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
Immunise – a new consumer-facing immunisation website
A new website (“Immunise”) directed at consumers and containing information on both maternal and childhood immunisation has been launched recently. In December, 2022, Te Whatu Ora released a report from an independent Immunisation Taskforce, with the aims of gaining back “lost ground” on immunisation coverage and achieving equity across the population. Improving childhood vaccination is the central goal, but immunisations for influenza and COVID-19 are also prioritised. The report makes 54 wide-ranging recommendations intended to improve our national immunisation coverage (a summary of these can be found here). One of the recommendations was to create a centralised website that could be easily accessed by parents, caregivers, hapū māmā and whānau to enable them to find consistent, reliable information on immunisation.
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.
Annual influenza vaccination
Influenza vaccination has been a focus in April. As mentioned in Bulletin 69 and Bulletin 71 funded access has been widened this year to include children aged six months to 12 years, and Māori and Pacific peoples aged 55 – 64 years. Community Influenza-like Illness (ILI) activity (reported by ESR) shows nationally that levels of illness are still low, however, higher than expected levels are occurring in Counties Manukau and MidCentral areas reflecting an earlier than usual start to the influenza season.
Funded COVID-19 boosters for people aged 30 years and older and those at higher risk of severe illness, using the bivalent vaccine have also been keeping primary care busy. Further information on these vaccines can be found in Bulletin 69 and Bulletin 72.
Cases of pertussis have now been reported in both North and South Islands and three infants aged < 3 months have died. There has been a national “call to action” by Te Whatu Ora and Te Aka Whai Ora. Immunisation is recommended and funded for pregnant women during every pregnancy and for all children. As outlined in Bulletin 70 it is also recommended but not funded for close family contacts of young infants and in some cases for those at higher risk of complications, e.g. patients with COPD. The exact duration of protection is unknown, but many groups (e.g. lead maternity carers, general practitioners, practice nurses, early childhood workers) are recommended to have a booster dose at least every 10 years: see the Immunisation Handbook for further information.
Since March, 2023, there has been widened access to funded meningococcal B vaccine. We reported on this in Bulletin 65 and 69, including the recommendation for prophylactic paracetamol for children aged under two years prior to vaccination with Bexsero. Eligible groups include all children aged up to 12 months and people aged 13 to 25 years in their first year of a specified close-living situation.
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:
- Cobal-B12 (three pack of ampoules) – stock is in New Zealand, although it may take time to reach pharmacies due to local supply delays
- Vita-B12 (three pack of ampoules) – registered in New Zealand. Stock is expected to be available from late May, 2023.
- Cobalin H (five pack of ampoules) – to be listed from 1 May, 2023. Stock is expected to arrive late April/early May, 2023.
These brands are not currently approved by Medsafe and so must be prescribed and dispensed under Section 29.
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.
Pholcodine is a component in various cold and flu preparations. Pholcodine-containing products were reclassified in December, 2022 (as reported in Bulletin 47) from pharmacy-only to pharmacist-only (restricted) medicines, due to potential safety concerns around the use of this medicine in the absence of pharmacist guidance.
There is increasing evidence that the benefit of pholcodine-containing medicines may outweigh the risks (related to anaphylaxis). This has prompted some regulators (e.g. in Australia and Europe) to withdraw supply of these medicines.
Read the full Communication here, including a list of affected products.
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.
Prescribers are being asked to schedule appointments with patients taking phenobarbitone tablets, prior to and after the brand change; patient co-payments for these appointments will be funded by Pharmac. The patient will also need to have a series of laboratory monitoring tests to measure serum drug levels before and after the change. See full details of this on the Pharmac website.
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.
A proportionate dose taper should be used
- A tapering regimen is recommended where the dose is reduced by a proportion of the previous dose, e.g. 50% of previous dose, depending on certain factors such as the patients symptoms and whether the available formulations of the SSRI allow the preferred reduction in dose. NICE guidelines for depression recommend that smaller dose reductions, e.g. 25% of previous dose, be considered when low doses are reached. If the required dose strength/formulation is not available, alternate day dosing may be useful for some patients.
- Dose tapering should occur slowly over months to years depending on individual circumstances. Higher doses of SSRIs, longer durations of use and SSRIs with shorter half-lives, e.g. paroxetine, are generally associated with more severe symptoms of withdrawal and patients may require tapering of the dose at a slower rate.
Monitor patients for symptoms of withdrawal
- Some patients will experience withdrawal symptoms despite an appropriate tapering regimen. If this occurs, slow the rate of taper and increase the period of time between reductions in dose.
- Reinforce the use of coping strategies, e.g. exercise, mindfulness-based techniques, sleep hygiene
- Acknowledge the impact of the patients symptoms, and ask about any fears or concerns that they may have. Ensure patients are aware of how to access acute crisis help and consider psychological referral as indicated.
- Regular monitoring of patients experiencing symptoms of withdrawal is recommended. Further changes to the tapering protocol may be required.
Differentiate between withdrawal and relapse
- Symptoms of withdrawal can sometimes be confused with symptoms of relapse. It is important to determine whether the patient is experiencing SSRI withdrawal or a relapse of their mental health condition.
- Symptoms of withdrawal are more likely to begin within days of discontinuation of the SSRI. In contrast, symptoms of relapse typically occur weeks to months after cessation of the SSRI.
- Symptoms of withdrawal typically improve promptly after re-introduction of the SSRI, whereas it is usually weeks after re-introduction of the SSRI before symptoms improve in patients who are experiencing a relapse
Provide education about withdrawal to patients:
- Discuss the possibility of withdrawal symptoms, including the importance of following the tapering protocol to minimise any symptoms. Advise that they should not abruptly stop taking the SSRI. A patient information sheet is available here.
- Advise patients to contact the clinic if they experience any symptoms of withdrawal and to return to the previous dose where they did not experience symptoms. Consider scheduling periodic reviews via telehealth or in-person to monitor progress or for adverse effects.
- Encourage patients to seek support from family/whānau or friends, or other services during the tapering process
For further information on antidepressants, including switching or discontinuing, see: https://nzf.org.nz/nzf_2225
For further information on the role of medicines in the management of depression in primary care, see: https://bpac.org.nz/2021/depression.aspx
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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