Published: 23 September, 2022
Update from the National Cervical Screening Programme
September is Cervical Screening Awareness Month, so we have taken this opportunity to share a brief update from the National Cervical Screening Programme Team.
From July, 2023, the primary method for cervical screening will test for human papillomavirus (HPV), the cause of over 95% of cervical cancers. Self-testing will be an option for everyone.
Participants can choose how to have their screening test performed - they can opt for:
- Self-testing using a swab, in a location of their choice (including at home)
- A clinician to take the HPV test using a swab
- A clinician to take a liquid-based cytology sample (using a speculum) which can be used for HPV testing, and cytology if required
Clinical oversight is required in order to explain the test, manage results and arrange follow up.
In the meantime, the key message is “keep screening”. We don’t want anyone holding off on screening until HPV Primary Screening becomes available next year because the time lag will make a difference for some people - cytology screening needs to continue while we prepare for the new programme.
If you have any questions about the HPV Primary Screening Project, or wish to sign up to the National Cervical Screening Programme Sector Update newsletters, please contact us at: email@example.com
Funding restrictions removed from progesterone
From 1 December, 2022, prescribing restrictions will be removed from oral progesterone, allowing it to be prescribed fully funded to any patient who requires this treatment.
Progesterone 100 mg oral capsules (Utrogestan) are approved for use in combination with oestrogen for menopausal hormone therapy in post-menopausal females with an intact uterus. Other uses include prevention of pre-term labour (unapproved indication) - see New Zealand Formulary for details on dosing.
Progesterone oral capsules are currently only funded with Special Authority approval for prevention of pre-term labour in patients who meet the criteria. This change in access will increase the options for women requiring a progestogen as part of their menopausal hormone therapy (MHT).
For women requiring combined oestrogen + progestogen MHT, this can be prescribed as:
- An oestrogen tablet or patch with a separate formulation of oral progestogen – provides greater dose control than combination formulations. The oral progestogen may be taken cyclically or continuously.
- An oestrogen tablet or patch with a levonorgestrel intrauterine system (Mirena) – provides progestogen without having to use an oral formulation; this option also provides contraception for women who may still become pregnant
- A combination oestrogen + progesterone formulation; cyclical and continuous formulations available
Currently funded progestogen options for MHT include medroxyprogesterone acetate tablets, norethisterone tablets (unapproved indication), levonorgestrel IUD (Mirena) and combination estradiol + norethisterone tablets (partly funded). Progesterone capsules (Utrogestan) will be a further funded option from 1 December; there is some evidence that this form of progestogen is less associated with adverse effects.
A bpacnz article about MHT is available here.
Read more about the decision and consultation process here.
Potential new treatment for inflammatory bowel disease
Pharmac is seeking feedback on a proposal to fund a new treatment for people with ulcerative colitis or Crohn’s disease: vedolizumab. Submissions are due by 5 October.
Vedolizumab is a biologic medicine that influences the inflammatory processes associated with inflammatory bowel disease. It is administered as an IV infusion, usually every eight weeks (after an initial induction regimen). Vedolizumab is an approved medicine and is indicated for adults with moderate to severe ulcerative colitis or Crohn’s disease who have had an inadequate response, lost response or are intolerant to conventional treatment or TNF antagonist treatment.
It is proposed that vedolizumab is funded with Special Authority approval from 1 February, 2023, for adults and children (unapproved indication), with application from any relevant practitioner, for patients who meet specific criteria related to their condition and prior treatment.
N.B. This consultation also includes a proposal to fund brentuximab vedotin for the treatment of patients with Hodgkin and anaplastic large-cell lymphoma.
New long COVID guidelines published
Manatū Hauora, The Ministry of Health, has published a “living document” providing clinical guidelines on the rehabilitation of people with long COVID. It includes a case definition and diagnostic criteria, symptoms and clinical management by body system. It is intended that guidance will be updated as further evidence evolves on managing long COVID. COVID-19 has disproportionately affected Māori and Pacific peoples, therefore future iterations of the guide will further build on holistic models of care and resources to support people with long COVID and their whānau equitably in the community.
Clinical case definition of long COVID
People with long COVID can present with symptoms affecting any part of the body. The symptoms often occur in a cluster and may fluctuate, relapse and change over time. Frequently reported symptoms of long COVID include fatigue, “brain fog”, memory impairment, breathlessness, anxiety, depression, swallowing difficulties, loss of taste and smell. Long COVID may also be associated with social and wellbeing issues, including health anxiety.
People who had severe COVID-19 symptoms during the acute phase of their illness may be more likely to develop long COVID, but it can also occur in those who initially had mild or moderate symptoms.
Definitions of clinical phases of COVID-19:
||Signs and symptoms of COVID-19 for up to four weeks
|Ongoing symptomatic COVID-19
||Signs and symptoms of COVID-19 that persist after four weeks and up to twelve weeks
|Post-COVID-19 syndrome (long COVID)
||Signs and symptoms that develop during or after an infection of COVID-19 that continue for more than twelve weeks and are not explained by an alternative diagnosis
Read the full guideline here: www.health.govt.nz/publication/clinical-rehabilitation-guideline-people-long-covid-aotearoa-new-zealand
Also see the associated guide on recovery from acute COVID-19, as covered in Bulletin 55: https://www.health.govt.nz/publication/guidance-acute-phase-rehabilitation-people-or-recovering-covid-19-aotearoa-new-zealand
Safety report on COVID-19 vaccines
Since March, 2021, Medsafe has been publishing data on adverse event reports and other safety monitoring for COVID-19 vaccination. Reports are now published two-monthly and the latest report for accumulated data up until the end of August, 2022 is now available.
It is important to note that these reports of adverse events following immunisation have been made by members of the public and health professionals, and have not been verified as being caused by, or associated with, COVID-19 vaccination.
- There have been over 11.6 million doses of Pfizer vaccine administered in New Zealand
- Just over 64,000 reports of adverse events following vaccination have been received, of which 3,550 were classified as serious
- The highest number of reports were in relation to people aged between 30 - 39 years, followed by 40 - 49 years and 20 – 29 years
- The top three most frequent reports were: headache, dizziness and injection site pain
- 43% of reports were from a member of the public, 23% were from vaccinators, 13% from nurses, 13% from general practitioners and 0.6% from pharmacists (the remainder were other/unspecified)
- Since reporting began, Medsafe has published monitoring communications on the following possible safety signals: myocarditis/pericarditis, blood clots, menstrual disorder, adverse events in the elderly, pregnancy.
Read the full report for data up to 31 August, 2022 here. An index page for all safety reports is available here.
Also see the Medsafe alert about myocarditis and pericarditis with Nuvaxovid, as reported in Bulletin 58
Community pharmacies can now offer Boostrix vaccine
As of 1 September, community pharmacies are able to offer Boostrix vaccine (diphtheria, tetanus and pertussis) to eligible patients at no cost. A list of eligibility criteria for funded vaccination can be found here. N.B. The current medicines classification of Boostrix means that it can only be administered by authorised pharmacist vaccinators to people aged 18 years or older or to pregnant females aged 13 years or older.
Pharmacies who choose to offer Boostrix will record administrations of vaccines in the National Immunisation Register. Pharmacists are encouraged to check with a patient’s general practice if their immunisation record of previous Boostrix/Tdap vaccination is unknown.
The Immunisation Advisory Centre ran a webinar earlier this week, covering questions about Boostrix, Nuvaxovid and more: the webinar replay is available here.
Paper of the Week: A walk in the park – how the great outdoors improves mental health
A recently published paper in Molecular Psychiatry (a Nature portfolio journal) examined the effect of natural versus urban environments on stress-related brain mechanisms. Study participants undertook a one hour walk in either a busy street or forest setting. Brain activation was assessed with psychometric tasks before and after the walks. It was found that participants had decreased amygdala activation after their nature walk, i.e. reduced stress levels, but amygdala activation remained the same with the urban walk.
Exercise is an important aspect of lifestyle measures for improving mental health. Next time you recommend that a patient takes a walk, suggest that they go further afield than their city block.
- The study involved 63 participants in Berlin, Germany, without any diagnosed psychological or neurological disorder; the average age was 27 years and 46% were female
- Participants were not fully briefed on the aim of the study, and were semi-randomly assigned to a nature or urban walk, controlling for equal distribution of males and females and time of walks
- Before the walk the participants performed a working memory task and various other stress-related psychometric tests, using MRI scanning to assess response; this was repeated after the 60-minute walk
- The nature environment was Grunewald Forest, a large green area within the city of Berlin
- The urban environment was a busy street in Berlin with shopping malls (participants did not enter shops)
- Participants walked alone, did not use their mobile phone and wore a wrist monitor that measured electrodermal activity, heart rate variability and heart rate as physiological indicators of stress
- Amygdala activity, the area of the brain most active in stress response, decreased after the nature walk and remained the same after the urban walk; the researchers concluded that there is evidence that nature alleviates stress but a lack of evidence that urban environments heighten stress
- Through analysis of the different types of stimuli in the psychometric tests, the researchers concluded that the nature walk increased the amygdala’s threshold for activation regardless of the type of stress encountered, i.e. being in nature was restorative to overall stress levels
- The authors theorise that repeated exposures to nature may result in a permanent increase in the threshold for amygdala activation and lower amygdala activity during stress
Sudimac S, Sale V, Kühn S. How nature nurtures: Amygdala activity decreases as the result of a one-hour walk in nature. Mol Psychiatry (2022). https://doi.org/10.1038/s41380-022-01720-6
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