Bhutan is strongly engaged in the prevention of cervical cancer. In the year 2000, the Ministry of Health launched a national cytology-based screening programme (Pap smear every three years for women aged 25–65 years) whose coverage ranges from 20% to 60% by district1. In the year 2010, Bhutan was the first low/middle-income country (LMIC) to initiate a successful national vaccination programme against HPV with >90% coverage in girls age 12–18 years2. In addition to monitoring the impact of HPV vaccination on HPV prevalence in the female population, IARC is engaged in demonstrating the feasibility and better effectiveness of HPV-based rather than cytology-based cervical screening, especially in rural settings.
Demonstration projects of HPV-based screening were carried out in the capital Thimphu3 and in rural areas (REACH-Bhutan4). In REACH-Bhutan 3,648 women aged 30–60 years were invited and 2590 women (median age: 41 years) were enrolled in 15 Basic Health Units (BHU) differing in accessibility, size, and ethnic composition of the population. Self-collected samples were used and samples were tested by careHPV in Thimphu.
Study participation in REACH-Bhutan was 71% (range by BHU: 31%–96%). Participation decreased with increase in age (81% in 30–39 year-old women but only 59% in ≥50 years), and travelling time. 50% of participants reported no previous screening, with the proportion of never-screened women varying significantly by BHU (range: 2%–72%). 265 women (10%; 95%CI 9%–11%) were careHPV-positive, with a significant variation by BHU (range: 5%–19%) and by number of sexual partners (prevalence ratio for ≥3 vs. 0–1=1.55; 95% CI: 1.05–2.27). HPV-prevalence in rural areas was slightly lower than that found in Thimphu in women of the same age group, i.e. 14.1% (95% CI: 12.0–16.4). Work-up of care-HPV+ women is ongoing.
Community-based cervical cancer screening, by testing self-collected samples for HPV, can achieve high coverage in rural Bhutan as shown in other LMICs. However, solutions to bring self-collection, HPV testing, and precancer treatment even closer to the remotest villages are needed.
1. Baussano I, Tshomo U, Clifford GM, Tenet V, Tshokey T, Franceschi S. Cervical cancer screening program in Thimphu, Bhutan: population coverage and characteristics associated with screening attendance. BMC Womens Health 2014;14: 147.
2. Dorji T, Tshomo U, Phuntsho S, Tamang TD, Tshokey T, Baussano I, Franceschi S, Clifford G. Introduction of a National HPV vaccination program into Bhutan. Vaccine 2015;33: 3726-30.
3. Tshomo U, Franceschi S, Dorji D, Baussano I, Tenet V, Snijders PJ, Meijer CJ, Bleeker MC, Gheit T, Tommasino M, Clifford GM. Human papillomavirus infection in Bhutan at the moment of implementation of a national HPV vaccination programme. BMC Infect Dis 2014;14: 408.
4. Baussano I, Tshering S, Choden T, Lazzarato F, Tenet V, Plummer M, Franceschi S, Clifford G, Tshomo U. The “REACH-Bhutan” study: cervical cancer screening in rural Bhutan. (submitted) 2017.