In the trial by Arrossi and
In the trial by Arrossi and colleagues in Argentina, Cyclopamine health workers randomly allocated to the intervention group delivered self-collection kits to women at their homes during routine visits, instructed women on how to obtain a cervicovaginal sample for HPV testing, and transported the gathered samples to health centres. Community health workers in the control group educated women about cervical cancer and HPV testing and encouraged women to visit a health centre for screening. Cervical cancer screening uptake was four times greater in the intervention group (86%) than in the control group (21%) over 12 months (risk ratio 4·02, 95% CI 3·44–4·71).
The novel strategy of using community health workers and self-collection to implement cervical cancer screening leaves many questions unanswered, most importantly the uncertainty of how to follow-up HPV-positive women. In this current trial, women with HPV-positive results from self-collected samples were all referred to colposcopy (n=232), whereas women who tested HPV-positive from clinician-collected samples were triaged with cytology before referral to colposcopy (n=23). The referral of all women with HPV-positive samples for colposcopy might not be a realistic sustainable strategy and would further strain the limited colposcopy services in many low-income and middle-income countries. On the other hand, triaging HPV-positive women with cytology means that women who provide self-collected samples at home must go to health centres for an additional visit, eliminating the convenience of self-collection at home and adding another opportunity for loss to follow-up. More research studies, particularly cost-effectiveness assessments, are needed to understand what the best strategy for follow-up of HPV-positive women would be with this screening strategy, under different resource settings.
Other screening strategies not considered in this study could be adapted on a wider scale. WHO promotes a strategy whereby women who are HPV-positive can be triaged by visual inspection with acetic acid and treated immediately with cryotherapy, thereby eliminating the reported 2 months from HPV test to colposcopy. A lower cost HPV test might also increase the adoption of HPV testing in low-resource settings. All women in this study also had to go to the clinic to get their results, whereas the negative predictive value afforded by a negative HPV test result could be communicated easily back to women without needing to visit the clinic.
Successful scale-up of programmes centred around community health workers is dependent on provision of adequate training, motivation (possibly in the form of material benefits), and supervision of community health workers, which would probably need additional funding; these extra costs to current cervical cancer screening programmes need to be evaluated.
Some important changes have occurred in global child health in the past decade. Socioeconomic development, action to address the broad social determinants of health, and the development and implementation of effective child health interventions have resulted in a steady and substantial fall in global child mortality. Mortality due to pneumonia, the leading cause of child death in the past decade, has fallen the most steeply. These changes have also resulted in a changing pattern of pneumonia incidence, cause, and risk-factor effects. Therefore, particularly at this time, reliable information about the epidemiology of pneumonia in low-income and middle-income countries should be collected, disseminated, and used to inform child health policy and priority setting. Since vital statistics and other routine health information are not widely available in the countries and regions with the highest child disease burden, to a large extent researchers are reliant on well designed and implemented population-based research in these settings to provide this essential information.