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• National Screening Unit Clinical Governance Group Established

  

  The National Screening Unit’s (NSU’s) Clinical Governance Group provides clinical, public health and strategic advice to support the delivery of high-quality national screening programmes in New Zealand.

  Chair Dr Julia Peters says quality assurance and monitoring are absolutely fundamental to having effective screening programmes, and the Group’s role is to help ensure these processes are in place.

  “Screening programmes have the potential to save many lives. But if we are going to have them, we have an ethical obligation to ensure they are as safe and effective as possible and of the highest quality.”

  She says the group will provide advice on issues that are brought to its attention and will also request reports on a range of issues affecting the NSU’s programmes.

  “Many of the NSU’s programmes have their own advisory groups that provide multidisciplinary advice, including on specific clinical and operational issues. The role of the Clinical Governance Group is to ensure a programme has all the right components operating at a national level.”

  The Group met for the first time recently, and will meet quarterly for 12 months. After that time its terms of reference will be reviewed. Dr Peters says the review will be to ensure the Group is fulfilling its purpose, and if it is, she expects meetings to continue.

  Specifically, the group is charged with providing advice on:

  • screening practice (including its effectiveness, feasibility, value for money, likely harms and benefits, and impact on the health care system)
  • social and ethical considerations in screening, including cultural considerations, and reducing inequalities both in access to screening and in outcomes of screening
  • the systems needed in order to monitor the quality, including safety and effectiveness, of screening in New Zealand
  • ways screening practice in New Zealand can maximise benefits and minimise harm
  • the level of resources needed for high-quality screening.

  A focus for the Group in the next 12 months will be supporting the NSU to ensure programmes have quality assurance and monitoring processes, and to provide endorsement of those processes already in place.

  “Because the National Cervical Screening Programme and BreastScreen Aotearoa are well-established programmes, they already have well-developed quality assurance processes. With these programmes it is a matter of refinement, and keeping on top of new technology and other developments.

  “However, some of the antenatal and newborn programmes are at an earlier stage, and there may be a greater need for the Group to have input into their monitoring, evaluation and quality standards.”

  She says the Group will support the work already done throughout the screening sector.

  “The Ministry of Health, the NSU and the whole screening sector does a fantastic job of providing high-quality programmes to New Zealanders. There are thousands of people working together every day to identify conditions or early changes, so action can be taken as soon as possible.

  “Collectively, they have a positive impact on the lives of many people.”

  Members of the Clinical Governance Group are:

  • Dr Julia Peters (Chair), Chief Advisor Screening, NSU
  • Jacqui Akuhata-Brown, Group Manager, NSU
  • Dr Hazel Lewis, Clinical Advisor, Cancer Screening, NSU
  • Clinical Leader, BreastScreen Aotearoa, NSU (to be appointed)
  • Dr John Childs, National Clinical Director, Cancer Programme, Ministry of Health
  • Dr Pat Tuohy, Chief Advisor Child and Youth Health, Ministry of Health
  • Dr Joanne Dixon, Geneticist and Advisor to the Neonatal Screening Programme
  • Norma Campbell, Midwifery Advisor, NZ College of Midwives.

• Newborn hearing screening rolled out to all DHBs

  

  The national newborn hearing screening programme is now in place in all 20 District Health Boards, and it is expected that around ten babies a month born with a significant hearing loss will be identified.

  Identifying babies with significant hearing loss early is very important as steps can be put in place to help babies learn language as part of their usual early development. This is much harder to do later. It is known that the earlier hearing loss is diagnosed and work with the child begins, the better the long-term outcomes for children and their families.

  The programme expects to identify up to 120 babies per year with moderate or more severe permanent hearing loss, all of whom are expected to be screened in their first month. Eleven DHBs have been screening for a full year and have found at least 32 babies with hearing loss who will now be helped with language learning and development. That number will grow as the screening is now country wide.

  In the past, many children were not diagnosed with hearing loss until around four years of age.
  

• Cervical Screening Awareness Month September 2010

  

  Planning is well underway to again promote September 2010 as ‘Cervical Screening Awareness Month’. The aim of the month is to encourage conversations among women about the benefits of regular cervical screening and to get them to support other women to go for a smear test.

  The focus on September as a dedicated awareness month enables providers to organise local promotional activities, which are supported by national advertising, promotions and additional resources.

  Partnerships
  The Cancer Society and Family Planning will both be lending their support to the month, with promotion through their network of branches and with product support.

  We are pleased to again partner with Johnson & Johnson (Stayfree) and Progressive Enterprises. The partnership will involve:

  • stickers on 250,000 packs of Stayfree sanitary pads carrying cervical screening messages in store during September
  • additional retail advertising profile for the National Cervical Screening Programme (NCSP) through Progressive Enterprises stores (Countdown, Woolworths and Foodtown) and catalogues to over 1 million households
  • an online competition to go in the draw to win 1 of 1000 Neutrogena lip glosses worth $24.95 – go to http://www.cervicalscreening.govt.nz/ to enter
  • 55,000 Stayfree sanitary pads for distribution through primary care and contracted providers
  • reciprocal mentions in advertising i.e. Johnson & Johnson mentions NCSP in all of its advertising; NCSP does the same for Stayfree during September.

  The Stayfree products and Neutrogena prizes have been generously donated by Johnson & Johnson.

  Promotional items
  As with last year, clinics and smear-taking practices throughout New Zealand will be provided with additional promotional resources for the month, which will include:

  • awareness month posters for display during September
  • miniature promotional stands for display on reception counters
  • free 30ml hand and body lotion samples from the Cancer Society’s elements range of skincare products for distribution to women who have their smear test during September (and while stocks last)
  • free samples of Stayfree sanitary pads for distribution to women. 

  Last year’s enhanced range of promotions achieved very positive results, including:

  • 20,591 new visitors to the NSU website
  • 11,410 Stayfree competition entries
  • approximately 1000 more calls to the NCSP 0800 number during September (nearly 50 percent higher than prior to the introduction of Cervical Screening Awareness Month)
  • quantitative research showed a positive response to the use of advertising in supermarkets and on women’s sanitary products to encourage women to have smear tests.

  Show your support for CSAM by adding an online ad to your website or blog during September. The ad is promoting Cervical Screening Awareness Month and the opportunity to win 1 of 1,000 Neutrogena lip glosses. Simply click here to view the online ad and to get the code to include on your site. Thanks in advance for your support.
  

• Changes to antenatal screening for Down syndrome screening and other conditions: implications for practices

  

  In February this year, the next stage of the quality improvements in antenatal screening for Down syndrome and other conditions were introduced. Women are now offered the option of first trimester combined screening, or for women unable to access scanning in their first trimester or who present later - second trimester maternal serum screening for Down syndrome and other conditions.

  International evidence shows that as many as one in five women who are screened using nuchal translucency (NT) alone, with a detection rate of 60 to 70 percent, are offered diagnostic testing. By comparison, first trimester combined screening, which includes maternal serums along with NT, as well as information such as maternal age and weight and gestational age, results in a detection rate of 83 percent.

  The intention, with the introduction of the two options, is to improve the consistency and availability of choices and services.

  Changes include:

  • the introduction of first trimester combined screening
  • adding a fourth analyte (Inhibin) to second trimester maternal serum screening
  • the development of guidelines and education for practitioners
  • production of consumer resources to support clinicians’ discussions with women
  • the withdrawal of support for the use of NT or age on their own as screening tools.

  Rachael McEwing (pictured) is Chair of the NSU’s Nuchal Translucency Working Group and also runs a busy radiology practice. She believes the combined screening will simplify and streamline the jobs of radiologists and sonographers/sonologists, and reduce unnecessary anxiety for women.

  “Because the scan results go to the lab, to be combined with the blood test results, those carrying out the scan no longer need to raise borderline results with women, and create what is often unnecessary anxiety.”

  She says if the NT is equal to or above 3.5, which happens in a minority of cases, the woman will be told there may be some concerns, and the radiologist will discuss a referral to a specialist with the Lead Maternity Carer (LMC).

  “But in the vast majority of cases, where everything looks normal, we can be reassuring during the scan, while ensuring the woman understands their LMC will deliver a single risk result.”

  Rachael says, before the introduction of combined screening, there were a few concerns expressed that women would be unhappy having to wait for their results, but these seem to have been unfounded.

  “Overall, LMCs have done a great job in communicating to women about the combined results and how they will be delivered.

  “It’s really important that all pregnant women understand that first trimester combined screening combines the results from a blood test and the NT scan with information like age and weight, to give one risk result, and that this result will be given to them by their LMC.

  “Having their blood tests before their scan will cut down the time women have to wait for results, and this should be encouraged. The blood tests are also more accurate if carried out earlier.

  “And remember that if there is a concern, or borderline results, the scanner or LMC can contact the lab and request an urgent result – so there is no need for a big delay if there is anxiety.”

  Summary of implications of combined screening for practices

  • The scanning process is unchanged.
  • Sonographers/sonologists still need to perform an annual audit and be accredited to perform NT scans.
  • Communication with the woman and her family during the scan is unchanged.
  • A consent form needs to be completed prior to the scan.
  • A risk assessment is no longer generated at the end of the scan.

  If NT is increased:

  • NT ≥ 3.5 mm contact LMC recommending specialist referral, urgent combined result
  • recommend careful anatomy scan including detailed cardiac examination
  • mildly increased NT, contact LMC, expedite combined result.

  Rachael says health professionals wishing to learn more about the screening options for Down syndrome and other conditions can go to www.learnonline.health.nz and work through the online education modules.
  

• NCSP Management of Women with Clinical Symptoms – A Reminder

  

  The NCSP would like to remind practitioners of the management of women with clinical symptoms. The NCSP Guidelines (2008) recommend that if a woman has symptoms or there is a concern about the appearance of the cervix, she should be referred for colposcopic assessment according to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Guidelines.

  Unusual symptoms include:

  • bleeding or spotting between menstrual periods
  • bleeding or spotting after sexual intercourse
  • bleeding or spotting after menstrual periods have stopped (menopause)
  • unusual discharge from the vagina (in particular if this is smelly, has changed colour or is blood stained)
  • persistent pain in their pelvis
  • pain during sexual intercourse.

  Copies of the 2008 NCSP Guidelines and separate flowcharts can be ordered through Wickliffe ph. 04 496 2277 or email moh@wickliffe.co.nz.

  The NCSP would also like to remind practitioners that the NCSP is a national programme and only applies to women residing in New Zealand. Women returning to New Zealand are likely to have had cervical screening while living overseas. The results of cervical smear tests taken overseas are not forwarded to the NCSP Register by overseas programmes. The NCSP recommends to smear takers that all women who have not had a cervical smear every three years in New Zealand should be offered this opportunity.
  

• Mammography Training Programme

  

  In 2008, BreastScreen Central welcomed its first trainee mammographer into its new mammography training programme. BreastScreen Central provides mammography services to women in the Wellington, Hutt Valley, Wairarapa and Kapiti Coast areas.

  Suzanne Searle (pictured on the right), who was a qualified radiographer in the radiation therapy speciality, has now completed her mammography qualification. She finished the scheduled 18-month course in just 12 months.

  This was the first time the New Zealand Medical Radiation Technologists Board (NZMRTB) has approved an already qualified radiographer to switch specialities between the diagnostic and therapy fields of radiography by completing post-graduate upgrade papers.

  Trained Medical Radiation Technologists (MRTs) are a scarce international resource.  BreastScreen Central has developed a high-calibre training programme to ‘grow their own’ mammographers.

  Jackie Rushton (pictured on the left), Lead MRT at BreastScreen Central, is a designated trainer for the qualification and ensures its quality and effectiveness.
   
  The BreastScreen Central initiative will help ensure service delivery is maintained through adequate staffing levels, and creates the opportunity for role extension within radiography in New Zealand.

  BreastScreen Central’s second trainee is now well into the course, and a new training post will be available in early 2011.
  

• New Commercials for NCSP Communications Campaign

  

  Three new television commercials are in development to ensure the NCSP communications campaign remains relevant and continues to support the programme and providers in their recruitment and retention objectives.

  The NCSP communications campaign was launched in 2007 to increase rates of cervical screening, particularly among Maori and Pacific women. It has delivered outstanding results over a sustained period, increasing awareness and discussion, phone calls and programme enrolments. 

  Since the launch there has been a relative increase in cervical screening coverage of 6.9 percent for all women, 14.3 percent for Maori women and 27.4 percent for Pacific women. The increases in coverage can be attributed to the communication campaign, health promotion activities and the efforts of providers to recruit women to the programmes.

  While the current campaign has been very successful, it has now been running for nearly three years. The challenge is to develop new evidence-based creative material to build on and continue the success of the current campaign.

  Qualitative testing with groups of Māori and Pacific women has been undertaken to inform the strategic direction of the new commercials. These results, along with three years worth of quantitative testing results and provider input from the initial campaign, have allowed us to further understand which barriers deter women from screening and how we can continue to engage priority audiences and motivate them into action. The creative approach will follow the same successful, humorous format of the existing campaign.

  The new commercials will be run with the top five performing ads in the current campaign and will launch in Cervical Screening Awareness Month, in September.

  The advertising will continue to encourage women to contact their doctor, nurse or health worker for more information or to call the programme’s 0800 number. The programme website address will also be included in the advertising.
  

• National Leadership and Workforce Development Forum – Register Now

  The NSU’s first National Leadership and Workforce Development Forum will be held at the Waipuna Hotel and Conference Centre in Auckland on 29 to 31 March 2011. The forum is for breast screening and cervical screening contracted providers only and will enable the NSU to bring key recruitment and management staff from the cancer screening workforce together. The forum’s overall objective is to support actions to increase NCSP and BreastScreen Aotearoa coverage rates for priority women. 

  On-line registrations for the forum are now open. Please go to: http://nsu.govt.nz/health-professionals/3585.asp for more information, and to register. Registrations will close on 30 November 2010.

  The NSU is also calling for abstracts on selected topics. If your abstract is selected for presentation at the forum, the NSU will pay the travel and accommodation costs for two staff members from your organisation to attend the forum. This process will close at 4pm on 5 November 2010.

  If you have any questions, please contact Mihikore Andrews on (09) 580 9025 or email mihikore_andrews@moh.govt.nz
  

• Screening for Cystic Fibrosis

  

  In this issue of Screening Matters we continue the series of articles about the disorders screened for by the Newborn Metabolic Screening Programme. Cystic Fibrosis is the third topic. 

  Description

  Cystic Fibrosis (CF) is an autosomal recessively inherited disorder caused by a defect in chloride transport, which causes mucus to become thick. This leads to abnormal secretions in the lungs, pancreas, intestine, liver, sweat glands and male reproductive tract. The abnormally thickened mucus in the pancreas and gut causes pancreatic insufficiency and reduced absorption of food from the gut. The lungs may be damaged by recurrent infections.

  Symptoms include meconium ileus, failure to thrive and chronic respiratory problems with cough and wheeze. Early intervention can lead to a significant improvement in quality of life and longevity.

  Diagnosis also enables parents/guardians and siblings to be aware of their potential carrier status and make informed choices about their families.

  Screening

  Screening for CF is a two-tier process. First, blood is tested for levels of immunoreactive trypsin (IRT). This is a very non-specific measurement of pancreatic damage. Secondly, the 1 percent of blood samples with the highest levels of IRT are tested for the most common CF mutations found in New Zealand. There are more than 700 possible CF mutations.

  Babies in whom one or two mutations are present produce a positive screening result.

  The notification letter to the LMC will report the presence of one or two mutations, and advise that the baby may either have CF or be a carrier and that further testing will determine this.

  LMCs should refer babies who test positive for CF to a paediatrician for full assessment and diagnostic testing as soon as possible. Diagnostic testing includes a sweat test, which measures the salt content in the baby’s sweat, and further genetic testing. Pancreatic function tests may also be ordered (for example, tests for faecal chymotrypsin).

  Action

  Positive mutation screening test
  If LMCs receive a letter from the laboratory advising of a positive mutation screening test result, they should:

  • contact the laboratory if they require further information
  • contact the family and inform them of the screening result and that further testing is required to confirm the CF status – the
  • screening result is not a diagnostic confirmation of CF
  • provide the family with the information on CF sent with the notification letter
  • discuss diagnostic testing with the family, as in the information sent with the notification letter
  • contact a local CF paediatrician
  • support the family by providing further information if required.

  Treatment

  Babies with CF are cared for by a clinical team which includes a CF paediatrician, physiotherapist, dietician and social workers. Treatment involves supplementation at the earliest opportunity of pancreatic enzymes, fat soluble vitamins and salts.

  Medications and supplements are added on an individual basis as required over time. Regular physiotherapy to treat pulmonary symptoms aims to keep the lungs as free of secretions as possible and reduce admissions associated with pulmonary exacerbations. Ongoing management of diet is required to minimise nutritional insufficiencies.

  Family History of Cystic Fibrosis

  If there is a family history of CF, consultation with a CF paediatrician is recommended. A negative newborn screening result does not give information about CF carrier status as the sample may not have had mutation testing.