Frequency of cervical premalignant lesions in the gynecologic patients of tertiary hospital in Mogadishu, Somalia

Frequency of cervical premalignant lesions in the gynecologic patients of tertiary hospital in Mogadishu, Somalia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Frequency of cervical premalignant lesions in the gynecologic patients of tertiary hospital in Mogadishu, Somalia Sabri Kurtay, Khadija Yusuf, Ahmed Issak Hussein This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1721788/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Cervical cancer is the fourth most common cancer worldwide and is the most frequently diagnosed cancer in 23 countries and the most common cause of death in 36 countries, mostly from Sub-Saharan African countries. Vaccination availability is increasing day by day, with more than 65% of girls vaccinated in 2019 were living in low- and middle-income countries. Cervical screening is a key element to reduce the incidence and mortality of cervical cancer. Cancer screening is low in Sub-Saharan Africa. Methods: The pathology results of cervicovaginal smear samples obtained from patients aged 25-65 years who applied to the gynecology outpatient clinic between October 5 and December 5, 2021 were analyzed retrospectively. SPSS 22.0 was used for statistical analysis of the data. Results: Among the 497 results, 63 premalignant lesions were detected. The rate of premalignant lesions (63/497) was found to be 12,3%. Most common premalign lesion was ASC-US. Conclusions: In this study, the frequency of cervical premalignant lesions in Somalia was found to be higher than in the literature. Vaccination, screening and early diagnosis are the most important components in the fight against cervical cancer. Access to vaccination, screening and early diagnosis, which are the most important components in the fight against cervical cancer for Somalia, will be possible with the cooperation of the national health system and international organizations. Cervical cancer Human Papilloma Virus (HPV) Somalia Sub-Saharan Africa Women’s health Background Cervical cancer is the fourth most common cancer worldwide and is the most frequently diagnosed cancer in 23 countries and the most common cause of death in 36 countries, mostly from Sub-Saharan African countries.[ 1 ] According to World Health Organisation (WHO), cervical cancer cases are expected to increase until 2030. More than 85% of cases are among young, low-education women living in the poorest countries in the world. 604,000 women were diagnosed with cervical cancer, and more than half of them died from the disease in 2020 globally.[ 2 ] In these regions where HIV prevalence is high, the risk of cervical cancer is 6 times higher than HIV-negative people.[ 2 ] The highest age-standardized rates for incidence, disability-adjusted life-years (DALYs) and death of cervical cancer were noted in Kiribati, Somalia, Eritrea, and Central African Republic between 2007 and 2017.[ 3 ] WHO's Global Strategy includes eliminating cervical cancer by the end of the century, and this is the first worldwide cancer-related initiative. The requirements to achieve this goal are summarized as 90-70-90 goals (90% of girls fully vaccinated with the Human Papilloma Virus (HPV) vaccine by the age of 15, 70% of women screened with a high-performance test by the age of 35, and again by the age of 45 (i.e. at least twice in their lifetime, a maximum of 10 years apart) and 90% of women with identified cervical disease receive treatment. [ 4 ] The target incidence to be achieved by all countries for elimination is less than 4 per 100,000 woman-years.[ 2 ] If the 90-70-90 targets are achieved in 2030, the reduction rate in the incidence of cervical cancer is expected to be 2%, 42% and 97% in 2030, 2045 and 2120, respectively, and as a result, 74 million cases are expected to be prevented. In the next century, as a result of the successful implementation of the WHO elimination strategy, almost all cervical cancer deaths will be prevented and the lives of more than 62 million women will be saved. [ 5 ] [ 6 ] Vaccination availability is increasing day by day, with more than 65% of girls vaccinated in 2019 were living in low- and middle-income countries.[ 2 ] WHO recommended incorporating the HPV vaccine into national vaccination programs in 2009, and over 100 countries have done so by 2020.[ 7 ] HPV infection, frequency of premalignant lesions and HPV clearance were found to be higher in HIV-positive women than in HIV-negative women. It has been suggested that a decrease in CD4 count may increase susceptibility to HPV and may decrease susceptibility to HPV transmission in those receiving antiretroviral therapy for HIV.[ 8 ] Cervical screening is a key element to reduce the incidence and mortality of cervical cancer. [ 9 ] Cancer screening is low in Sub-Saharan Africa.[ 10 ] In the review where the efficacy of HPV and Pap smear in cervical cancer screening was compared, the rate of precancerous changes was found to be approximately 20 per thousand. The sensitivity and specificity of these two methods are summarized in the Table 1 . (Table 1 ) [ 11 ] Table 1 Sensitivity and specifity of HPV and Pap smear tests HPV Pap smear Sensitivity (95% CI) 89.9% (88.6 to 91.1%) 72.9% (70.7 to 75%) Specificity (95% CI) 89.9% (89.7 to 90.0%) 90.3% (90.1 to 90.5%) The 2018 recommendations of the US Preventive Services Task Force on cervical cancer screening (USPSTF) are as follows: -Cytology screening every 3 years between the ages of 21–29 (A recommendation). -Screening 30–65 years with cytology every 3 years, or hrHPV (high-risk) every 5 years, or a test every 5 years (A recommendation). - Do not screen under the age of 21 or over the age of 65 (D recommendation).[ 12 ] The American Cancer Society recommends HPV testing every 5 years between the ages of 25–65. In cases where HPV testing is not possible, it recommends screening with HPV co-testing every 5 years or cytology every 3 years between the ages of 25–65.[ 13 ] There are two main screening and treatment approaches recommended by the WHO for cervical cancer screening currently. In the screen-and-treat approach, the treatment decision is made only based on the positive primary screening result. In the screening, triage and treatment approach, the treatment decision is made according to the second positive test (triage test) made following the positive primary screening test, with or without histological confirmation. WHO recommends HPV DNA primarily.[ 14 ] All methods used in scanning are shown in Table 2 . Table 2 Three current approaches to cervical cancer screeningAdapted from Jane W-N. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention: use of mRNA tests for human papillomavirus (HPV): World Health Organization; 2021 Molecular Cytologic Visual inspection Nucleic acid amplification tests (NAAT) -high-risk HPV DNA / NAAT -mRNA Conventional Pap smear Liquid-based cytology (LBC) Visual inspection with acetic acid or with Lugol’s iodine (VIA / VILI) -naked eye -magnified by colposcope or camera American College of Obstetricians and Gynecologists (ACOG) recommends HPV testing or testing with acetic acid in low-income countries where cytology is not available.[ 15 ] There is no national strategy for cervical cancer screening in Somalia. There is a small number of studies in the literature on cancer rates in Somalia. According to a study which reports the pathology results were examined retrospectively, cervical cancer is the fourth most common cancer among all cancers in Somalia, and the second most common type of cancer in women. In this study, it was stated that 88 cervical cancer cases were detected in a 3-year period.[ 16 ] However, considering that gynecological oncological surgery was not performed in the center where the study was conducted, this number seems contradictory. The rates of benefiting from cervical cancer screening programs are low in Ethiopia and Kenya (5.5% and 16.4%, respectively).[ 17 ]. Somalia, on the other hand, does not have data to compare with the data of these neighboring countries. Material And Method In Somalia Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital (MRTE-TREH), cervicovaginal smear examination is performed from patients with suspected lesion because there are no facilities for nucleic acid amplification test (NAAT), acetic acid and colposcopy for HPV. The pathology results of cervicovaginal smear samples obtained from patients aged 25–65 years who applied to the gynecology outpatient clinic between October 5 and December 5, 2021 were analyzed retrospectively. The complaints of these patients, smoking status, body mass index, age at menarche, duration of sexual activity, multipartnership status, multipartnership status of their partner, exposure to traditional procedures (cauterization, female genital mutilation) and examination findings were observed. The relationship of patients with premalignant lesions with variables was evaluated. The analyses were performed using IBM SPSS Statistics Version 22.0. Descriptive statistics were computed for sociodemographic data and clinical characteristics. Results Records of 514 patients who underwent cervicovaginal smear examination within the specified date range were reached. Results of 17 patients could not be reached. It was understood that these patients did not have the examination done because of the fee. Among the 497 results seen, 63 premalignant lesions were detected. Cervicovaginal smear results were evaluated according to the Bethesda 2014 classification. [ 18 ] 3 Atypical glandular cells of undetermined significance (AGUS), 6 Atypical squamous cells cannot exclude HSIL (ASC-H), 50 Atypical squamous cells of undetermined significance (ASC-US), 2 Low-grade squamous intraepithelial lesion (LSIL) and 2 High-grade squamous intraepithelial lesion (HSIL) were detected. The results of 434 patients were negative for intraepithelial lesion or malignancy (NILM). The rate of premalignant lesions (63/497) was found to be 12,3%. (Table 3 ) Most common premalign lesion was ASC-US. (Table 4 ) Table 3 Frequency of cervical premalign lesions Count % Premalign 63 12,3 Negative for lesion or malignancy 451 87,7 Total 497 100 Table 4 Distribution of premalign results Count % ASC-US 50 79,4 ASC-H 6 9,5 AGUS 3 4,8 LSIL 2 3,2 HSIL 2 3,2 Total 63 100,0 Discussion The frequency of cervical precancerous lesions in the USA is 5%.[ 19 ] The prevalence of precancerous lesions in Ethiopia is 15.16%.[ 20 ] In a study examining 22 Eastern Mediterranean countries, including Somalia, it was found that breast, cervical and esophageal cancers were most common in Somali women, age-standardized incidence rates (ASR) were higher in women, and age-standardized mortality rates (ASMR) 117 per 100,000 person -years among females. [ 21 ] The reason why cervical cancer is more common in low- and middle-income countries than in high-income countries is the lack of screening programs in these countries.[ 22 ] Lack of data about cervical cancer in low- and middle-income countries is one of the most important barriers for cancer screening. [ 23 ] The characteristics of the target population are as important as the quality of the interventions for cervical cancer screening. [ 24 ] Access to cervical cancer screening, HPV vaccine, pathological examination, cancer surgery, chemotherapy and radiotherapy is closely related to the financial situation of countries. [ 2 ] In Somalia, where the effects of the civil war still continue, there is no screening program for cervical cancer. Pathological examination is available in the hospital where the study was conducted. As a result of samples taken from patients who may be related to cervical pathology, it was possible to obtain information about the frequency of cervical premalignant lesions. The cost-effectiveness of screening, which is effective in the prevention of cervical cancer, was examined among countries with different income levels, and it was seen that HPV DNA was the most effective screening method in almost all countries examined.[ 25 ] HPV testing has shown to be effective in low-income countries, as well.[ 26 ] In a review examining the effectiveness of the self-sampling screening method, it was stated that this method was generally effective in cervical cancer screening.[ 27 ] Self-testing of HPV is an effective and applicable method, especially in high-income countries, and increases the success of screening.[ 28 ] [ 29 ] Based on this information, cervical cancer screening with HPV DNA method can be considered as a reasonable option for Somalia in terms of feasibility and cost-effectiveness. The sensitivity of the visual inspection with acetic acid (VIA) method in detecting cervical intraepithelial lesion – 2 (CIN-2) lesions is 16.6%-82.6%, the specificity is 82.1%-96.8%, and this method provides both diagnosis and treatment at the same visit. [ 30 ] In another study, although it was stated that both HPV testing and VIA methods are effective in screening in Sub-Saharan Africa, it was claimed that the main effective struggle should be based on population-based screening and vaccination. [ 31 ] Comparing the screening methods available in Sub-Saharan Africa, VILI was found to be more sensitive than VIA and more affordable and simple than cytology.[ 32 ] VILI/VIA screening, which is applied in low-income countries, is also a cervical cancer screening method that can be applied in Somalia. In a study conducted in 10 different countries in sub-Saharan Africa, the conditions that could prevent screening related to patients, healthcare providers and the system were examined and it was observed that there were problems in all three components in general.[ 33 ] In low-income countries, screening alone is not enough. Standardized laboratories and specialized equipment and personnel are required to carry out the cervical cancer screening program at the national level.[ 34 ] Health care providers also need to work with a holistic approach in screening, diagnosis and treatment.[ 35 ] If the cervical cancer screening method to be chosen is integrated into the national system, it will be possible to reach global targets. The presence of a cervical cancer screening program is not sufficient by itself. The level of knowledge of the target population and the perception about cancer are also important factors. It has been demonstrated that low level cancer awareness can be increased in programs for Somali women who have immigrated to high-income countries.[ 36 ] Although the positive effects of interventions to increase participation in cervical cancer screening are known, there is no definite consensus on which method is more appropriate.[ 37 ] A low level of awareness of cervical cancer screening was observed among Somali women living in the UK.[ 38 ] The rate of pap testing among African immigrants in the United States is the lowest among Somali women.[ 39 ] In a study where the cervical cancer screening rates were low in Somali migrant women in Minnesota, and Pap smear and self-HPV testing were compared, it was observed that compliance with HPV testing was higher and women who were spoken to in their friends/family about cervical cancer were more likely to comply with any test. In this study, insecurity about the vaccine in the same population was also noted. [ 40 ] [ 41 ] As a matter of fact, it has been reported that the level of knowledge about HPV vaccination and cervical cancer screening in Somali men in the same city is low. [ 42 ] Another study emphasized the importance of cultural differences in the attitudes of Somali immigrant families in the United States regarding HPV vaccination. Families consider vaccination unnecessary in line with their cultural beliefs and do not trust the health system at some points. [ 43 ] Therefore, a screening and vaccination program that can take into account cultural characteristics in Somalia and be integrated into the local health system will be effective in combating cervical cancer. The rate of breast cancer screening among Somali immigrants living in the United States is also lower than in the general population. [ 44 ] [ 45 ] In the United States, the cost-effectiveness of breast, cervical and colorectal cancer screening programs has been found to be effective in people who are deprived of social services. [ 46 ] In a study, after it was determined that cervical and breast cancers were more common in Somali immigrants than in the general population, it was suggested that information could be transferred through imams, who are religious leaders, in order to raise awareness about these cancers in Somali Muslim women.[ 47 ] Targeted, comprehensive initiatives and involving family members among Somali immigrants in the United States will result in high successes in screening and vaccination.[ 48 ] Although the rates of Pap smear and HPV vaccination are low in Somali women in the Netherlands, it is seen that sociocultural differences regarding vaccination for cervical cancer awareness and prevention are important.[ 49 ] The factors affecting cervical cancer screening of immigrants, including Somalis, in Finland were examined. Although the rate of participation in cervical cancer screening is at the lowest level in Somali women, the most important factor affecting participation in screening is expressed as having had a gynecological examination within the last 1 year. [ 50 ] Adding a screening method to the gynecological examination in Somalia will enable early diagnosis of cervical cancer. Considering cultural characteristics will increase compliance with screening. [ 51 ] Positive results have been achieved by raising the awareness of practitioners in Norway to increase participation in cervical cancer screening program among immigrants.[ 52 ] It has been stated that the awareness of immigrants in Norway about cervical cancer screening can also be increased with community-based education activities.[ 53 ] Considering the low number of obstetricians in Somalia, the role of physicians and midwives working in primary care will be high in screening. The common result of studies examining Somali immigrants is the lack of information about cancer screening and HPV vaccination, and large-scale organizations are needed to combat the frequency of cervical cancer. Abbreviations ACOG: American College of Obstetricians and Gynecologists; AGUS: Atypical glandular cells of undetermined significance; ASC-H: Atypical squamous cells cannot exclude HSIL; ASMR: Age-standardized mortality rate; ASC-US: Atypical squamous cells of uncertain significance; CD4: Cluster of differentiation 4; CIN: Cervical intraepithelial lesion; DALYs: Disability-adjusted life-years; HPV: Human Papilloma Virus; HSIL: High-grade squamous intraepithelial lesion; LSIL: Low-grade squamous intraepithelial lesion; MRTE-TREH: Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital; NAAT: Nucleic acid amplification NILM: Negative for intraepithelial lesion or malignancy; USPSTF: United States Preventive Services Task Force on cervical cancer screening; WHO: World Healt Organisation; VIA: Visual inspection with acetic; VILI: Visual inspection with Lugol’s iodine Declarations Ethical approval and constent to participate Ethical clearance and permission was obtained from the Institutional Review Board (IRB) of the Somali Mogadishu Türkiye Recep Tayyip Erdoğan Training and Research Hospital, approval number 432 dated 04/10/2021. Informed consent was obtained from all the participants. All methods were performed in accordance with the relevant guidelines and regulations. The Declaration of Helsinki has been adhered to. Written and signed informed consent was obtained from all participants and/or their legal surrogates. Consent for publication Not applicable. Conflict of interest All authors have no conflict of interest to declare. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding No funds were used for this study. Author contribution SK and AIH designed the study, KY collected data. SK, AIH and KY critically reviewed the results and contributed in finalizing the manuscript. All authors read and approved the final manuscript. Acknowledgement Not applicable. 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Moen KA, Kumar B, Igland J, Diaz E: Effect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial . JAMA Netw Open 2020, 3 (4):e201903. Qureshi SA, Igland J, Moen K, Gele A, Kumar B, Diaz E: Effect of a community-based intervention to increase participation in cervical cancer screening among Pakistani and Somali women in Norway . BMC Public Health 2021, 21 (1):1271. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 13 Oct, 2022 Reviews received at journal 02 Oct, 2022 Reviewers agreed at journal 16 Sep, 2022 Reviewers agreed at journal 28 Jul, 2022 Reviews received at journal 14 Jul, 2022 Reviewers agreed at journal 14 Jul, 2022 Reviewers invited by journal 08 Jul, 2022 Editor assigned by journal 08 Jul, 2022 Editor invited by journal 08 Jun, 2022 Submission checks completed at journal 08 Jun, 2022 First submitted to journal 03 Jun, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1721788","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":112066060,"identity":"0c68d17c-3d3f-4912-bdc7-305861ec6056","order_by":0,"name":"Sabri Kurtay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYFACHgaGhANgFuMDEJePaC1AitkAxGUjSgsDRAubBIhPUIt8+9ljHx6cOZxvz37GrPJrjp0MGwPzw0c38GgxOJOXPCPhxmHLHp4cs9uy25KBDmMzNs7Bp4Uhx5gh4cNhAx4GoBbJbcxALTxs0vi0yPe/gWrhf2NWLLmtnrAWhhsgW24AtUjkmDF+3HaYsBaDG++SGRLOpBvw3HhWLM247TgPGzMBv8j35x5m/HHM2oC9P3njx5/bqu352ZsfPsbrMATgMGAGxREDM3HKQYD9AeMP4lWPglEwCkbBCAIAQOpFwyU5C1cAAAAASUVORK5CYII=","orcid":"","institution":"Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sabri","middleName":"","lastName":"Kurtay","suffix":""},{"id":112066061,"identity":"458332eb-a7ff-4a03-ac3a-df85c0923609","order_by":1,"name":"Khadija Yusuf","email":"","orcid":"","institution":"Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Khadija","middleName":"","lastName":"Yusuf","suffix":""},{"id":112066062,"identity":"063eb415-6908-4b01-a1b2-594593d7e1ae","order_by":2,"name":"Ahmed Issak Hussein","email":"","orcid":"","institution":"Somalia Mogadishu Turkey Recep Tayyip Erdoğan Training and Research Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Issak","lastName":"Hussein","suffix":""}],"badges":[],"createdAt":"2022-06-03 07:44:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1721788/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1721788/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22469736,"identity":"c3d7dce8-6f4e-4ee6-a941-bc407c03752d","added_by":"auto","created_at":"2022-06-09 16:38:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1590815,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1721788/v1/6757e879-a628-4579-8073-c8e294c490c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frequency of cervical premalignant lesions in the gynecologic patients of tertiary hospital in Mogadishu, Somalia","fulltext":[{"header":"Background","content":"\u003cp\u003eCervical cancer is the fourth most common cancer worldwide and is the most frequently diagnosed cancer in 23 countries and the most common cause of death in 36 countries, mostly from Sub-Saharan African countries.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] According to World Health Organisation (WHO), cervical cancer cases are expected to increase until 2030. More than 85% of cases are among young, low-education women living in the poorest countries in the world. 604,000 women were diagnosed with cervical cancer, and more than half of them died from the disease in 2020 globally.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In these regions where HIV prevalence is high, the risk of cervical cancer is 6 times higher than HIV-negative people.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The highest age-standardized rates for incidence, disability-adjusted life-years (DALYs) and death of cervical cancer were noted in Kiribati, Somalia, Eritrea, and Central African Republic between 2007 and 2017.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWHO's Global Strategy includes eliminating cervical cancer by the end of the century, and this is the first worldwide cancer-related initiative. The requirements to achieve this goal are summarized as 90-70-90 goals (90% of girls fully vaccinated with the Human Papilloma Virus (HPV) vaccine by the age of 15, 70% of women screened with a high-performance test by the age of 35, and again by the age of 45 (i.e. at least twice in their lifetime, a maximum of 10 years apart) and 90% of women with identified cervical disease receive treatment. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe target incidence to be achieved by all countries for elimination is less than 4 per 100,000 woman-years.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] If the 90-70-90 targets are achieved in 2030, the reduction rate in the incidence of cervical cancer is expected to be 2%, 42% and 97% in 2030, 2045 and 2120, respectively, and as a result, 74\u0026nbsp;million cases are expected to be prevented. In the next century, as a result of the successful implementation of the WHO elimination strategy, almost all cervical cancer deaths will be prevented and the lives of more than 62\u0026nbsp;million women will be saved. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eVaccination availability is increasing day by day, with more than 65% of girls vaccinated in 2019 were living in low- and middle-income countries.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] WHO recommended incorporating the HPV vaccine into national vaccination programs in 2009, and over 100 countries have done so by 2020.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHPV infection, frequency of premalignant lesions and HPV clearance were found to be higher in HIV-positive women than in HIV-negative women. It has been suggested that a decrease in CD4 count may increase susceptibility to HPV and may decrease susceptibility to HPV transmission in those receiving antiretroviral therapy for HIV.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCervical screening is a key element to reduce the incidence and mortality of cervical cancer. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Cancer screening is low in Sub-Saharan Africa.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In the review where the efficacy of HPV and Pap smear in cervical cancer screening was compared, the rate of precancerous changes was found to be approximately 20 per thousand. The sensitivity and specificity of these two methods are summarized in the Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity and specifity of HPV and Pap smear tests\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePap smear\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.9%\u003c/p\u003e \u003cp\u003e(88.6 to 91.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.9%\u003c/p\u003e \u003cp\u003e(70.7 to 75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.9%\u003c/p\u003e \u003cp\u003e(89.7 to 90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.3%\u003c/p\u003e \u003cp\u003e(90.1 to 90.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe 2018 recommendations of the US Preventive Services Task Force on cervical cancer screening (USPSTF) are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e-Cytology screening every 3 years between the ages of 21\u0026ndash;29 (A recommendation).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e-Screening 30\u0026ndash;65 years with cytology every 3 years, or hrHPV (high-risk) every 5 years, or a test every 5 years (A recommendation).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Do not screen under the age of 21 or over the age of 65 (D recommendation).[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe American Cancer Society recommends HPV testing every 5 years between the ages of 25\u0026ndash;65. In cases where HPV testing is not possible, it recommends screening with HPV co-testing every 5 years or cytology every 3 years between the ages of 25\u0026ndash;65.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere are two main screening and treatment approaches recommended by the WHO for cervical cancer screening currently. In the screen-and-treat approach, the treatment decision is made only based on the positive primary screening result. In the screening, triage and treatment approach, the treatment decision is made according to the second positive test (triage test) made following the positive primary screening test, with or without histological confirmation. WHO recommends HPV DNA primarily.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] All methods used in scanning are shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThree current approaches to cervical cancer screeningAdapted from Jane W-N. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention: use of mRNA tests for human papillomavirus (HPV): World Health Organization; 2021\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMolecular\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCytologic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisual inspection\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNucleic acid amplification tests (NAAT)\u003c/p\u003e \u003cp\u003e-high-risk HPV DNA / NAAT\u003c/p\u003e \u003cp\u003e-mRNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConventional Pap smear\u003c/p\u003e \u003cp\u003eLiquid-based cytology (LBC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVisual inspection with acetic acid or with Lugol\u0026rsquo;s iodine (VIA / VILI)\u003c/p\u003e \u003cp\u003e-naked eye\u003c/p\u003e \u003cp\u003e-magnified by colposcope or camera\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmerican College of Obstetricians and Gynecologists (ACOG) recommends HPV testing or testing with acetic acid in low-income countries where cytology is not available.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] There is no national strategy for cervical cancer screening in Somalia. There is a small number of studies in the literature on cancer rates in Somalia. According to a study which reports the pathology results were examined retrospectively, cervical cancer is the fourth most common cancer among all cancers in Somalia, and the second most common type of cancer in women. In this study, it was stated that 88 cervical cancer cases were detected in a 3-year period.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] However, considering that gynecological oncological surgery was not performed in the center where the study was conducted, this number seems contradictory.\u003c/p\u003e \u003cp\u003eThe rates of benefiting from cervical cancer screening programs are low in Ethiopia and Kenya (5.5% and 16.4%, respectively).[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Somalia, on the other hand, does not have data to compare with the data of these neighboring countries.\u003c/p\u003e"},{"header":"Material And Method","content":"\u003cp\u003eIn Somalia Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital (MRTE-TREH), cervicovaginal smear examination is performed from patients with suspected lesion because there are no facilities for nucleic acid amplification test (NAAT), acetic acid and colposcopy for HPV. The pathology results of cervicovaginal smear samples obtained from patients aged 25\u0026ndash;65 years who applied to the gynecology outpatient clinic between October 5 and December 5, 2021 were analyzed retrospectively. The complaints of these patients, smoking status, body mass index, age at menarche, duration of sexual activity, multipartnership status, multipartnership status of their partner, exposure to traditional procedures (cauterization, female genital mutilation) and examination findings were observed. The relationship of patients with premalignant lesions with variables was evaluated. The analyses were performed using IBM SPSS Statistics Version 22.0. Descriptive statistics were computed for sociodemographic data and clinical characteristics.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eRecords of 514 patients who underwent cervicovaginal smear examination within the specified date range were reached. Results of 17 patients could not be reached. It was understood that these patients did not have the examination done because of the fee. Among the 497 results seen, 63 premalignant lesions were detected. Cervicovaginal smear results were evaluated according to the Bethesda 2014 classification. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] 3 Atypical glandular cells of undetermined significance (AGUS), 6 Atypical squamous cells cannot exclude HSIL (ASC-H), 50 Atypical squamous cells of undetermined significance (ASC-US), 2 Low-grade squamous intraepithelial lesion (LSIL) and 2 High-grade squamous intraepithelial lesion (HSIL) were detected. The results of 434 patients were negative for intraepithelial lesion or malignancy (NILM). The rate of premalignant lesions (63/497) was found to be 12,3%. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) Most common premalign lesion was ASC-US. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of cervical premalign lesions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremalign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative for lesion or malignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of premalign results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASC-US\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASC-H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAGUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSIL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSIL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe frequency of cervical precancerous lesions in the USA is 5%.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] The prevalence of precancerous lesions in Ethiopia is 15.16%.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn a study examining 22 Eastern Mediterranean countries, including Somalia, it was found that breast, cervical and esophageal cancers were most common in Somali women, age-standardized incidence rates (ASR) were higher in women, and age-standardized mortality rates (ASMR) 117 per 100,000 person -years among females. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe reason why cervical cancer is more common in low- and middle-income countries than in high-income countries is the lack of screening programs in these countries.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Lack of data about cervical cancer in low- and middle-income countries is one of the most important barriers for cancer screening. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The characteristics of the target population are as important as the quality of the interventions for cervical cancer screening. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Access to cervical cancer screening, HPV vaccine, pathological examination, cancer surgery, chemotherapy and radiotherapy is closely related to the financial situation of countries. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In Somalia, where the effects of the civil war still continue, there is no screening program for cervical cancer. Pathological examination is available in the hospital where the study was conducted. As a result of samples taken from patients who may be related to cervical pathology, it was possible to obtain information about the frequency of cervical premalignant lesions.\u003c/p\u003e \u003cp\u003eThe cost-effectiveness of screening, which is effective in the prevention of cervical cancer, was examined among countries with different income levels, and it was seen that HPV DNA was the most effective screening method in almost all countries examined.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] HPV testing has shown to be effective in low-income countries, as well.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] In a review examining the effectiveness of the self-sampling screening method, it was stated that this method was generally effective in cervical cancer screening.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Self-testing of HPV is an effective and applicable method, especially in high-income countries, and increases the success of screening.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Based on this information, cervical cancer screening with HPV DNA method can be considered as a reasonable option for Somalia in terms of feasibility and cost-effectiveness.\u003c/p\u003e \u003cp\u003eThe sensitivity of the visual inspection with acetic acid (VIA) method in detecting cervical intraepithelial lesion \u0026ndash; 2 (CIN-2) lesions is 16.6%-82.6%, the specificity is 82.1%-96.8%, and this method provides both diagnosis and treatment at the same visit. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] In another study, although it was stated that both HPV testing and VIA methods are effective in screening in Sub-Saharan Africa, it was claimed that the main effective struggle should be based on population-based screening and vaccination. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Comparing the screening methods available in Sub-Saharan Africa, VILI was found to be more sensitive than VIA and more affordable and simple than cytology.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] VILI/VIA screening, which is applied in low-income countries, is also a cervical cancer screening method that can be applied in Somalia.\u003c/p\u003e \u003cp\u003eIn a study conducted in 10 different countries in sub-Saharan Africa, the conditions that could prevent screening related to patients, healthcare providers and the system were examined and it was observed that there were problems in all three components in general.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] In low-income countries, screening alone is not enough. Standardized laboratories and specialized equipment and personnel are required to carry out the cervical cancer screening program at the national level.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Health care providers also need to work with a holistic approach in screening, diagnosis and treatment.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] If the cervical cancer screening method to be chosen is integrated into the national system, it will be possible to reach global targets.\u003c/p\u003e \u003cp\u003eThe presence of a cervical cancer screening program is not sufficient by itself. The level of knowledge of the target population and the perception about cancer are also important factors. It has been demonstrated that low level cancer awareness can be increased in programs for Somali women who have immigrated to high-income countries.[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] Although the positive effects of interventions to increase participation in cervical cancer screening are known, there is no definite consensus on which method is more appropriate.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA low level of awareness of cervical cancer screening was observed among Somali women living in the UK.[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] The rate of pap testing among African immigrants in the United States is the lowest among Somali women.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] In a study where the cervical cancer screening rates were low in Somali migrant women in Minnesota, and Pap smear and self-HPV testing were compared, it was observed that compliance with HPV testing was higher and women who were spoken to in their friends/family about cervical cancer were more likely to comply with any test. In this study, insecurity about the vaccine in the same population was also noted. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] As a matter of fact, it has been reported that the level of knowledge about HPV vaccination and cervical cancer screening in Somali men in the same city is low. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Another study emphasized the importance of cultural differences in the attitudes of Somali immigrant families in the United States regarding HPV vaccination. Families consider vaccination unnecessary in line with their cultural beliefs and do not trust the health system at some points. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] Therefore, a screening and vaccination program that can take into account cultural characteristics in Somalia and be integrated into the local health system will be effective in combating cervical cancer.\u003c/p\u003e \u003cp\u003eThe rate of breast cancer screening among Somali immigrants living in the United States is also lower than in the general population. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] In the United States, the cost-effectiveness of breast, cervical and colorectal cancer screening programs has been found to be effective in people who are deprived of social services. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] In a study, after it was determined that cervical and breast cancers were more common in Somali immigrants than in the general population, it was suggested that information could be transferred through imams, who are religious leaders, in order to raise awareness about these cancers in Somali Muslim women.[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] Targeted, comprehensive initiatives and involving family members among Somali immigrants in the United States will result in high successes in screening and vaccination.[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAlthough the rates of Pap smear and HPV vaccination are low in Somali women in the Netherlands, it is seen that sociocultural differences regarding vaccination for cervical cancer awareness and prevention are important.[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] The factors affecting cervical cancer screening of immigrants, including Somalis, in Finland were examined. Although the rate of participation in cervical cancer screening is at the lowest level in Somali women, the most important factor affecting participation in screening is expressed as having had a gynecological examination within the last 1 year. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] Adding a screening method to the gynecological examination in Somalia will enable early diagnosis of cervical cancer. Considering cultural characteristics will increase compliance with screening. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e Positive results have been achieved by raising the awareness of practitioners in Norway to increase participation in cervical cancer screening program among immigrants.[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] It has been stated that the awareness of immigrants in Norway about cervical cancer screening can also be increased with community-based education activities.[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] Considering the low number of obstetricians in Somalia, the role of physicians and midwives working in primary care will be high in screening.\u003c/p\u003e \u003cp\u003eThe common result of studies examining Somali immigrants is the lack of information about cancer screening and HPV vaccination, and large-scale organizations are needed to combat the frequency of cervical cancer.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACOG: American College of Obstetricians and Gynecologists; AGUS: Atypical glandular cells of undetermined significance; ASC-H: Atypical squamous cells cannot exclude HSIL; ASMR: Age-standardized mortality rate; ASC-US: Atypical squamous cells of uncertain significance; CD4: Cluster of differentiation 4; CIN: Cervical intraepithelial lesion; DALYs: Disability-adjusted life-years; HPV: Human Papilloma Virus; HSIL: High-grade squamous intraepithelial lesion; LSIL: Low-grade squamous intraepithelial lesion; MRTE-TREH: Mogadishu Turkey Recep Tayyip Erdogan Training and Research Hospital; NAAT: Nucleic acid amplification NILM: Negative for intraepithelial lesion or malignancy; USPSTF: United States Preventive Services Task Force on cervical cancer screening; WHO: World Healt Organisation; VIA: Visual inspection with acetic; VILI: Visual inspection with Lugol\u0026rsquo;s iodine\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and constent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance and permission was obtained from the Institutional Review Board (IRB) of the Somali Mogadishu T\u0026uuml;rkiye Recep Tayyip Erdoğan Training and Research Hospital, approval number 432 dated 04/10/2021. Informed consent was obtained from all the participants. All methods were performed in accordance with the relevant guidelines and regulations. The Declaration of Helsinki has been adhered to.\u0026nbsp;Written and signed informed consent was obtained from all participants and/or their legal surrogates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds were used for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSK and AIH designed the study, KY collected data. SK, AIH and KY critically reviewed the results and contributed in finalizing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eSomali Mogadişu T\u0026uuml;rkiye Recep Tayyip Erdoğan Training and Research Hospital: Mogadishu, Banadır, Somalia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e Corresponding author\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F: \u003cb\u003eGlobal Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries\u003c/b\u003e. 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Int J Equity Health 2015, \u003cb\u003e14\u003c/b\u003e:68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdehen EE, Korhonen T, Castaneda A, Juntunen T, Kangasniemi M, Pietila AM, Koponen P: \u003cb\u003eFactors associated with cervical cancer screening participation among immigrants of Russian, Somali and Kurdish origin: a population-based study in Finland\u003c/b\u003e. BMC Womens Health 2017, \u003cb\u003e17\u003c/b\u003e(1):19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdehen EE, Koponen P, Harkanen T, Kangasniemi M, Pietila AM, Korhonen T: \u003cb\u003eDisparities in cervical screening participation: a comparison of Russian, Somali and Kurdish immigrants with the general Finnish population\u003c/b\u003e. Int J Equity Health 2018, \u003cb\u003e17\u003c/b\u003e(1):56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoen KA, Kumar B, Igland J, Diaz E: \u003cb\u003eEffect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial\u003c/b\u003e. JAMA Netw Open 2020, \u003cb\u003e3\u003c/b\u003e(4):e201903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi SA, Igland J, Moen K, Gele A, Kumar B, Diaz E: \u003cb\u003eEffect of a community-based intervention to increase participation in cervical cancer screening among Pakistani and Somali women in Norway\u003c/b\u003e. BMC Public Health 2021, \u003cb\u003e21\u003c/b\u003e(1):1271.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer, Human Papilloma Virus (HPV), Somalia, Sub-Saharan Africa, Women’s health","lastPublishedDoi":"10.21203/rs.3.rs-1721788/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1721788/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eCervical cancer is the fourth most common cancer worldwide and is the most frequently diagnosed cancer in 23 countries and the most common cause of death in 36 countries, mostly from Sub-Saharan African countries. Vaccination availability is increasing day by day, with more than 65% of girls vaccinated in 2019 were living in low- and middle-income countries. Cervical screening is a key element to reduce the incidence and mortality of cervical cancer. Cancer screening is low in Sub-Saharan Africa.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe pathology results of cervicovaginal smear samples obtained from patients aged 25-65 years who applied to the gynecology outpatient clinic between October 5 and December 5, 2021 were analyzed retrospectively. SPSS 22.0 was used for statistical analysis of the data.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 497 results, 63 premalignant lesions were detected. The rate of premalignant lesions (63/497) was found to be 12,3%. Most common premalign lesion was ASC-US.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn this study, the frequency of cervical premalignant lesions in Somalia was found to be higher than in the literature. Vaccination, screening and early diagnosis are the most important components in the fight against cervical cancer. Access to vaccination, screening and early diagnosis, which are the most important components in the fight against cervical cancer for Somalia, will be possible with the cooperation of the national health system and international organizations.\u003c/p\u003e","manuscriptTitle":"Frequency of cervical premalignant lesions in the gynecologic patients of tertiary hospital in Mogadishu, Somalia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-09 16:38:09","doi":"10.21203/rs.3.rs-1721788/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-10-13T19:06:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-10-02T06:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34515c70-e1ab-4f20-b2dc-a28443508a7e","date":"2022-09-17T03:53:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1a048eb7-91f2-4fe5-89e1-7d9e815d96cc","date":"2022-07-28T07:02:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-14T08:49:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4fab69a0-968d-40e4-87a5-4001894eb4df_SNPRID","date":"2022-07-14T06:55:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-08T05:38:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-08T05:34:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-08T12:41:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-08T12:37:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2022-06-03T07:42:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec7b8968-bb75-47f8-b087-1e0b0561a6c1","owner":[],"postedDate":"June 9th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-12-01T12:32:58+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-09 16:38:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1721788","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1721788","identity":"rs-1721788","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}