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• Reflecting on 2009

  

  Population screening programmes continue to challenge and reward those charged with delivering services. We operate in an environment of constant change but continue to make progress towards improving the health and wellbeing of all New Zealanders. Reflecting on 2009 it is encouraging to observe significant progress in a number of key areas for the National Screening Unit (NSU). The National Cervical Screening Programme (NCSP) successfully introduced Human papillomavirus testing (HPV testing) into the NCSP on 1 October 2009, enabling full implementation of the new Guidelines for Cervical Screening (2008). For the NCSP, this follows a long period of guideline development, securing funding, education and training of clinicians, standards development, contract variations and stakeholder communication. New NCSP standards for laboratories, including standards for HPV testing and automated imaging systems, were released in September and the new resource – “Prevention of Cervical Cancer – a Guide for Women in New Zealand was published in October.

  The development of professional guidelines for the Newborn Metabolic Screening Programme and the Quality Improvements to Antenatal Screening for Down syndrome and other conditions were significant projects for the Antenatal Newborn programmes. Five on-line education modules completes another considerable project for the Unit. The education modules for practitioners providing services within antenatal and newborn screening have been developed and will be available by December 14 at www.learnonline.health.nz.

  I’d like to acknowledge the contribution of Dr Madeleine Wall to BreastScreen Aotearoa following her recent departure as Clinical Leader. Her experience in screening and her passionate advocacy for women with breast cancer will be missed. I also want to recognise the work and achievements of all those who deliver screening programmes and look forward to the coming year. On behalf of the National Screening Unit I wish you a safe and happy holiday season.

  Jacqui Akuhata-Brown, Group Manager, National Screening Unit

• Change 2009 - Meeting the challenge: better, sooner, more convenient health services

  Message from Stephen McKernan, Director-General of Health

  Cabinet decisions in October marked the start of a significant programme of work for the Ministry and the sector. Establishing the National Health Board Business Unit is one of five workstreams resulting from Cabinet’s decisions on the Ministerial Review Group recommendations. The new National Health Board, working within the Ministry of Health, will consolidate national planning and funding of all IT, workforce planning and capital investment. The National Screening Unit, as part of the Health and Disability National Services Directorate, now sits under the National Health Board.

  On December 2 Health Minister Tony Ryall announced the members of the new National Health Board. Seven of the ten appointments are doctors or nurses. Dr Murray Horn, who was appointed establishment Chair in October, has been confirmed as Chair. Dr Virginia Hope, a public health physician and Programme Leader for the Institute of Environmental Science and Research (ESR) at the National Centre for Biosecurity and Infectious Disease, has been appointed Deputy Chair.

  Other workstreams involve examining Shared Services arrangements and providing advice on the MRG recommendations awaiting more detail or further consideration. Cabinet is also expected to make decisions on more MRG recommendations before Christmas and advice is being prepared on these now.

  There will also be analysis and organisational design work for revising the Ministry’s structure. That should be completed early next year so any changes can be implemented by June 2010.

  As the different workstreams gather momentum, the Ministry is keen to ensure the sector is given details as they come to hand – this information is part of keeping everyone up to date.

• Resignation of Dr Madeleine Wall, Clinical Leader, BreastScreen Aotearoa

  

  Dr Madeleine Wall has resigned from her position as Clinical Leader for BreastScreen Aotearoa.

  Dr Wall has been involved with BreastScreen Aotearoa since the inception of the programme in 1999, having served on the Breast Cancer Screening Policy Advisory Group which gave advice to the Minister of Health on the establishment of the programme. She helped draft the initial quality standards (radiology sections) and helped set up the Wellington regional breast screening programme where she was Clinical Director from 1999, until starting with the Ministry in 2002.

  In 2002, Dr Wall was appointed as Clinical Leader for BreastScreen Aotearoa.  In the seven years since, Dr Wall has overseen many significant clinical, technological and logistical challenges for the programme. Dr Wall's leadership, expertise and tireless dedication for breast screening in New Zealand and more specifically for BreastScreen Aotearoa ensured the women of New Zealand continued to have a world class screening programme. By international standards, BreastScreen Aotearoa has excellent clinical results, with high cancer detection rates and good pick-up of small, lymph node negative cancers, which, apart from the numbers of eligible women screened, are the most important elements to ensuring breast cancer deaths are reduced.

  Madeleine is going to take time out to look after her mokopuna and will continue with her clinical work with Hutt Valley DHB.

• Screening Matters Goes Online

  

  From this month Screening Matters will be an online, bi-monthly publication. The increased frequency will provide a more responsive publication and help ensure the screening sector is fully informed of all developments and issues.

  An e-newsletter will be emailed to subscribers containing a link to the full edition on the NSU website. If you wish to subscribe to the newsletter please email screeningmatters@atlantishealthcare.com or phone 0800 872 285. You can also subscribe online at www.nsu.govt.nz/news/3291   
  

• Cervical Screening Clinical Update

  The purpose of this update is to highlight some aspects of good practice for smear takers, provide an update on recent changes to cervical screening in New Zealand, and inform health practitioners of new information resources now available for women.

  False Negative Smears
  Cervical screening, like all screening, is not 100% effective and some women will still develop cervical cancer despite regular screening. While the risk of cervical cancer can be reduced, it cannot be eliminated by screening. All smear takers are required by law to explain the cervical smear procedure and provide information to women about the limitations as well as the benefits of cervical screening. The National Cervical Screening Programme (NCSP) provides educational resources to help health professionals with this.

  It is estimated that, in New Zealand, an average woman’s risk of cervical cancer is 1 in 90 without regular screening but reduces to 1 in 570 with regular screening. The fact that risk is not eliminated implies that some false negative smears are inevitable. Laboratories who perform cervical cytology report a false negative result of up to 20%.

  The educational resources available from the NCSP (as well as information provided by the laboratories themselves) may assist health professionals to provide this information to women participating in cervical screening.

  The introduction of human papillomavirus (HPV) testing, together with liquid based cytology (LBC), should help to reduce the rate of false negative smears. In the longer term, HPV vaccine will help to further reduce the risk of cervical cancer.

  Clinical Symptoms
  Revised Guidelines for Cervical Screening in New Zealand were published in September 2008. These guidelines set out best practice. Clinicians however must continue to exercise judgment and make decisions in consultation with their patients, that reflect individual clinical circumstances.  In this regard, if a woman is symptomatic or if there is a concern about the clinical appearance of her cervix, she should be referred for a colposcopic assessment irrespective of her cytology results.

  Referrals to Colposcopy
  The NCSP monitors waiting times for women with high grade and low grade lesions who have been referred to DHB colposcopy services. Women with high grade lesions should be seen within 4 weeks. Health practitioners should advise the Programme if they have any concerns about delays in women being seen.

  Recent Changes to Cervical Screening in New Zealand
  From 1 October this year, HPV testing became part of the cervical screening pathway. HPV testing is used to supplement (not replace) cytological testing and is funded for use in three clinical situations:

          for women over 30 years of age who have a low grade cytological result (ASC-US/LSIL). NCSP contracted laboratories will undertake this test automatically
         to guide further patient management following treatment at colposcopy. Smear takers will need to request this test from NCSP laboratories
         to assist colposcopists (who will request this test) where cytology and colposcopy results are not clear or are inconsistent with each other.

  New Patient Education Resources
  The following new resources are available to support health professionals in providing information to women.

  The recently revised NCSP booklet Prevention of cervical cancer: A guide for women in New Zealand (additional copies of this resource can be obtained on-line from http://www.healthed.govt.nz/). A fact sheet for women on HPV and HPV testing. Additional information for women and smear takers can be found at www.cervicalscreening.govt.nz

  All smear takers should have their own copy of the Guidelines for Cervical Screening in New Zealand (published in September 2008). These can be ordered through Wickliffe ph 04 496 32277 or email moh@wickliffe.co.nz

• He ora te whakapiri, he mate te whakatakariri - A New Way Forward

  

  The NCSP and BSA screening programmes rely heavily on health promoters for recruiting women to screening, providing regional co-ordination between services, liaising with GPs and supporting women along the screening pathway from screening to treatment and follow up. Every year for over a decade, 40-50 kaimahi have met to focus on screening workforce development. Most attendees are Maori health promoters, some are nurse smear-takers and some service providers. NSU staff also attend.

  Workforce development activities include a series of screening workshops and presentations. Keynote speakers have included many eminent Maori leaders, and kaimahi from each region present their work over the previous year and share successful initiatives.

  This year, Kaimahi Hui was held at Maraeroa Marae, Porirua in October. Keynote speakers were International Treaty lawyer, Director of Te Hau Tikanga, The Maori Law Commission, Moana Jackson, and the Hon. Tariana Turia.

  The Hon. Tariana Turia acknowledged the work, passion and commitment of health promotors and their importance in reducing the incidence and mortality from breast and cervical cancer.  She also spoke about Whanau Ora as being "the gateway to te Ao Maori for us all."

  In an excerpt from her speech she said.  "We will know whanau ora is achieved, when our kuia and koroua play a full role in the family, and in the life of the marae and community.”. . . “when we bear witness to our matua supporting and nurturing the extended whanau.” . . “when all our tamariki are loved, nurtured, protected and enabled to grow to their full potential.”

  Moana Jackson urged kaimahi Maori to contribute to Maori participation in decision making, politics and media representation around health. 

  Image: Hon. Tariana Turia (second from left) meets kaimahi at the October hui
  

• Cervical Screening Awareness Month

  

  The Cervical Screening Awareness month activities outlined in the last edition of Screening Matters produced outstanding results. A new online media strategy saw 20,591 new visitors to the NSU website and resulted in just over 10,000 entries for the online competition. On average, 1300 more calls were received to the NCSP 0800 number in September than in previous months. A new partnership with Johnson & Johnson has created an exciting platform for future activities. The effect of the campaign on screening numbers will be reported in the next edition of Screening Matters but an increase in the previous month is anticipated.

• Prevention of Cervical Cancer – A Guide for Women in New Zealand – Now Available

  The “Prevention of Cervical Cancer – A Guide for Women in New Zealand” was published in October. The resource for women has been updated to help women understand HPV infection and cervical cancer, preventing cervical cancer and the National Cervical Screening Programme. The resource reflects recent developments in HPV immunisation and HPV testing and can be ordered through www.healthed.govt.nz 
  

• HPV Immunisation Programme has Encouraging First Year

  

  This year saw the roll out of the new HPV immunisation programme in primary care and schools across New Zealand.

  HPV immunisation is being offered to girls and young women born on or after 1 January 1990 to help prevent them from developing cervical cancer later in life. This year, over 86,000 girls and young women have had the HPV immunisation.

  Ministry of Health HPV immunisation programme spokesperson Barbara Phillips says uptake in the first year of the programme has been extremely encouraging.

  “Over half the girls and young women offered the immunisation have chosen to have it, which is a great result. HPV immunisation and cervical screening will work together to greatly reduce the risk of New Zealand women developing cervical cancer.

  “As more than 99 percent of cervical cancer is linked to HPV infection, and this vaccine protects against 70 percent of them, this is a huge step forward for cancer control.

  “Women who have been immunised will also have a greatly reduced chance of having an abnormal smear. Over 25,000 cervical smears appear to be abnormal each year in New Zealand and many require follow-up examinations and treatment. The HPV vaccination programme will remove the need for much of this treatment.”

  Barbara Phillips says the uptake of the vaccine amongst Maori and Pacific teenagers has been particularly pleasing.

  “In schools, there has been 71 percent uptake among Pacific teenagers, and 62 percent uptake among Maori teenagers. This is a very positive result as regular cervical screening is undertaken by fewer Pacific and Maori women than other groups. They therefore have a lot to gain from the vaccine, which will greatly reduce their risk of cervical cancer.

  “In time, the HPV immunisation is expected to help halve the number of women in New Zealand who die from cervical cancer. We are looking forward to offering it to more girls and young women in 2010.” 

  The combination of HPV immunisation (before the onset of sexual activity), regular cervical smear tests (from age 20 to 70), practising safe sex and not smoking provides New Zealand women with the best means of preventing cervical cancer.

• Quality Improvements to Antenatal Screening for Down Syndrome and other Conditions

  For many years women have been offered screening for Down syndrome based on their age. More recently screening by the ultrasound measurement of nuchal translucency has gained popularity. These screening tools, used in isolation, are no longer supported by international evidence. 

  The National Screening Unit is introducing quality improvements to antenatal screening for Down syndrome and other conditions. The quality improvements will enable New Zealand women to access screening options consistent with international practice. The two publicly funded screening options are first trimester combined screening or second trimester maternal serum screening. These new options will be available from February 2010.

  In early December health practitioners will receive a copy of the Guidelines for maternity providers offering antenatal screening for Down syndrome and other conditions and a laminated summary sheet. Online education is also available via http://www.learnonline.co.nz from December 14.

  The guidelines and education modules have been made available before the screening options are implemented, so that practitioners have the opportunity to become familiar with new information before offering this screening to women. 

  Consumer pamphlets to support discussions with women will be available to order from 5 January 2010 however practitioners will need to ensure that women are aware the service does not go live and new options will not be available until 8 February 2010. The consumer pamphlets will be available to order through www.healthed.govt.nz For additional copies of the professional guidelines or for further information please contact Nicola Deveraux: nicola_deveraux@moh.govt.nz or 09 580 9423.

• Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP)

  Rollout of the Universal Newborn Hearing Screening Programme continues with eleven DHBs now offering newborn hearing screening. In November the UNHSEIP coordinators met in Auckland to share their experiences of setting up a new screening programme. The two days were used to establish collaborative relationships between the DHBs, share strategies for ongoing training and support of the new UNHSEIP workforce, and plan ongoing quality improvement of the programme. The meeting also provided support to those coordinators in the process of implementation.

  Newborn hearing screening is now offered by Waikato, Hawke’s Bay, Tairawhiti, Lakes, Bay of Plenty, Taranaki, Capital and Coast, Hutt Valley, South Canterbury and Canterbury and Whanganui DHBs.

  Screening in Northland, Waitemata, Auckland, Counties Manukau, MidCentral, Wairarapa, Nelson Marlborough, West Coast, Otago and Southland will be implemented by June 2010.

  Image: UNHSEIP coordinators gather in Auckland, November 2009
  

• New On-line Education Modules for Antenatal and Newborn Screening

  The National Screening Unit has developed 5 on-line education modules for practitioners providing services within antenatal and newborn screening. The modules have been developed for Midwives, GPs, newborn hearing screeners and other health professionals involved with the programmes. The Unit has also developed powerpoint based 'train-the-trainer' resources for each module, containing the same information but designed to train educators to deliver the education in a face-to-face format. The new resources have been developed with Otago Polytechnic.

  There are five education modules. Two modules (Screening Principles and QIASD) are available for completion from December 14, with AHIV and UNHSEIP from December 21. NMSP will be available following the publication of programme guidelines in early 2010.

  The 5 modules are:
  1.  Screening Principles and Practice
  2. Quality Improvement Measures in Screening for Down syndrome and other conditions
  3.  Universal Offer Antenatal HIV Screening Programme
  4.  Universal Newborn Hearing and Early Intervention Screening Programme
  5.  Newborn Metabolic Screening Programme

  The modules are designed to be completed on-line but can be down-loaded in pdf format and completed off-line.  If completed off-line the accompanying self marking tests must be completed on-line so that the practitioner can receive a certificate and gain the professional points allocated.

  Please note:  The QIASD module includes the information you will need to offer the new screening options to women.  These screening options however will not be available until 8 February 2010.

  The Midwifery Council has endorsed the modules with 5 elective education points for each module.

  The Royal New Zealand College of GPs have also endorsed the programme with up to 2 hours (per module) CME for General Practice Educational Programme Stage 2 (formerly AVE) and Maintenance of Professional Standards (MOPS) purposes.

  The face-to-face education process is yet to be finalised.

• Working Together to Achieve Screening Targets for Pacific Women

  The 2009 National Pacific Screening Workers Conference, held 15 – 16 October 2009 in Rotorua, focused on sharing and building best practice for achieving screening targets for Pacific women. This theme of collaboration was strongly reflected in all aspects of the conference – through the range of organisations represented, the suite of topics addressed and the different cultural perspectives (Pacific and non-Pacific) presented.  (Collaboration was also evident in the cultural items presented in the evening session!).

  The conference provided a wonderful opportunity for the 36 participants from breast screening lead providers, regional screening services, independent service providers, PHOs, and general practices all around New Zealand to share practice and knowledge on health promotion and screening practices that work for Pacific women. The presence of a wide range of organisations with an interest in screening meant that issues could be discussed in the context of the whole screening pathway. The conference included sessions around specific screening interest areas – health promotion, nursing services, management and administration and the Data Advisory Group. There were also sessions on practical scenarios faced by those providing screening services. All these sessions enabled participants to discuss practices in specific areas, and identify and share different strategies for working with Pacific women.

  Image: Pacific screening workers share best practice at national conference, October 2009