary analysis - Field survey- Structured interview

- NCI guideline of Pap smear- JHPIEGO guideline of VIA- DOH and NCI reports- Questionnaire- PHO reports

NCIDOH4 Sitesa

Jan – May

Component Approach Data source Place

Time

3.1 Program effectiveness 3.2 Service adherence3.3 Test performance

- Desk-based Systematic review- Field observation

- Published articles- Pap-smear vs. VIA demonstration sites- Population-based cancer registry (5 provinces) b

4 Sitesa

Feb – Apr

4. Local level practice variations

- Field observation - In-depth interview

- PHO organization and management- Nurses and MD in district hospitals- Health workers in sub-district health centers

4 Sitesa

Feb – May

Component

Approach Data source Place Time

5. Stakeholder analysis

- In-depth interview

Administrators, Policy makers

NHSODOHNCI

Second half of 2007

6. Qualitative demand-side barriers

- Field survey- Structured interview

Screened female population 4 Sites a

Second half of 2007

7. Qualitative supply-side barriers

- Field observation- In-depth interview

- PHO organization and management- District hospitals- Sub-district health centers

4 Sites a

Second half of 2007

a Pap smear model demonstration sites: Nakhon Phnom, Arng-Thong; VIA sites: Roi Et, Chiang Maib Chiang Mai, Lampang, Songkla, Khon Kaen, Bangkok

HPV overview

Brief of cervical cancer screening in Thailand

• Cytology screening with pap smear has been available for more than 40 years

• In 1997, MOPH began to offer reproductive health services in conjunction with family planning. Nation

al policy for cervical cancer proposed thatscr 35 54eening be offered to women aged –

wwww w www wwww wwwww wwww wwwww wwww ww www www, theastofThai l and,usi ngvi sual i nspecti onmethod s.


• 13.5% of the female aged 35-59 years have not been screened for cervical cancer during the last 5 year period.

• 36.7% have never been screened for their lifetimes.

• Only 49.8% exposed to the screening service at least once within the interval of 5 years. (NSO, 2006)

• 37.7% of the female aged 15-44 years in 2005 by Reproductive Health Division.

• The national program target set by National Health Security Office (NHSO) and MOPH for cervical cancer screening in 2005.

• 0.70 million (or 34% of the target group), divided 0.60 million for Pap smear and 0.10 million for VIA are the target group.


Screening

Strengths Limitations

Cytology • History of long use • Widely accepted • Permanent record of tes

t • Training and mechanism s for quality control establ

ished • Modest investments in

existing programmes can improve services

• High specificity

• Results not immediatelyavailable

• Requires elaborate, complex infrastructure

• Requires laboratory quality assurance

• Moderate sensitivity

VIA • Relatively simple and inexpensive

• Single visit approach • Can be performed at any

level of the healthcare sys - tem, by a mid level provid

er with proper training • Low level of infrastructu

rerequired

• Requires competency based training

• Limited evidenceavailable

• False positive, High pr ovider variability

• No permanent record • Not appropriate for

postmenopausal

Visual inspection with acetic acid

Cryotherapy unitVIA positive

Data system: PapRegistry

Collect sample

Slide reading

Colposcopy or refer

NCI

PHO

NHSO

Data System: CPIS

VIA

Colposcopy or refer

DHO

PHO

NHSO

Situation analysis for coverage and program outcome in

selected area•Pap smear : demonstration

site of NCI (Nakhon Phanom)•VIA : one oldest site (Roi Et,

started 2000) and one other newly implemented site (Chiang Mai, started 2005)

Data Source

Quantitative data Qualitative data

- Report on Pap/VIA delivery (sub-district/district/provinces)- Sexual and Reproductive Health Survey (2006)- MOH reports (CPIS)- NCI reports (PapRegistry)- Population census- target population set by district/provinces

- Indepth interview- Official letters of MOPH, NHSO, NCI, MOH- Memorandum of Understanding between NHSO and MOPH

PapRegistry• N = 472,694• Chiangmai = 11,901• Smear_hcode, province, pid, age,

read_hcode, finding, adequacy

CPIS

• N = 307,442 (18 provinces)

• Chiangmai = 28,737

• VIA, cryo, refer, suspca, VIA-pap

PapRegistry

YearN

(472,694)%

2004 213 0.05

2005 214,185 50.1

2006 167,023 39.1

Cum 381,421

CPIS

YearN

(307,442)%

2000 4,567 1.492001 3,444 1.122002 14,787 4.812003 45,399 14.772004 62,064 20.192005 107,419 34.942006 68,684 22.34Cum 306,364

Target group: 30-45 yr. (VIA) 2006 2005 2004 2003 2002 Average

Roiet 186,715 185,579184,13

7186,69

2 179,405 184,505.60

Nongkai 125,054 123,978122,91

2120,89

3 123,209.25

Amnartcha. 51,177 51,266 51,221.50

Yasothorn 77,009 76,742 76,194 76,648.33

Surat 131,131 128,679 129,905.00

Uttaradij 65,978 66,961 66,469.50

Chiang mai 203,602 206,798 205,200.00

Nakorn 191,300 190,146 190,723.00

Nan 64,775 65,706 65,240.50

Petchaboon 137,302 137,302.00

Tak 58,098 58,098.00

Krabi 51,948 51,948.00

Lopburi 103,958 103,958.00

Pitsanulok** 4,287 4,303 4,295.00

Ubon** 8,173 8,173.00

Mokdaharn** 4,950 4,950.00

Srisakad** 24,604 24,604.00

1,490,06

11,100,15

8383,24

3307,58

5 179,4051,486,450.

68

** One amphur

Append Pap-VIA

Year N %

2002 14,787 2.01

2003 45,404 6.18

2004 62,277 8.47

2005 321,604 43.75

2006 235,707 32.07

Cum 679,779

Population coverage

Denominator Numerator

No. of target pop. for Pap smear, VIA• by MOI registration • by PHO/district hospital updates

• No. of all cases screened for Pap smear, VIA• No. of new cases screened for any type• by subgroups : year, region, age, facility level

Definition of coverage

• Coverage 1 = No. target cases / No. target population

• Coverage 2 = No. new cases in 5 y / No. target population

• Coverage 3 = No. new cases in 5 y regardless of the screen type / No. target population

Proportion of case

0

20

40

60

80

100

PapRegistry CPIS Append

Case1 visit2 visit3 visit4 visit

88.1% 90.0% 88.2%

%

Screen type and year distribution

PapReg-VIA append Individual database

Year Pap VIA Unknown Cum

PapReg

CPISVIA-Pap

%VIA-Pap

2002 48 14,600 139 14,787 0 14,787 48 0.32

2003 5,017 39,950 437 45,404 5 45,399 5,01211.0

4

2004 11,476 50,184 617 62,277 213 62,064 11,26318.1

5

2005241,47

179,551 582

321,604

214,185

107,419

27,28625.4

0

2006181,84

953,601 257

235,707

167,023

68,684 14,82621.5

9

Total439,86

1237,88

62,03

2679,77

9

298,353

58,43519.5

9

Coverage subgroup by time periods

(Pap and VIA)

YearYearly visits

Yearly cases

new cases

Performan

ce(%)

Target(female pop.)

Coverage(%)

2002 14,787 14,643 13,041 89.12,514,58

90.52

2003 45,404 44,612 40,714 91.32,685,00

81.52

2004 62,277 61,488 56,860 92.52,853,21

21.99

2005321,60

4310,34

0302,64

597.5

3,648,510

8.30

2006235,70

7190,90

1184,49

896.6

4,070,582

4.53

Total679,77

9621,98

4597,75

896.1

13,797,900

4.33

Coverage subgroup by age

Age

Pap smear VIAMissing

Total2002 2003 2004 2005 2006 2002 2003 2004 2005 2006

All ages

9,988

230,987

134,978

12,831

36,064

45,894

70,127

49,160

3,541

594,217

Non-target gr.

8,039

53,752

19,500

1,007

2,407

3,901

3,777

1,962

97,756

Target gr.

1,949

177,235

115,478

11,824

33,657

41,993

66,350

47,198

496,461

Performance 19.5 76.7 85.6 92.2 93.3 91.5 94.6 96.0 83.5

Target pop2,335,1

842,377,4

232,469,9

692,548,3

522,580,5

21179,405 307,585 383,243

1,100,158

1,490,061

13,797,9

00

Coverage by age

0.1 7.0 4.5 6.6 10.9 11.0 6.0 3.2 3.6

Coverage in 5 years

12,311,449

295,439 2.4

1,486,45

1

201,022

13.5

Average performance

380,141

295,439

77.7 214,076

201,022

93.9

Performance

0102030405060708090

100

Time periods Pap VIA

20022003200420052006Average

%

Month\Year 2005 2006 Total

1 0 410 410

2 0 208 208

3 0 283 283

4 0 290 290

5 0 701 701

6 258 1,103 1,361

7 694 1,578 2,272

8 1,188 1,292 2,480

9 786 350 1,136

10 619 194 813

11 905 47 952

12 910 84 994

Total 5,360 6,540 11,900

Screendate distribution (PapReg)Chiang Mai

Screendate distribution (CPIS)

Month\Year 2005 2006 2007 Total

1 8 1,500 143 1,651

2 2 1,826 2 1,830

3 9 2,413 0 2,422

4 9 1,237 0 1,246

5 634 1,103 0 1,737

6 1,312 1,630 0 2,942

7 1,759 1,348 0 3,107

8 1,900 1,132 0 3,032

9 1,744 1,391 1 3,136

10 855 1,003 0 1,858

11 2,486 1,025 0 3,511

12 1,697 563 0 2,260

Total 12,415 16,171 146 28,732

Screening Visits, Chiang Mai

0

5000

10000

15000

20000

25000

30000

35000

40000

45000


Visit

Missing ofHcodeOverall visit

98.7%

99.6%

99.9%

No. of visit

Screening Cases

0

5000

10000

15000

20000

25000

30000

35000

40000

45000


1234Total casesVisits

79.2%

90.1%

97.3%

No. of case

Cases VS Visits

CUM40,326

37,705

37,140

98.5%

Screen

type

Visits (05-06)

Yearly case-

05

Yearly case-

06

New Cases

Case-05

Case-06

Perfor-

mance

PapRegist

ry

11,746

5,262 4,154 9,303 5,157 4,14679.2

%

CPIS

28,580

12,242

16,047

27,837

12,242

15,595

97.4%

Classified screen – Append file

• screen "via " if via result =1 or 2• screen "pap " if via result are blank and papdate indicate (via-pap)• 6,147/28,731 = 21.4% conducted the via-pap group.• 79.76% not completely the SCJ to determine

YearYearl

y visit

Yearly

cases

New cases

200517,67

417,14

417,142

200622,65

220,03

319,239

Total40,32

637,17

736,381

Population Coverage

Yrscreen

Yearly cases

New cases

Performance Target Coverage

200517,14

417,14

299.9%

174,254

9.8%

200620,03

319,23

996.0%

170,832

11.3%

Total37,17

736,38

197.9%

345,086

10.5%

Coverage subgroup by age

Group

Pap smear

VIA Missing

Total

2005 2006 2005 2006

< 30 87 81 121 101 1 390

30-45 9,744 11271 44 21015

30-34 203 416 619

35 602 466 461 575 2 1068

36-39 288 659 2529 2990 12 947

40 1,077 857 712 861 6 1934

41-44 489 1002 3295 3830 14 1491

45 1,307 1,027 664 682 7 2334

46-49 233 449 176 96 7 954

50 1,320 1,270 7 4 1 2601

51-54 175 309 29 3 1 516

55 821 692 5 2 0 1520

56-59 84 119 2 0 1 205

60 313 335 0 0 0 648

> 60 16 28 1 0 0 45

Overall age 7,015 7,710 10,085 11,477 62 36,287

Non-target gr. 1,575 3,063 341 206 5,185

Target gr. 5,440 4,647 9,744 11,271 31,102

Performance (%) 77.6 60.3 96.6 98.2 85.71

Target pop 345,086

Coverage by age (%) 9.0

Coverage subgroup by geo. location

Code Name

2005 2006

Target Visit

Cases

Performance

Target Visit

Cases

Performance (%)

1 เมื�อง1410

4 463 462 3.2812,98

8 309 244 1.88

2 จอมืทอง 78942,71

5 2,685 34.01 7,8742,61

92,32

6 29.54

3 แมื�แจ�มื 73221,22

9 1,225 16.73 73941,08

21,02

8 13.90

4 เชี�ยงดาว 7,2042,10

0 2,022 28.07 7,360 953 810 11.01

5ดอยสะเ

ก็�ด 9778 433 433 4.43 97971,07

4 742 7.57

6 แมื�แตง 7814 223 219 2.80 7378 205 109 1.48

7 แมื�ริ�มื1052

91,16

2 1,134 10.771054

5 583 546 5.18

8 สะเมื�ง 2512 78 78 3.11 2483 380 189 7.61

9 ฝาง1190

2 380 380 3.191159

81,37

51,16

7 10.06

10 แมื�อาย 7535 100 100 1.33 7397 494 354 4.79

11 พริ�าว 7331 569 565 7.71 7142 148 145 2.03

12ส�นป่ าตอ

ง 96482,02

3 1,919 19.89 93962,60

22,36

6 25.18

Coverage subgroup by geo. location

Code Name

2005 2006

Target VisitCase

sPerformanc

e Target Visit CasesPerforman

ce

13ส�นก็!าแ

พง 8089 778 766 9.47 7597 2,138 1,674 22.04

14ส�นทริา

ย 11532 660 587 5.09 11655 168 105 0.90

15 หางดง 10311 38 19 0.18 10468 467 372 3.55

16 ฮอด 4981 141 140 2.81 5041 1,531 1,524 30.23

17 ดอยเต�า 3470 357 357 10.29 1766 84 81 4.59

18 อมืก็$อย 4935 56 56 1.13 5628 157 153 2.72

19 สาริภี� 11116 387 385 3.46 10989 1,948 1,350 12.29

20เว�ยงแหง 1689 148 148 8.76 1808 192 118 6.53

21ไชีย

ป่ริาก็าริ 2934 371 369 12.58 3075 1,656 1,466 47.67

22 แมื�วาง 3690 1,6361,47

439.95 3633 974 879 24.19

23ก็.แมื�ออน 3509 1 1 0.03 3524 443 434 12.32

24ก็.ดอยหล่�อ 4425 1,626

1,618

36.56 4296 1,070 1,057 24.60

Total 174,25

417,67

41714

29.84

170,832

22,652

19,239

11.26

Coverage by denominator

Type YearScreene

dCensus %

CMPOP

%

PapRegistry 2005 5360 49382 10.9

2006 6540 51923 12.6 59845 10.9

CPIS 2005 1241515481

6 8.0

2006 1617114779

0 10.918844

9 8.6

Append 2005 1714217425

4 9.8

2006 1923917083

2 11.3

Coverage by denominator: Chiang Daw hospital 2006

TypeScreene

dSurvey Census

PapRegistry 276 1166 774

(50-55-60) % 23.67 35.66

CPIS 562 2725 6586

(30-45) % 20.62 8.53

Append 810 3891 7360

% 20.82 11.01

Trend over time

0

5

10

15

20

25

30

2003 2004 2005 2006

Coverage of Papsmear (by CMPOP)

Coverage of CPIS (byCMPOP)

Coverage ofPapRegistry (bycensus)Coverage of CPIS (bycensus)

Coverage of Append(by census)

% coverage

Roi Et, VIA started 2000

0

5000

10000

15000

20000

25000

1998 2002 2003 2004 2005 2006

Pap smearVIA

VIA started

Case

NHSO involved

3.45

6.50

10.41

8.39

11.06

9.06

Coverage in %

Coverage subgroup by

0

2

4

6

8

10

12

14

16

Timeperiod

Pap VIA Age Age-Pap Age-VIA

NationalChiang Mai

%

Facility Performance (Pap smear)

Subdistricthealth centerDistrict hospital

ProvincialhospitalNonMOPHgovt. hosp.Private hospital

District healthoffice

2005

2006

56.11

36.87

3.40 3.35

42.3254.45

1.371.48

Facility Performance (VIA)

Subdistricthealth center

Districthospital

Provincialhospital

6.81

92.92 15.91

84.09

2005

2006

Program outcome

Pap Smear VIA• % positive• % F/U• Missing (Unmapping)• Unsatisfactory slide

• % VIA-pap• % Missing• % positive• % Cryotherapy• % False positive

National Chiang Mai

Outcome N Case % N Case %

% positive of pap

350,118

6,646 1.910,27

997 0.9

Missing (Unmapping)

47,60474,65

9 17.5 11,900

1,624 13.7

% Unsatisfactory

353,121

2,827 0.810,32

850 0.5

Missing (VIA)307,44

22,049 0.7

28,586

49 0.2

VIA-pap307,44

258,65

2 19.128,58

66,083 21.3

Incompletely SCJ

58,65225,86

7 44.1 6,083 4,854 79.8

% positive of VIA

246,741

10,389 4.2

22,438

1,394 6.2

% cryotherapy 7,652 7,319 95.6 1,178 1,162 98.6