Atypical cervical transformations (ACTs), defined in this study as visual positivity on Visual Inspection with Acetic Acid VIA) and/or Lugol’s iodine (VILI), represent early detectable changes that may progress to cervical cancer if untreated. Cervical cancer is a major health problem worldwide, with about 570,000 new cases and 311,000 deaths in 2018. Of infectious origin, it represents the fourth most common cancer and the fourth leading cause of cancer death in women
[1]
. In Africa, however, this cancer remains the leading cause of death from female cancer. Its incidence remains high, with an increasing mortality rate
[2]
. Primary prevention, including vaccination against Human Papilloma Virus (HPV), and secondary prevention screening, are essential levers to significantly reduce the incidence and mortality related to this disease. While HPV Vaccination has been introduced in Gabon, national coverage remains low due logistical, sociocultural, and awareness barriers
[3]
. In this context, low-cost screening methods such as VIA and VILI remain crucial. Cervical screening is recognized as a major intervention in public health, effective in reducing both prevalence and mortality
[4]
. This study aimed to evaluate the outcomes of the October 2022 cervical screening campaign in Port-Gentil, characterize the detected atypical transformations and identify associated risk factors.
2. Patients and Methods2.1. Framework and Study Period
The analytical cross-sectional study was carried out from October 1 to 31, 2022, during the annual “October Rose” campaign in four screening centers in the municipality of Port-Gentil, the economic capital of Gabon, namely the Port-Gentil Regional Hospital, the Bendje Departmental Hospital, the PMI (Maternal and Child Protection) of the Social Center, and the Ndougou dispensary.
2.2. Population and Sampling
Of the 1 022 women screened, 646 were included in the final analysis; 373 were excluded due to incomplete records. Inclusion criteria were women aged ≥ 16 years who consented to VIA/VILI screening. Exclusion criteria included pregnancy, postpartum period, menstruation at the time of screening, and refusal of examination.
2.3. Variables and Data Collection
A standardized questionnaire collected sociodemographic data (age, occupation, and level of education). Socioeconomic status was classified based on a composite index combining education level, occupation, and self-reported household income, adapted from Demographic and Health Survey methodology. Levels were defined as Low, Medium, or High. Reproductive data (parity, gravidity) and history of sexually transmitted infection (STI) were also reported. Informed verbal consent was obtained before each test, in accordance with the ethical approval of the local committee.
2.4. Statistical Analysis
Collected data entered Epi info 7.2. Qualitative variables were expressed as percentages, quantitative variables as means +/− standard deviations (SD). Variable initially entered into the multivariate logistic regression included: age group, socioeconomic level, occupation, education, parity, age at first sexual intercourse, number of sexual partners, and history of sexually transmitted infections. Stepwise, backward elimination was applied. Significance was set at p < 0.05.
3. Results
A total of 646 women aged 16 to 89 participated in the study. The mean age was 40.2 years (±12.8). The most represented age group was 30 - 44 years, with 280 women (43.3%). Most women (96.5%) came from Port-Gentil, while 23 (3.5%) came from the village of Ndougou. Socioeconomically, nearly half (49.4%) were categorized into a low-status group. Most women were employed (385 cases; 59.6%). The highest level of education for the majority of participants was secondary school (n = 406; 62.8%). In contrast, 120 (18.6%) had pursued higher education, and only a minority (n = 26; 4.0%) had not received any formal instruction (
Table 1
).
<xref ref-type="bibr" rid="scirp.145454-"></xref>Table 1. Sociodemographic characteristics of the participants (n = 646).
Variable
Staff (n)
%
Age
Average age
40.2 (±12.8)
16 - 29
137
21.2
30 - 44
280
43.3
45 - 59
176
27.2
60 et +
53
8.2
Origin
Port-Gentil
623
96.5
Ndougou village
23
3.5
Social level
Low
319
49.4
Average
290
44.9
High
37
5.7
Occupation
Employees/Workers
385
59.6
Student
73
11.3
Retired
159
24.6
Unemployed person
29
4.5
Level of education
Primary
94
14.6
Secondary
406
62.8
Superior
120
18.6
None
26
4.0
Participants’ mean gravidity was 4.0 ± 3.1 and the number of pregnancies ranged from 0 to 15. Grand multigravid (≥ 6 pregnancies) represented 27.9% (180 women), while multigravid (4 - 5 pregnancies) were 152 (23.5%). The average parity was 2.6 children (±2.3), ranging from 0 to 11 children. The pauciparous (2 - 3 children) represented 186 women (28.8%), and the nulliparous constituted 159 women (24.6%). In terms of sexual behavior, the participants reported having had an average of 3.8 (±1.7) sexual partners ranging from 0 to 12. The average age of first sexual intercourse was 17.6 years, with extremes of 9 and 35 years. An early onset of sexual intercourse (before age 17) was found in 249 women, representing 38.5% of the sample (
Table 2
).
<xref ref-type="bibr" rid="scirp.145454-"></xref>Table 2. Distribution of patients according to reproductive profile.
Variable
Staff (n)
%
Management
Average (ET)
4.0 (±3.1)
Nulligravidity (0)
97
15.0
Primigravidity (1)
75
11.6
Paucigravidity (2 - 3)
142
22.0
Multigravidity (4 - 5)
152
23.5
Large multigravidity (≥6)
180
27.9
Parity
Average (ET)
2.6 (±2.3)
Nulliparous
159
24.6
Primiparous
95
14.7
Pauciparous (2 - 3)
186
28.8
Multiparous (4 - 5)
134
20.7
Large multiparity (36)
72
11.2
Age at 1st sexual intercourse
Average (ET)
17.6 (±2.9)
<17 ans
249
38.5
17 ans
397
61.5
Of the women included in the study, 123 (19.0%) had a history of Chlamydia infection. Four women (0.6%) were HIV-positive, while three women (0.5%) reported having a gonococcal infection. A history of vaginal candidiasis was rare, with only one woman concerned (0.2%). Finally, one woman (0.2%) had a history of syphilis (
Table 3
).
<xref ref-type="bibr" rid="scirp.145454-"></xref>Table 3. Distribution of women by STI history.
IST
Staff (n)
%
Short
514
79.6
Chlamydia
123
19.0
HIV-positive person
4
0.6
Gonorrhea
3
0.5
Chlamydia et Syphilis
1
0.2
Vaginal candidiasis
1
0.2
The unprepared visual examination revealed metrorrhagia in 5 women (0.8%) and an inflammatory aspect of the cervix in 13 women (2.0%). The results of the visual acetic acid inspection tests (IVA) were positive in 3 women (0.5%), while those of the Lugol application test (IVL) were positive in 8 women (1.2%). Thus, the overall prevalence of atypical cervical transformations detected by combined IVA and IVL was 1.7%, or 11 cases out of 646 women examined (95% CI: 1.0% - 3.0%).
Multivariate analysis has identified several factors significantly associated with atypical transformations of the cervix. A low socioeconomic level increased the risk of atypical lesions with an adjusted Odds Ratio (ORa) of 3.5 (95% CI: 1.2 - 10.1; p = 0.02). Similarly, a history of Chlamydia infection multiplied the risk by 3 (ORa = 2.9; 95% CI: 1.1 - 7.6; p = 0.03). Finally, women who had five or more sexual partners were four times more likely to have atypical cervical lesions (ORa = 4.2; 95% CI: 1.3 - 13.5; p = 0.02) (
Table 4
).
This study aimed to evaluate the atypical transformations of the cervix in Port-Gentil as part of the “October Rose” 2022 campaign. The observed prevalence of atypical transformations (positive IVA and IVL) was 1.7% (11 cases out of 646), indicating a low prevalence in this region. This result is significantly lower than those observed in Libreville by Ambounda et al.
[5]
, where 5.9% of women were positive for IVA and 12.6% for IVL. This discrepancy may be due to regional differences in sociodemographic profiles, screening access, and health-seeking behaviors:
1) Sociodemographic differences: For instance, Libreville has a more diverse population, which likely includes a wider range of risk profiles compared to Port-Gentil.
2) Screening access: distinct recruitment approaches also played a role. Port Gentil’s data come from a one-off campaign, whereas Libreville implemented more targeted and organized screening across several areas, potentially reaching different segments of the population.
3) A use of private structures for screening, sometimes with smear or colposcopy, in the best-equipped areas, which could underestimate the public figures of Port-Gentil. Health seeking behaviors: The reliance on private healthcare facilities in Port-Gentil’s best equipped areas, where methods like smears or colposcopy are common, represents a potential limitation of the current data is an area that warrants further investigation.
Kabibou et al.
[6]
in Benin observed a higher prevalence than in Port-Gentil (6.2%), reflecting increased exposure to risk factors in this country, with an average age of 32.6 ± 9.0 years and a preponderance among the 22 - 34-year-olds. In Mali, Keita et al.
[7]
reported an average age of participants like ours (38.4 ± 11.9 compared to 40.2 years in our study) but with a higher proportion of lesions screened, or 5.8% of women tested positive to visual tests for suspected precancerous lesions. The 31-and 45-year-olds were the most representative.
Low socioeconomic status emerged as a strong risk factor (ORa: 3.5), aligning with literature linking limited resources to delayed diagnosis and lower screening uptake. Keita et al. <xref ref-type="bibr" rid="scirp.145454-7">
[7]
</xref> in Mali and Diarra et al. <xref ref-type="bibr" rid="scirp.145454-8">
[8]
</xref> also underlined strong association between socioeconomic disadvantage and cervical precancerous lesions. History of Chlamydia trachomatis infection was significantly associated with atypical cervical transformations (ORa: 3.5 and ORa: 2.9, respectively). Mpiga E et al. <xref ref-type="bibr" rid="scirp.145454-9">
[9]
</xref> found 35% of women who reported a history of Chlamydia trachomatis infection, an even higher rate than ours: 19% (123 women out of 646).The multiplicity of sexual partners (≥5) was also associated with an increased risk (ORa = 4.2), which is biologically consistent with the mode of transmission of the human papilloma virus (HPV), the main etiological agent of cervical cancer as shown by the study by Liu et al. <xref ref-type="bibr" rid="scirp.145454-10">
[10]
</xref>, and which agrees with the data of Zhang et al. <xref ref-type="bibr" rid="scirp.145454-11">
[11]
</xref> about the increased risk of cervical damage with multiple active sex life. The participants in our study said they had an average of 3.8 ± 1.7 sexual partners, to be compared to Belglaiaa et al. <xref ref-type="bibr" rid="scirp.145454-12">
[12]
</xref>, who mention an average of 3 partners.
Early age at the beginning of sexual activity characterized 38.5% of the participants in our study reported having first intercourse before the age of 17. This result is like that found by Tebeu et al.
[13]
in Cameroon (average age of 17.9 years) and slightly higher than that reported by Milogo et al.
[14]
in Burkina Faso (16.7 years). In Côte d'Ivoire, Boni et al.
[15]
observed a much higher proportion of early reports (77.2%). However, our multivariate analysis did not show a significant link between early age of sexuality and the occurrence of atypical transformations (p = 0.16). It is likely that the low overall prevalence and sample size limit the detection power of this association. On the biological level, early-started sexual activity exposes a still immature cervical mucosa to persistent HPV infection, which remains a possible mechanism of carcinogenesis, as shown by Louie et al.
[16]
in his series. Early sexual debut and multiple sexual partners increase HPV exposures, while Chlamydia infection may contribute to cervical carcinogenesis via chronic inflammation, disruption of epithelial barriers, and facilitation of HPV persistence
[17]
[18]
. Studies from Tanzania
[19]
and Nigeria
[20]
have confirmed higher odds of cervical neoplasia among women with past Chlamydia infection.
5. Conclusion
Cervical cancer remains one of the main female cancers in Gabon, ranking second after breast cancer in terms of incidence and mortality. However, it is a preventable cancer thanks to the prevention and early detection of cervical lesions. Our study conducted in Port-Gentil, the second city in the country, shows a low prevalence of atypical transformations of the cervix, lower than that reported in Libreville, the capital, but also in the sub-region. The Visual Inspection tests with Acetic Acid (IVA) and Lugol (IVL), used in this campaign, proved to be simple, inexpensive tools adapted for primary screening in a context of limited resources. The identified risk factors, including low socioeconomic level, history of Chlamydia infection, multiplicity of sexual partners, and early initiation of sexual activity, underline the need to strengthen prevention strategies for vulnerable populations.
NOTES
*Corresponding author.
References
Estimated Crude Incidence and Mortality Rates in 2020. World, Females, All Ages (Excl. NMSC). >https://gco.iarc.fr/
Okonofua, F. (2015) Prévention et contrôle du cancer du col en Afrique: Appel à l’action. Revue africaine de santé de la reproduction, 19, 11-13.
Bruni, L., Albero, G., Serrano, B., Mena, M., Gómez, D., Muñoz, J., et al. (2022) Human Papillomavirus and Related Diseases Report: Gabon. ICO/IARC HPV Information Centre.
Peirson, L., Fitzpatrick-Lewis, D., Ciliska, D. and Warren, R. (2013) Screening for Cervical Cancer: A Systematic Review and Meta-Analysis. Systematic Reviews, 2, 1-35. >https://doi.org/10.1186/2046-4053-2-35
Woromogo, S.H., Ambounda Ledaga, N., Yagata-Moussa, F.E. and Mihindou, A.S. (2021) Uterine Cervical Neoplasms Mass Screening at the University Hospital Centre of Libreville, Gabon: Associated Factors with Precancerous and Cancerous Lesions. PLOS ONE, 16, e0255289. >https://doi.org/10.1371/journal.pone.0255289
Kabibou, S., et al. (2015) Facteurs associés aux lésions précancéreuses et cancéreuses du col de l’utérus dans la ville de Parakou au Bénin.
Keita, M., et al. (2020) Dépistage des Lésions Précancéreuses et Cancéreuses par les Tests Visuels à la Commune VI du District de Bamako. Health Sciences and Disease, 21, No. 7. >https://www.hsd-fmsb.org/index.php/hsd/article/view/2143
Diarra, S. (2015) Bilan des activités de dépistage des lésions précancéreuses et cancéreuses du col de l’utérus par les méthodes d’inspection visuelle (IVA/IVL) au CSREF CII du District de Bamako. >https://www.bibliosante.ml/handle/123456789/855
Mpiga, E., Ivanga, M., Koumakpayi, H., Engohan-Aloghe, C., Ankély, J.C., Belembaogo, E., et al. (2015) Intérêt de l’inspection visuelle à l’acide acétique et au soluté de Lugol avec colposcope dans le dépistage des lésions du col utérin au Gabon. Pan African Medical Journal, 22, Article No. 165. >https://doi.org/10.11604/pamj.2015.22.165.7038
Liu, Z.C., Liu, W.D., Liu, Y.H., et al. (2015) Multiple Sexual Partners as a Potential Independent Risk Factor for Cervical Cancer: A Meta-Analysis of Epidemiological Studies. Asian Pacific Journal of Cancer Prevention, 16, 3893-3900. >https://doi.org/10.7314/apjcp.2015.16.9.3893
Zhang, Z., Dong, L., Zhang, L. and Zhang, W. (2020) Risk Factors for Human Papillomavirus Infection and Cervical Intraepithelial Neoplasia: A Systematic Review. Oncology Letters, 20, 1421-1429.
Belglaiaa, E. and Mougin, C. (2019) Le cancer du col de l’utérus: État des lieux et prévention au Maroc. Bulletin du Cancer, 106, 1008-1022. >https://doi.org/10.1016/j.bulcan.2019.08.020
Tebeu, P.M., Sandjong, I., Nkele, N., Fokoua, S., Achu, P., Kouam, L., et al. (2005) Lésions précancéreuses du col utérin en zone rurale: Étude transversale. >https://www.gfmer.ch/Presentations_Fr/Pdf/52016.pdf
Millogo Traore, F.D., Ouattara, A., Hounsounou, I.V. and Nebie, P.S. (2017) Prise en charge des lésions précancéreuses du col utérin par la résection à l’anse diathermique au Centre Hospitalier Universitaire Yalgado Ouédraogo: Bilan de huit mois d’activité. Journal de la SAGO, 18, 27-33.
Boni, S., N’guessan, K., Kouakou, F., Loué, V., Angoi, V. and Abauleth, Y. (2009) Cervical Cancer: Epidemiology and Medical Assistance in African Society. Mali Medical, 24, 27-30. >http://www.malimedical.org/2009/27c.pdf
Louie, K.S., de Sanjose, S., Diaz, M., Castellsagué, X., Herrero, R., Meijer, C.J., et al. (2009) Early Age at First Sexual Intercourse and Early Pregnancy Are Risk Factors for Cervical Cancer in Developing Countries. British Journal of Cancer, 100, 1191-1197. >https://doi.org/10.1038/sj.bjc.6604974
Ogembo, R.K., Gona, P.N., Seymour, A.J., Park, H.S., Bain, P.A., Maranda, L., et al. (2015) Prevalence of Human Papillomavirus Genotypes among African Women with Normal Cervical Cytology and Neoplasia: A Systematic Review and Meta-Analysis. PLOS ONE, 10, e0122488. >https://doi.org/10.1371/journal.pone.0122488
World Health Organization (2020) Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem. World Health Organization.
Adegbesan-Omilabu, M., Okunade, K., Oluwole, A., Gbadegesin, A. and Omilabu, S. (2014) Chlamydia Trachomatis among Women with Normal and Abnormal Cervical Smears in Lagos, Nigeria. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 3, 501-506. >https://doi.org/10.5455/2320-1770.ijrcog20140905
Kafuruki, L., Rambau, P.F., Massinde, A. and Masalu, N. (2013) Prevalence and Predictors of Cervical Intraepithelial Neoplasia among HIV Infected Women at Bugando Medical Centre, Mwanza-Tanzania. Infectious Agents and Cancer, 8, Article No. 45. >https://doi.org/10.1186/1750-9378-8-45