Globally, cervical cancer is the fourth most common cancer in women with an estimated 570,000 new cases and with about 311,000 deaths in 2018[1]. Up to 85% of these new cases occurs in the low-and middle income countries [2]. The highest incidence rates are observed in Latin America and the Caribbean, sub-Saharan Africa, and south and south-east Asia [3]. In Somalia, cervical cancer ranks among second leading cause of female cancer related deaths with an age-standardized incidence rate at 25.1 per 100,000 and a mortality rate at 20.2 per 100,000 [4] Widespread cytology based cervical screening has registered a marked reduction in the incidence of cervical cancer in developed countries. In such countries the mortality and morbidity associated with cervical cancer has also significantly reduced [5]. Access to cytology services in Somalia remains a challenge due to a limited number of pathology laboratories and trained cytologists personnel for cervical cancer screening. As a result of this a majority of patients are forced to seek for cytology services in other neighbouring countries such as Kenya & Uganda were resources available for screening are as well as moderately available. Patients who are unable to access these services end up presenting with advanced stage of disease (stage III & IV) that is too difficult to treat. To address this challenge, the management of AL Zahra Specialty hospital contracted a cytologist to guide in the setting up of a cervical cytology laboratory. Terms of reference involved guiding in purchase of equipment, reagents, consumables, training of smear takers & laboratory technicians. In this article we share the experiences encountered by the team in the first twelve (12) months after establishing the said cytology laboratory.
Facility description
The cytology laboratory was established at AL Zahra Specialty Hospital which is a private hospital with a bed capacity of ten (10) beds, located along Liberia road, Hodan district, Mogadishu-Somalia. The hospital receives referrals from other neighbouring private, government hospitals for cytology mainly focuses on gynaecological cytology and maternity services. The hospital also participates in community cervical cancer screening programs in other states such as Somali land & Puntland
Description of intervention
a) Planning and setting up
The idea to set up a cytology started as early as February, 2018 which was followed by a series of talks and contractual agreements between the management of AL Zahra Specialty Hospital and with the cytotechnologist based in Uganda. Laboratory space measuring 5 by 2 square meters was acquired at the second floor of the hospital building for setting up a cytology unit. Different suppliers were contacted for invoices on equipment and reagents from which a suppliers with the least quotation was selected for the service. At the beginning of the project a total amount of 8,601 USD was mobilized by the hospital management so as to kick start the project (see Table 1). By 26th August, 2018 installations of furniture and purchase of equipment, reagents, solvents and consumables had already started after having identified a potential supplier. Equipment that was purchased included a microscope (Olympus CX 23), tissue-tek slide staining set (sakura), laptop (dell), digital eye piece camera, colour lazer printer and air conditioner (see fig 1). Reagents/solvents purchased included harris hematoxylin, eosin azure 50 (EA 50), orange G6, xylene and graded alcohols (see fig 2A &2B). Due to limitation of space, the specimen processing area was combined with the reporting area (see fig 3). In the absence of a cytologist (while on leave) a laboratory technician was trained to take images using a digital eye piece fitted on CX 23 microscope and transmit the captured images electronically to Kampala for reporting (see fig 4). For safety purposes, personnel protective equipment such as gaggles, nasal masks and gloves was provided to the laboratory staff to minimize exposure to xylene and other toxic substances (see fig 5).
b) Training of health workers
To acquire skills in cervical screening and diagnostics, the laboratory technicians and nurses underwent a three days CME in various aspects of cervical sample collection and processing. Nurses were trained on standard operating procedures for collecting of an adequate cervical specimen. Laboratory technicians received training in cytopreparatory procedures such as papanicolaou staining, mounting and coverslipping (fig 6A &6B)).
Challenges & mitigation;
Somalia is a developing country with quite a high economically constrained health systems coupled with limited funding & no policies to tackle non-communicable diseases such cervical cancer. General challenges included failure to acquire local suppliers for cytology reagents and consumables. To minimize stock-outs, supplies were obtained from local distributors based in Uganda and shipped to Mogadishu via DHL. Insecurity in Mogadishu also affected the functionality of cytology laboratory as foreign workers (cytologists) were at risk of getting kidnapped by Al-Shabab militants. To address this challenge we developed a telemicroscopy system (telecytology) where digital images (microphotographs) were sent to the cytologist for reporting in Kampala. Local laboratory technicians were trained on how to take quality images which enhanced continuity of cytology services in the absence of an on-site cytologist.
Lessons learnt;
In order to reduce the growing burden of cervical cancer & other non-neoplastic diseases in Somalia, setting up a cytology laboratory proved to be highly beneficial to the population. In order to increase access to cytology services, we learnt that the federal government of Somalia should consider making cervical cytology service (Pap smear test) as part of routine screening policy for all sexually active women and focus on including this in the algorithm of the health care package. An increase in sample volume may be improved through awareness campaigns and by conducting community screening activities.
Table 1: Start-up items used in setting up a cytology laboratory
Item
|
Quantity
|
Cost (USD)
|
Manufacturer/
Origin
|
Distributor/Origin
|
|
|
|
|
|
Equipment
|
|
|
|
|
Olympus CX 23 Microscope
|
1pc
|
1500
|
Olympus, japan
|
Crown Healthcare Uganda Limited
|
Digital eye piece camera
|
1pc
|
200
|
Amscope
|
Netkeep Healthcare Engineering, Kampala-Uganda
|
Tissue-tek slide staining set
|
1pc
|
2750
|
Sakura, Germany
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Printer
|
1pc
|
140
|
N/A
|
N/A
|
Dell laptop
|
1pc
|
300
|
N/A
|
N/A
|
Air conditioner
|
1pc
|
400
|
N/A
|
N/A
|
Furniture (chair, tables )
|
1set
|
500
|
N/A
|
N/A
|
|
|
|
|
|
Reagents and solvents
|
|
|
|
|
Harris hematoxylin
|
1ltr
|
286
|
RAL Diagnostics, France
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
EA50 Papanicolaou
|
1ltr
|
286
|
RAL Diagnostics, France
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
OG6 Papanicolaou
|
1ltr
|
286
|
RAL Diagnostics, France
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Bioclear (Xylene)
|
5ltrs
|
150
|
BioGnost, Croatia
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Histanol (Ethanol absolute)
|
5ltrs
|
150
|
BioGnost, Croatia
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Biomount DPX
|
500ml
|
385
|
BioGnost, Croatia
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Oil immersion solution
|
100ml
|
22
|
Cypress diagnostics, Belgium
|
Medilab Uganda
|
Consumables & accessories
|
|
|
|
|
Coverslips (24x50mm)
|
10x100/cs
|
385
|
Sakura, Germany
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Pap smear kits (25 per kit)
|
4 boxes
|
216
|
Andwin Scientific, USA
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
Disposable speculums
|
150pcs
|
283
|
Advin Health Care
|
Laborex Uganda Ltd
|
20 Slides folder white
|
10/cs
|
308
|
Sakura, United Kingdom
|
Al Zahrawi Medical Supplies, LLC/ Dubai-UAE
|
PPE (Mask, gaggles)
|
1pc
|
54
|
Bioptica, Italy
|
Histclear diagnostic supplies/ Kampla-Uganda
|
T0TAL
|
|
8,601
|
|
|