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Published: 28 April, 2023


New: Gynaecological cancers

To complete the topics in our gynaecological cancer series, we look at the detection of two rare cancers: vulval and vaginal. Most vulval cancers are squamous cell carcinoma (SCC) and are usually related to high-risk HPV infection or vulval inflammatory disorders such as lichen sclerosus. The majority of primary vaginal cancers are also SCC; however, most cancers affecting the vagina are secondary, involving metastases from another site such as the cervix. The series will conclude with an article on follow-up in primary care of patients who have undergone curative-intent treatment for a gynaecological cancer. Thank you to Te Aho o Te Kahu, Cancer Control Agency, for supporting this important series of resources.

B-QuiCK summaries for these topics are available here.

View the complete gynaecological cancer series here

"The Big Catch Up" – World Immunisation Week

This week (24th – 30th April) is World Immunisation Week. The theme in 2023 is “The Big Catch-Up”. The aim of this global campaign led by the World Health Organization (WHO) is to regain immunisation coverage as rates have fallen since 2019, due in part to the COVID-19 pandemic. Worldwide data on vaccination rates are available up until 2021, and coverage may now have further decreased; the WHO estimates that:

  • Global childhood immunisation rates (represented by those who have received three doses of diphtheria-tetanus-pertussis [DTP3] vaccine) have fallen from 86% in 2019 to 81% in 2021
  • Approximately 25 million children aged < 1 year were not vaccinated in 2021 (the highest number since 2009) and five million more children, compared to 2019, were completely unvaccinated

A similar picture of falling immunisation rates has been seen in New Zealand with the latest data from 2022 showing that national immunisation coverage for all children was 82.9%.* This is a significant decrease from a national level of 91.7% in 2020. Immunisation rates for tamariki Māori are much lower at only 66.4%.

*Children aged two years who had received all age-appropriate immunisations for 12-month period ending 31 December, 2022

Data for the three month period ending 31 December, 2022

Immunisation reminders

Immunisation is a “hot topic” in primary care at the moment with vaccines for influenza, ongoing COVID-19 vaccination and several national campaigns designed to increase coverage for pertussis, measles, mumps and rubella (MMR) and meningococcal disease.

Routine polio wastewater testing implemented

In an update to Bulletin 66, where we reported an increased risk of polio in New Zealand due to an international outbreak, routine wastewater testing has now been established. If poliovirus is detected, further testing is then performed to identify the type, i.e. disease or non-disease causing poliovirus. Testing is currently being carried out from sites in Auckland, Wellington, Christchurch and Queenstown.

Clinicians are reminded to review the polio vaccination status of patients, particularly children. Polio vaccination (IPV) is funded for catch-up immunisation in people who are not immunised or are partly immunised.

Consider poliomyelitis in a patient with “flu-like” symptoms and a history of recent overseas travel to an outbreak country/area, although in many cases patients will be initially asymptomatic. Any rapidly evolving symptoms such as muscle weakness, difficulties with swallowing or breathing can indicate the development of paralysis. Urgent notification and hospital assessment is required for a patient with acute flaccid paralysis.

Hydroxocobalamin (vitamin B12) supply issue

There is an ongoing supply issue affecting stock of the currently funded brand of hydroxocobalamin (vitamin B12) injections, PanPharma. Pharmac has listed three alternative brands to cover the shortage:

Medsafe seeking feedback on pholcodine-containing products

Medsafe has issued a Monitoring Communication seeking feedback on the use of pholcodine-containing medicines (available over-the-counter as a cough suppressant) and whether they should continue to be available in New Zealand. Responses are due by 8th May.

Phenobarbitone brand change: 15 mg and 30 mg tablets

The funded brand of 15 mg and 30 mg phenobarbitone tablets is changing (due to API Consumer Brands withdrawing from the market). Other formulations of phenobarbitone are unaffected. There are approximately 400 people in New Zealand taking phenobarbitone (mainly for epilepsy). While many clinicians will not have patients taking this medicine, it is important to be aware of this brand change as alterations in medicine regimens for patients with epilepsy may in some cases result in adverse outcomes.

Stock of the currently funded brand of 30 mg tablets is expected to be exhausted in July, 2023 and stock of the 15 mg tablets in October, 2023. A new supplier is currently being assessed.

Paper of the Week: Advice for withdrawing SSRIs in primary care

Selective serotonin reuptake inhibitors (SSRIs) are generally the first-line pharmacological treatment for patients with major depressive disorder as they are usually associated with a lower risk of adverse effects and toxicity in overdose than other classes of antidepressants. SSRIs are also used for other mental health conditions, e.g. anxiety, eating disorders. In New Zealand, the number of SSRIs dispensed has been steadily increasing over time despite there being limited evidence of effectiveness. A study published in 2020 has also found insufficient evidence that antidepressants are more effective in people with severe depression, than those with mild to moderate depression.

If there has been no benefit or inadequate response to SSRI treatment after an appropriate trial or if adverse effects are intolerable, the antidepressant should be withdrawn. Antidepressants can also usually be discontinued in patients who are coping well one year after recovery from a single episode of depression or at least three years after recovery from multiple episodes. However, withdrawal from SSRIs needs to be done carefully as adverse effects may occur. Symptoms of withdrawal (e.g. irritability, sleep disturbance, hallucination, suicidal ideation dizziness, headaches, sweating) are reported by more than half of patients when discontinuing SSRIs.

There is differing advice on how best to taper a patient off a SSRI. A 2023 article published in the British Journal of General Practice discusses practical recommendations for primary care on the appropriate withdrawal of SSRIs.

For further information on antidepressants, including switching or discontinuing, see:

For further information on the role of medicines in the management of depression in primary care, see:

Palmer EG, Sornalingam S, Page L, et al. Withdrawing from SSRI antidepressants: advice for primary care. Br J Gen Pract 2023;73:138–40. doi:10.3399/bjgp23X732273

This Bulletin is supported by the South Link Education Trust

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