women’s health update
Cervical Cancer vaccine doesn’t rule out the need for screening The new cervical cancer vaccine has taken the world by storm. Jesse Solomon looks at cervical cancer in New Zealand and the implications of the vaccine for New Zealand women. Cervical Screening has had a dramatic impact on the incidence of cervical cancer and cervical cancer mortality in developed countries including New Zealand. The New Zealand screening programme started in 1991 and now achieves around 75% coverage of eligible women. However, this is significantly lower amongst some groups including Maori women at 55%. The screening programme has seen a decline of mortality from cervical cancer of 60% between 1990 and 2001. Mortality amongst Maori is approximately four times that of non Maori which reflects the difference in coverage of the programme amongst these groupsi. Cervical Screening is available to all women in New Zealand and women can be screened by their GP, Family Planning or sexual health clinic. Cervical Cancer Screening is the single most effective intervention against cervical cancer.
vol 11 no 2 • May 2007
I n s i d e Screening for HIV in pregnancy ● The national rollout for HIV screening ● NZ Medical Council looks at guidelines for cosmetic surgery ● Noticeboard ●
Of the types of HPV affecting the genital area, around 12 are described as ‘high risk’ types, the rest are ‘low risk’. ‘Low risk’ infections will often go unnoticed but may cause genital warts and lesions. Genital warts do not pose a health risk, they will usually resolve themselves and are easily treated. Persistent infection with high risk strains of HPV is the primary cause of cervical cancer. HPV types 16 and 18 account for 70% of HPV infections causing cervical cancer. Gardasil, the new Cervical cancer vaccine has taken the world by storm, but does it herald a new dawn for prevention of this disease?
Facts on HPV: Human Papillloma Virus (HPV) is a very common virus, responsible for causing harmless common warts, genital warts and abnormal cells that can evolve into cervical cancer. Over 200 types of the virus have been identified, with around 40 affecting the genital areai. Over 70% of women will be infected with HPV during their lives. In the vast majority
of cases, the immune system will clear the infection and usually the infected person will be unaware of it. When the immune system is unable to clear the infection, sometimes because the immune system is compromised by ill health, the infection will persist. Most women (70%) test negative for HPV infection one year after diagnosis and 90% test negative after two yearsii. However, persistent ‘high risk’ infections, usually lasting a decade or more, can lead to the development of cervical cancer.
i Dr Hazel Lewis 2006: Screening Matters Newsletter of the National Screening Unit New Zealand November 2006
ii Adriane Fugh-Berman, M.D. 2007: Prescription for Change: Cervical Cancer Vaccines in Context The Women’s Health Activist March/April 2007 p1 – 2.
Gardasil: A vaccine for some types of HPV has been approved for use in New Zealand for females aged 9 – 26 years and males 9 – 15 years. The vaccine, called Gardasil, covers four strains of the HPV virus. These are types 16 and 18 which cause 70% of cervical cancers and HPV strains 6 and 11 which cause 90% of genital warts. Three doses of the vaccine are required. The cost is around $150 for each dose and doctors’ fees for the three visits need to be added. This brings the cost for a course of continued on page 2
Women’s Health Update features women’s health news, policy and scientific findings, to enable health care professionals and community-based workers to be at the forefront in women’s health. Women’s Health Update is published by the Women’s Health Action Trust
• Women’s Health Update • vol 11 no 1 • May 2007 continued from page 1 treatment to parents and young women to over $500. If the vaccine were to be nationally funded through the immunisation schedule, this would constitute a significant financial outlay for the health budget. There is currently only enough research to show that the vaccine is effective for five years. Further research will determine whether booster shots are needed after this time. As cervical cancer usually effects women over the age recommended for vaccination (9 – 26) questions must be raised about using such a vaccine to treat young girls for a condition that affects older women. Long term effects of the vaccine’s safety and efficacy are not known. Concerns have been raised about some safety aspects of the vaccine, including the aluminium content and its long term neurological effects. The Food and Drug Administration in the United States have required Merck to undertake further trials for safety amongst younger girls as the studies so far have not included many girls. Merck (the makers of Gardasil) are lobbying the Ministry of Health to have the vaccine included on the national immunisation schedule and provided to health consumers free of charge. The Immunisation Technical Working Group is considering whether an HPV vaccine should be state funded and included on the free national schedule of childhood vaccinations. Any change to the national immunisation schedule is unlikely before 2008. The cost to the health budget of providing the vaccine would be considerable and robust evidence of considerable health benefits to the population must be required. The New Zealand distributers of Gardasil began direct to consumer advertising (DTCA) in a television campaign which started on 4th March 2007. The television commercials encourage women and parents to consider whether Gardasil is appropriate for them or their daughters and asks them to discuss this with their doctors. Gardasil - What is still unknown: The cost of implementing the vaccine must be weighed against the benefit of investing the same resources in improving access to the cervical screening programme. The cervical screening programme has a robust and demonstrable impact on cervical cancer incidence and mortality. The availability of the vaccine does not reduce the need for a screening programme. Screening remains necessary because: • Cervical screening remains of central importance to the management of cervical cancer. • Gardasil does not provide total protection from pre-cancerous cervical lesions or genital warts.
Facts on cervical cancer: In 2002 cervical cancer in New Zealand • Was diagnosed in 180 women • Was responsible for 0.46% of cancer deaths In 2002 • All cancers accounted for 25.95% of all female mortality • Lung cancer accounted for 4.27% of female mortality • Breast cancer accounted for 4.41% • The biggest single contributor to female mortality was heart disease 27.3% Data from New Zealand Health Information Service
• Gardasil does not pick up all cancer causing strains of HPV. Gardasil is not effective amongst women who already have strains 6, 11, 16 or 18 of the virus. • Women who have been vaccinated against HPV must still participate in cervical screening to protect themselves against cervical cancer. Merck have been active internationally lobbying to facilitate the inclusion of Gardasil in mandatory vaccination schedules (Germany, many US States, Australia). Considerable concern is emerging amongst commentators around the role of pharmaceutical manufacturers in recommending and developing health policy. We see a use for this vaccine amongst populations who are not well served by screening programmes, for instance, in developing countries where cervical cancer prevention is minimal or non existent. Especially where associated risk factors for cervical cancer are high – such as poverty, poor nutrition, compromised immunity and other risk factors. In countries such as New Zealand, where a screening programme is well established, and cervical cancer incidence low, a more precautionary response to widespread vaccination of young women is warranted. For more information: http://www.medsafe.govt.nz/profs/Datasheet/ g/Gardasilinj.htm http://www.immune.org.nz http://en.wikipedia.org/wiki/Human_ papilloma_virus http://www.hpv.org.nz/ or contact the Cancer Society’s information helpline: 0800 226 237 Women’s Health Action has an Information Pack on Gardasil available. Contact our office for details.
Misleading? This pamphlet advertising Gardasil implies that you can immunise against cervical cancer. In fact, Gardasil vaccinates for some types of Human Papilloma Virus which can cause precancerous lesions. So far it cannot be shown that Gardasil prevents cervical cancer.
Women’s Health Update
• vol 11 no 2 • May 2007 •
Screening for HIV in pregnancy Antenatal blood tests are accepted medical practice in New Zealand as in other countries. Wende Jowsey looks at the reasons for adding HIV screening and the issues raised for informed consent. In March of 2006, testing for HIV was added to the current list of five antenatal blood tests by the Waikato District Board of Health. The aim is to prevent the spread of the virus from a mother to her unborn child. According to HIV Specialist Dr Jane Morgan, if a woman is untreated during pregnancy, transmission occurs approximately 25-30% of the time, as opposed to a 1% transmission rate if treated. In 1997, the Ministry of Health recommended that pregnant women whose medical history suggested they could be at risk should be screened. However there has been a growing awareness among medical practitioners that a woman’s partner may have engaged in high risk behaviour, and that generally applied testing has less risk of discriminating against, or stigmatising individual women. The difficulty is that many high risk populations are not NZ born which raises Quote given during phone interview 20/03/07 Aids Medical Technical Advisory Committee 1997
the issue of informed consent to screening. How does a woman knowingly opt in or out of testing if English is not her first language, or indeed, a language that she speaks at all? Ideally she would have the assistance of a trained medical interpreter. The 1996 Health and Disability Code of Services states that: “Every consumer has the right to effective communication in a form, language, and manner that enables the consumer to understand the information provided. Where necessary and reasonably practicable, this includes the right to a competent interpreter”. This issue of refugee and migrant women’s access to qualified interpreter services has serious implications for the quality of care received. Christine Goodman, Director of the Wellington Community Interpreting Service notes that non-English speaking women need to be aware of their right to ask for a professional interpreter. Members of Primary Health Organisations (PHOs) can draw on ‘access funding’ for such costs. Women who cannot afford to pay for interpreter services may be reduced to communicating through family members. This she says, “carries the risk that they (family members) may not be the HDC code of Health and Disability Services Consumers’ Rights regulation 1996
competent to translate, may be selective about what they translate, or the patient may be reluctant to self-disclose confidential information in front of a relative”. She also expressed concerns that a movement to promote phone rather than face to face interpretation services often results in a lower degree of confidentiality and a higher margin of error. Dr. Morgan also reports that “GPs are feeding back that patients are choosing not to use interpreters because of the cost being channelled back to the patient”. She states that prior to the implementation of HIV testing in the Waikato District, notification was sent out to all registered health practitioners of a training session on standards for informed consent where HIV testing was being offered and approximately two thirds of those contacted attended. However, she agrees that the issue of access to interpreters remains an ongoing challenge. A local PHO pilot of funded phone interpreter services for GP consultations has been proposed in Hamilton. It is planned that the pilot will be trialled in local GP practices known to provide care to numbers of new migrants.
Quote given phone interview 20/03/07
The national rollout for HIV screening The National Antenatal HIV Screening Implementation Advisory Group (NAHSIAG) was established by the National Screening Unit in 2005 to oversee and provide advice on the establishment and roll out of a national HIV screening programme for pregnant women. The advisory group was scheduled to meet in Auckland at quarterly intervals throughout the year but due to the cancellation of the meeting in November met only three times in 2006. Four meetings have been planned for this year. Lynda Williams reports on work to date. Waikato DHB was the first DHB to begin the routine offer of an HIV test to pregnant women with the launch of its screening programme in March 2006. In November 2006 the DHB announced its first HIV diagnosis as a result of the screening programme. Dr Graham Mills, Waikato DHB’s infectious diseases consultant, announced that the New Zealand woman concerned had contacted the virus locally and had not traveled overseas. Subsequently, an immigrant woman has also been identified as being HIV positive in the Waikato. From 20 March to 30 September 2006 Waikato DHB performed a total of 4700 antenatal HIV tests and there were 18 women who declined to be screened for HIV. There were 18 inconclusive results, and one positive
result obtained during this period. The NSU is negotiating with a further eight DHBs regarding roll out of HIV screening later in 2007. The minutes of the December 2006 meeting of the Auckland DHB state that the three Auckland DHBs have agreed to undertake a regional approach to the implementation of antenatal HIV screening. Capital & Coast, Hutt Valley and Wairarapa DHBs may do the same. Pamphlets Educational resources are being developed for consumers in the form of a pamphlet that provides written information to pregnant women and their families about the Antenatal HIV Screening Programme. These will be available at a national level and support verbal information provided by Lead Maternity Carers, general practitioners, and other health practitioners. Initial pre-testing of the leaflet is expected to be completed in early 2007, with a draft leaflet available for review by NAHSIAG and other key stakeholders in May 2007. Consultation on guidelines for health practitioners will begin in June 2007. Monitoring and evaluation Monitoring and evaluation of the HIV
screening programme will be undertaken by the AIDS Epidemiology Group (AEG) of the University of Otago. The first two activities the AEG will carry out will be to liaise with the NSU and other key stakeholders to confirm the scope, process, timing and direction of the specific evaluation activities, and clarify longer term arrangements for data collection, sharing and storage. Informed consent to HIV screen The programme proposes that HIV screening be offered to women in pregnancy. This does not mean that all pregnant women will be routinely screened for HIV, rather, all pregnant women should be offered HIV screening, to which they can choose to consent or decline. It will be important for GPs and Lead Maternity Carers to make this distinction clear to pregnant women and resist including HIV screening with other routine tests in order to ensure that women can make an informed decision. The necessity for informed consent (and the right to decline) here is very important, and, as many women who are high risk for HIV infection are migrants to New Zealand, difficulties with language can be a significant barrier to true understanding and informed consent (see article on interpreter services in this Update).
NZ Medical Council looks at guidelines for cosmetic surgery In New Zealand, many doctors who are not qualified as surgeons also perform cosmetic procedures, including invasive surgery. In recent years, the demand for ‘appearance medicine’ has increased substantially, largely in response to unrealistic media images of ‘perfect’ faces and bodies, coverage of ‘designer vaginas’, and makeover television programmes with promises of ‘looking 10 years younger in two weeks’. Joanne Adams looks at what is proposed: As with any form of major surgery, the risks and side effects of plastic surgery can be extreme. In the past seven years, ACC has paid compensation to 73 people for injuries suffered during plastic surgery, and the Health and Disability Commissioner reports sufficient complaints he strongly recommends clarification in the area is needed. Currently, ‘cosmetic medicine’ is not recognised as a scope of practice under the Health Practitioner’s Competence Assurance Act (2003). The principle purpose of the Act is to protect public health and safety and ensure that doctors are competent. The Act also states that the New Zealand Medical Council is to set standards and codes of conduct for medical practitioners.
In recognition of the lack of regulation in the cosmetic surgery industry, the Council has recently put out a revised draft Statement on cosmetic procedures. The statement was first released for comment in June 2006 and has been reworked after wide consultation. In the current version, the Council recommends that operations should be performed only by a doctor with “appropriate training, skill and expertise to deal with all routine aspects of care and any likely complications”. The statement also stipulates that doctors’ work be regularly reviewed for quality, and proposes a system of categorisation depending on the type of procedure. Currently, any registered medical practitioner can carry out any kind of procedure. In the categorisation system, the Council propose that only doctors with appropriate qualifications and experience can perform particular types of surgery. Category 1 covers procedures that involve cutting of the skin, such as breast implants, face lifts and extensive liposuction (some of the most popular procedures) and may only be performed by qualified surgeons. Category 2 covers skin piercing procedures such as varicose vein removal and laser treatments; the Council propose that these
can be carried out by any registered doctor. Category 3 includes ‘low risk’ techniques such as botox and laser hair removal, and may be carried out by GPs, dermatologists and nurses working in doctors’ practices. Importantly, the Statement includes mention of advertising and promotion; however the requirements need to be strengthened and stipulate, for example, that risk information be provided in any promotional material. Also, there is no mention made of the need to clarify what qualifications actually mean. Publicly, there is a great deal of confusion about this-the difference between a ‘plastic surgeon’ and a ‘cosmetic surgeon’ is a good example. A plastic surgeon is required to undergo 8 years training; a cosmetic surgeon is not required to do this. A booklet containing all the relevant information for patients to make an informed choice is urgently needed such as the UK Department of Health’s “Cosmetic Surgery: Information for Patients”. So while the draft Statement is a good start in regulating a burgeoning industry, more needs to be done to ensure that vulnerable clients, usually women, have all the information they need to make an informed decision about whether to proceed, and if so, ensure the risk of harm is minimised.
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Public Health Association Te torino: re-imagining health Conference 4 – 6 July 2007
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School of Population Health, Tamaki Campus University of Auckland. The Public Health Association Conference is a ‘must attend’ for anyone who works in, or has an interest in, public health. Conference themes are urban design, food matters and voices. Topics will include kaupapa Maori, systems and structures, workforce, inequalities, determinants of health, and globalisation. Further information: www.pha. org.nz/phaconf2007.html
The Newborn Metabolic Screening Programme is about to commence a major public consultation process on consent for screening newborn babies for metabolic conditions and the storage, retention and use of the New Zealand collection of newborn blood spot cards (commonly known as ‘Guthrie cards’). An on-line questionnaire is available at : www.nsu.govt.nz
● Where is the value in evaluation?
26 November 2007 Waipuna Lodge Auckland New Zealand Guidelines Group, the Office of the Health and Disability Commissioner and other partners welcome consumers to participate in the 2nd National Summit. A draft constitution for a national consumer entity, including it’s roles, the principles by which it will work and rules for it’s membership has been developed. The summit will provide an opportunity for input and further discussion. Attendance for consumers is free. Register interest now at: www.nzgg. org.nz or contact, Phillipa Scott, Phone: 04 471 4181 or email: pscott@nzgg.org.nz
Noticeboard ● We can make a difference. Social marketing in the health sector.
16 – 18 May 2007 Te Papa, Wellington This conference aims to build a culture of medicines safety. Its objective is to identify practical solutions for safe and quality use of medicines in healthcare by focusing on the patient experience. Themes include: • Medicines and the patient experience • Practical solutions – sharing innovation and models of care • How do we build a culture of safety http://www.wecanmakeadifference.org.nz/
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Innovation and Collaboration in the NGO Sector NGO Forum
18 May 2007 9am - 4pm Hotel Grand Chancellor on Cashel Street, Christchurch. The day will include: • an opportunity for you to identify the barriers to Innovation and Collaboration in health • challenge speakers from outside the health sector • tall tales and True of Working Innovations and Collaborations in Health • input from Ministers and the Ministry of Health. http://www.moh.govt.nz/ngo
Leading, learning, and participating in change
Aotearoa New Zealand Evaluation Association Conference 9-11 July 2007 Solway Copthorne Hotel and Resort, Masterton Theme: Where is the value in evaluation? Leading, learning, and participating in change • The impact and use of evaluation thinking, practices and findings in programme, strategy and policy development, management and implementation • Knowledge management within organisations and programmes • Building evaluation capacity and culture • Emphasising results – the improvement of social conditions http://www.anzea.org.nz/conference.htm
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Public Consultation on ‘Guthrie Cards’ to commence – newborn heel prick test.
Strengthening Consumer Voice 2nd National Consumers’ Summit
Women’s Health Update is produced by Women’s Health Action Trust • Edited by Jo Fitzpatrick To receive copies of Women’s Health Update, make suggestions about future contents or send items for publication please contact: Women’s Health Action Trust • PO Box 9947, Newmarket, Auckland, New Zealand • 2nd Floor, 27 Gillies Avenue • Ph (09) 520 5295 • Fax (09) 520 5731 • email: info@womens-health.org.nz Internet address: http://www.womens-health.org.nz • Women’s Health Update is published with the assistance of the Ministry of Health