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In Aotearoa, New Zealand, the majority of cervical cancer cases occur in women who have never been screened or are under-screened. Wāhine Māori, Pacific and Asian women have the lowest rate of cervical screening. Self-sampling for human papillomavirus (HPV-SS) has been shown to increase participation in cervical cancer screening. A whole-of-system approach, driven by evidence in the most effective delivery of HPV-SS, is required to mitigate further widening of the avoidable gap in cervical screening access and outcomes between groups of women in Aotearoa. This single-arm feasibility and acceptability study of HPV self-sampling invited never- and under-screened (≥5 years overdue) 30–69-year-old women from general practices in Auckland, Aotearoa. Eligible women were identified by data matching between the National Cervical Programme (NCSP) Register and practice data. Focus groups were additionally held with eligible wāhine Māori, Asian and Pacific women to co-design new patient information materials. Questionnaires on HPV knowledge and post-test experience were offered to women. Our follow-up protocols included shared decision-making principles, and we committed to follow-up ≥90% of women who tested positive for HPV. Data matching identified 366 eligible never- and under-screened wāhine Māori, Pacific and Asian women in participating practices. We were only able to contact 114 women, and 17, during the discussion, were found to be ineligible. Identifying and contacting women overdue for a cervical screen was resource-intensive, with a high rate of un-contactability despite multiple attempts. We found the best uptake of self-sampling was at focus groups. Of the total 84 HPV-SS tests, there were five positive results (6%), including one participant with HPV18 who was found to have a cervical Adenocarcinoma at colposcopy. In our feasibility study, self-sampling was acceptable and effective at detecting HPV and preventing cervical cancer in under-screened urban wāhine Māori, Pacific and Asian women in Aotearoa. This is the first report of cervical Adenocarcinoma (Grade 1B) as a result of an HPV-18 positive self-sample in Aotearoa. We co-designed new patient information materials taking a health literacy and ethnicity-specific approach. This work provides policy-relevant information to the NCSP on the resources required to implement an effective HPV self-sampling programme to improve equity in national cervical cancer screening.

BACKGROUND The diagnosis of Hereditary Haemochromatosis (HH) is not straightforward since symptoms are often absent or non-specific. Biochemical markers of iron-overloading, may be affected by other conditions. This study measured the correlation between iron studies and HFE genotype to inform evidence-based recommendations for laboratory testing in NZ. METHODS Results from 2388 patients genotyped for C282Y, H63D and S65C in Wellington NZ from 2007- 2013 were compared to their biochemical phenotype as quantified by SF, transferrin saturation (TS), serum iron (SI) and serum transferrin (ST). The predictive power of these markers was evaluated by Receiver Operator Characteristic (ROC) curve analysis, and if a statistically significant association for a variable was seen, sensitivity, specificity and predictive values were calculated. RESULTS Test ordering patterns showed that 62% of HFE genotyping tests were ordered because of an elevated SF alone and only 11% of these had a C-Reactive Protein (CRP) test to rule out an acute phase reaction. The association between SF and significant HFE genotypes SF was low. However, TS values ≥45% predicted HH mutations with the highest sensitivity and specificity. A SF of >1000 µg/L was found in one at-risk patient (C282Y homozygote) who had a TS < 45%. CONCLUSIONS Our analysis highlights the need for clear guidelines for investigation of hyperferritinaemia and HH in NZ. Using our findings we developed an evidence-based laboratory testing algorithm based on a TS ≥ 45%, a SF ≥ 1000 µg/L and/or a family history of HH which identified all C282Y homozygotes in this study.

Background Māori, Pacific and Asian women in New Zealand have lower cervical-cancer screening rates than European women, and there are persistent inequities in cervical cancer outcomes for Māori and Pacific women. Innovative ways to address access barriers are required. New Zealand is transitioning to screening with human papillomavirus (HPV) DNA testing, which could allow women themselves, rather than a clinician, to take the sample. Internationally, self-sampling has been found to increase screening participation rates. The aim of this open-label community-based randomised controlled trial is to investigate whether self-sampling increases screening participation among un- and under-screened Māori, Pacific and Asian women in New Zealand. Methods/design We aim to invite at least 3550 un- or under-screened (≥5 years overdue) Māori, Pacific and Asian women (1050, 1250, 1250 respectively), aged 30–69 years, for screening. The three study arms are: usual care in which women are invited to attend a clinic for a standard clinician-collected cytology test; clinic-based self-sampling in which women are invited to take a self-sample at their usual general practice; and mail-out self-sampling in which women are mailed a kit and invited to take a self-sample at home. Women will be randomised 3:3:1 to the clinic and mail-out self-sampling groups, and usual care. There is also a nested sub-study in which non-responding women in all allocation groups, when they subsequently present to the clinic for other reasons, are offered clinic or home-kit self-sampling. The primary outcome will be the proportion of women who participate (by taking a self-sample or cytology test). Discussion This trial is the first to evaluate the effectiveness of mailed self-sampling in New Zealand and will be one of the first internationally to evaluate the effectiveness of opportunistic in-clinic invitations for self-sampling. The trial will provide robust evidence on the impact on participation proportions from different invitation approaches for HPV self-sampling in New Zealand un- and under-screened Māori, Pacific and Asian women. Trial registration ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111–1189-0531.

Background Human papillomavirus (HPV) is a common sexually transmitted infection implicated in 5% of cancers worldwide including most cervical cancer cases. In the UK, the HPV vaccine has been offered routinely to girls aged 11-13 since 2008 while cervical screening is offered to women aged 25-64. HPV testing will soon replace cytology as the primary screening method. This research evaluates what healthcare professionals (HCPs) across the UK know about HPV. Methods A total of 643 UK-based HCPs from primary and secondary care took part in an anonymous cross-sectional survey between March and April 2018. The survey measured general HPV knowledge; HPV triage and test of cure knowledge; HPV vaccine knowledge; attitudes to the HPV vaccine and self-perceived adequacy of knowledge. Results Participants had a generally good understanding of HPV and the vaccination but there were gaps in detailed knowledge of the National Health Service HPV testing processes. There were some gaps in knowledge about the health sequelae of HPV for males. Years since HPV training was associated with triage and test of cure and vaccine knowledge scores. Furthermore, nurses and doctors in colposcopy clinics had much greater odds of having higher knowledge across all domains than other roles. In total, 76.2% of participants felt adequately informed about HPV and 35.6% made suggestions for improvements in training, many of which requested additional frequency and topics. Conclusion Our results suggest that additional training is needed to ensure HCPs are equipped to deal with the changing landscape of HPV screening and vaccination in the UK.

Reactive arthritis (ReA) is an inflammatory spondyloarthritis occurring after infection at a distant site. Chlamydia trachomatis is proposed to be the most common cause of ReA, yet the incidence of sexually acquired ReA (SARA) has not been well established. We therefore carried out a systematic literature review to collate and critically evaluate the published evidence regarding the incidence of SARA. MEDLINE and EMBASE databases were searched using free-text and MeSH terms relating to infection and ReA. The title and abstract of articles returned were screened independently by two reviewers and potentially relevant articles assessed in full. Data was extracted from relevant articles and a risk of bias assessment carried out using a validated tool. Heterogeneity of study methodology and results precluded meta-analysis. The search yielded a total of 11,680 articles, and a further 17 were identified from review articles. After screening, 55 papers were assessed in full, from which 3 met the relevant inclusion criteria for the review. The studies reported an incidence of SARA of 3.0-8.1 % and were found to be of low to moderate quality. More studies are required to address the lack of data regarding the incidence of SARA. Specific and sensitive classification criteria must be developed in order for consistent classification and valid conclusions to be drawn. In clinical practice, it is recommended clinicians discuss the possibility of ReA developing at the time of STI diagnosis and to encourage patients to return if they experience any relevant symptoms.

BackgroundHuman papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health care professionals suggest knowledge about HPV may not be sufficient.MethodsA total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.ResultsThe mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 14.0% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 62.6% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 71.8% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.DiscussionAlthough overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health practitioners and the public.

To assess the clinical utility of replacing microbial culture for Neisseria gonorrhoeae with a nucleic acid amplification test (NAAT), we compared N. gonorrhoeae culture with the cobas 4800 CT/NG test for 18,247 urogenital and 666 nongenital samples. For urogenital specimens, the sensitivity, specificity, and positive and negative predictive values of the cobas N. gonorrhoeae PCR were 98.7%, 100%, 95.6%, and 100%, respectively, and for nongenital specimens, the values were 100%, 99.8%, 92.9%, and 100%, respectively. In our test population, 37% (10,185) of patients tested over the study period were screened for C. trachomatis by PCR but were not screened for gonorrhea by culture. Of these, 43 were N. gonorrhoeae positive by PCR and therefore went undiagnosed. The cobas 4800 CT/NG test diagnosed 33% ( n = 30) more urogenital and 25% ( n = 3) more rectal gonorrhea infections than culture and, based on the above performance indicators, does not require supplementary testing for urogenital or rectal specimens. The ability to test noninvasive specimens (such as urine and self-taken vulvovaginal swabs) for N. gonorrhoeae will enable more patients to be screened for infection, thus offering significant positive public health benefits.

Objective: To describe population rates of chlamydia testing and detection by sociodemographic characteristics, and to determine whether testing is reaching those groups most at risk of infection. Methods: Laboratory data for urogenital chlamydia tests in an urban region of New Zealand were collated for the period 1999 to 2005. Census data were used to estimate rates of testing and diagnosis (per 100,000 population). Regression analyses summarised patterns in testing and diagnosis by age, sex, ethnicity and socioeconomic deprivation (controlling for potential confounding factors). Results: Rates of chlamydia testing and detection differed significantly by age, sex, ethnicity and deprivation. Females had lower rates of chlamydia diagnoses than males (OR 0.4, 95% CI 0.39–0.42) but were tested five times more often. When tested, rates of chlamydia detection were significantly higher among Pacific (OR 2.33, 95% CI 2.16–2.5), and Māori (OR 2.01, 95% CI 1.87–2.17) than among European (reference group), and among individuals living in areas of greater socioeconomic deprivation (OR 1.66, 95% CI 1.55–1.77). Chlamydia diagnoses were significantly higher in the under 25 year old age group, with the highest odds of a positive result among the 15–19 year age group (OR 9.06, 95% CI 8.23–9.98). Conclusion: This analysis identified higher-risk groups who appeared to be underserved by testing relative to their higher rates of infection (including Māori, Pacific, 15–19 year olds and individuals living in areas of high socioeconomic deprivation). Implications: Appropriate chlamydia control programs with testing targeted towards higher-risk groups are urgently needed in NZ.

This study shows that given a choice, New Zealand women at high risk for sexually transmitted infections (STI) opt to provide a self-taken vaginal swab over a clinician-taken sample for STI testing. Self-obtained vaginal swabs have previously been shown to have equal sensitivity and specificity to endocervical swabs and greater sensitivity than urine for the detection of Chlamydia trachomatis by polymerase chain reaction (PCR). We suggest that self-obtained vaginal swabs should be a readily available option offered to women for chlamydia testing by PCR in New Zealand.

Background Sexually transmitted infections increase the risk of postoperative complications after termination of pregnancy. Mycoplasma genitalium is sexually transmitted and associated with adverse clinical outcomes in both males and females. The prevalence of M. genitalium is not yet known in New Zealand women or among women presenting for termination of pregnancy. Study Design This study involved prospective data collection at a public hospital clinic for termination of pregnancy. Participants were 300 under 25-year-old women presenting for termination of pregnancy. The study aimed to describe the prevalence of M. genitalium in women presenting for termination of pregnancy using real-time polymerase chain reaction (PCR) testing. Women provided a vaginal swab that was sent to the laboratory for PCR detection of M. genitalium . Data collection included age, ethnicity, previous pregnancy history, gestational age, procedure type, results of STI tests performed on referral for a termination of pregnancy ( C. trachomatis , N. gonorrhoeae , T. vaginalis and bacterial vaginosis) and use of antimicrobials in the past 3 weeks. Results M. genitalium was detected in 26 women (8.7%). Rates of infection did not differ significantly by patient characteristics such as age, ethnicity or previous pregnancies. Infection with M. genitalium was not significantly associated with bacterial vaginosis or C. trachomatis infection. Conclusions To our knowledge, this is the first prospective study designed to determine the prevalence of M. genitalium in women presenting for termination of pregnancy. Given the high proportion of cases observed in this study, further research is needed to determine the clinical significance of M. genitalium in postoperative termination of pregnancy complications.

Objective: Hereditary haemochromatosis (HH) follows a prolonged pre-symptomatic phase. The clinical features of HH are non-specific and subsequently, an accurate diagnosis may not be reached until the irreversible manifestations of the disease are apparent. Genetic testing for SNPs of the HFE gene is diagnostic of HH; however it is not economically viable in New Zealand to screen all patients with molecular testing unless there is sound clinical, familial or biochemical evidence to indicate testing. Abnormalities in iron biochemical assays are often the first indicator of HH and it has now become widely accepted that transferrin saturation (TS) and serum ferritin (SF) are the best initial tests for HH (Bacon et al 2011; King and Barton, 2006). These results however, particularly SF, may be affected by other conditions, making interpretation difficult and often misunderstood e.g. acute phase response. There is currently no national guideline for requesting HFE testing in New Zealand and existing recommendations are based on international data. This study evaluates the correlation between the iron phenotype and HFE genotype to inform future guidelines and cost-effective clinical pathways specific to our population. Materials and Methods: We audited the results from 2388 patients genotyped for HFE at Aotea Pathology Ltd; Wellington, between 2007 and 2013, and compared their C282Y, H63D and S65C genotypes to their iron status as quantified by SF and TS, as well as serum iron (SI) and serum transferrin (ST). The predictive power of the iron studies markers was evaluated by Receiver Operator Characteristic (ROC) curve analysis and if a statistically significant association for a variable was seen, the sensitivity, specificity, positive and negative predictive values were calculated at varying intervals. Results: Test ordering patterns showed that the majority (62%) of HFE genotyping tests were ordered on the basis of an elevated SF alone, without a full iron studies profile performed (which includes TS). Furthermore, only 11% of these patients had a C-Reactive Protein (CRP) test performed, which is a clinically useful marker of inflammatory states to establish if an elevated SF is acute phase in origin. In ROC curve analysis, the Area Under the Curve (AUC) of TS is larger than any other marker and a decision threshold of 45% produces the most favourable outcomes for patients in statistical analysis. Our results show that there is little association between SF and individual HFE genotypes and that SF values < 1000 µg/L are relatively insensitive to genotype. A SF of >1000 μg/L was found in one at-risk patient (C282Y homozygote) who had a TS < 45%, which provides some evidence to support the incorporation of SF into a diagnostic screening strategy for HH. AUCs for SI are analogous to that of TS, however, the sensitivity is poor at cut-offs above the normal range. ST showed no statistically significant association with any HFE genotype in ROC curve analysis. Using the thresholds of SF ≥ 1000 µg/L or TS ≥ 45% for consideration of HFE genotyping, any additional misidentified C282Y homozygotes in this study cohort were found to have a family history of HH, highlighting the importance of HFE testing on this basis. Conclusion: We conclude that an elevated SF of Disclosures No relevant conflicts of interest to declare.

Commentary on Stewart CM, Schoeman SA, Booth RA, et al. Assessment of self taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre, diagnostic accuracy study. BMJ 2012; 345: e8107.[OpenUrl][1][Abstract/FREE Full Text][2] Neisseria gonorrhoea (NG) has a low prevalence in most developed countries. NG causes significant pathology including pelvic inflammatory disease, neonatal transmission and increased susceptibility to HIV. It has been usual practice to detect NG by culturing endocervical and urethral specimens that are obtained by pelvic examination. However, there is a significant false-negative rate. The use of nucleic acid amplification tests (NAATs) increases detection of NG.1 This study examines the diagnostic accuracy of NAATs for gonorrhoea detection by self-taken vulvovaginal swabs compared with culture of clinician taken urethral and endocervical samples. The participants (n=3973) … [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.e8107%26rft_id%253Dinfo%253Apmid%252F23236033%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bmj&resid=345/dec12_1/e8107&atom=%2Febmed%2F18%2F5%2Fe46.atom

BACKGROUND: The national Human Papillomavirus (HPV) Immunisation Programme in New Zealand was introduced in 2008, and involves routine vaccination of girls 12-13 years with a catch-up for females aged up to 19 years. The aims of this study were to measure the pre-vaccination prevalence of oncogenic HPV infection in women aged 20-69 years who were participating in the New Zealand National Cervical Screening Programme (NZ-NCSP) and who were: (1) referred with high grade cytology with a subsequent histologically-confirmed high grade cervical intraepithelial neoplasia (CIN2/3) or adenocarcinoma in situ (AIS); or (2) were in the wider group of women who had a cytological prediction of high grade squamous disease or glandular abnormality (ASC-H/ HSIL+/AGC/AIS). METHODS: Women aged 20-69 years appearing on the NZ-NCSP register between August 2009-February 2011 with a cytology record of ASC-H/HSIL+/AGC/AIS were invited to participate in the study. Liquid-based cytology specimens were tested for 37 HPV types using Linear Array genotyping. The prevalence of type-specific HPV infection was reported within women with histologically-confirmed CIN 2/3 and within the wider group with ASC-H/HSIL+/AGC/AIS cytology. Age-specific trends for the relative proportion of HPV 16/18 vs. other oncogenic types in CIN2/3 were assessed. RESULTS: A total of 594 women with ASC-H/HSIL+/AGC/AIS cytology and a valid HPV test were recruited; of these 356 (60%) had confirmed CIN2/3 and 6 (1%) had confirmed AIS or glandular dysplasia. Positivity rates for any oncogenic HPV infection and for HPV16 and/or 18 within confirmed CIN2/3-AIS were 95% (95%CI: 92-97%) and 60% (54-65%) respectively; in all women with ASC-H/HSIL+/AGC/AIS cytology it was 87% (84-89%) and 53% (49-57%), respectively. The most common reported HPV types in women with CIN 2/3 were 16 (51%), 52 (19%), 31 (17%), 33 (13%) and 18 (12%). A trend for higher rates of HPV 16/18 infection compared to other oncogenic types was observed in younger women (p=0.0006). CONCLUSIONS: The prevalence of HPV 16/18 in confirmed high grade disease in New Zealand is comparable to that observed in Australia and European countries. Test positivity rates for type 52 appear higher than in comparable studies in other developed countries. A greater proportion of high grade lesions in younger women appear to be associated with HPV 16/18 infection

INTRODUCTION: Genitourinary Chlamydia trachomatis infection is common and associated with considerable personal and public health cost. Effective detection strategies are needed. Aim: To assess feasibility of an opportunistic incentivised chlamydia screening programme in general practice over six months. METHODS: This study was designed as a pilot for a randomised controlled trial in primary care. Three general practices were randomly allocated to intervention (two practices) and control groups. The intervention involved practice education, self-sample collection and practice incentives (funding and feedback) for a three-month ‘active’ intervention period. Feedback and education was discontinued during the second three-month period. Practice-specific nurse- or doctor-led strategies were developed for identifying, testing, treating and recalling male and female patients aged 16–24 years. The main outcome measure was the difference between the practices’ chlamydia screening rates over the six months following introduction of the intervention, controlling for baseline rates from the previous year. RESULTS: Chlamydia testing rates during the year prior to the intervention ranged from 2.9% to 7.0% of practice attendances by 16–24-year-olds. The intervention practices had higher rates of screening compared with the control practice (p

We report New Zealand’s first two cases of anorectal lymphogranuloma venereum (LGV). Although infection in these cases was probably acquired off-shore, the cases are reported to demonstrate the need to be vigilant to the possibility of LGV when men who have sex with men present with symptoms of proctitis. Investigation and management of LGV is discussed.

Background New Zealand initiated HPV vaccination in 2008, and has attained 3-dose coverage of ~50 % in 12–13 year old girls. Due to the success of program initiatives in Māori girls, higher coverage rates of ~60 % have been achieved in this group. We have previously reported a benchmark overall pre-vaccination prevalence of oncogenic HPV infection in high grade cervical lesions in New Zealand. The current extended analysis provides separate pre-vaccination benchmark prevalence for Māori and non-Māori women. Methods The National Cervical Screening Programme Register (NCSP-R) was used to identify any woman aged 20–69 years of age with an index high grade cytology report from 2009–2011. Extended recruitment was performed until 2012 in clinics with a high proportion of Māori women. Ethnicity status was based on self-reported information by participating women through phone contact supplemented by recordings on the study questionnaire (the NCSP-R was not used to extract ethnicity status). A total of 730 women consented to participate and had a valid HPV test result; 418 of these had histologically-confirmed cervical intraepithelial neoplasia (CIN) 2/3 lesions (149 Māori, 269 non-Māori). The prevalence of any cervical oncogenic HPV infection, HPV16, and HPV18 was calculated in women with CIN2/3. Results In confirmed CIN2/3, the prevalence of any oncogenic HPV, HPV16 and HPV18 was 96 % (95 % CI:91–99 %), 54 % (95 % CI:46–63 %), 11 % (95 % CI:7–18 %) in Māori and 96 % (95 % CI:93–98 %), 54 % (95 % CI:48–60 %), 11 % (95 % CI:7–15 %) in non-Māori women, respectively. Age-specific patterns of infection for HPV16/18 in confirmed CIN2/3 differed between the two groups (Pinteraction = 0.02), with a lower prevalence in younger vs. older Māori women (57 % in 20–29 years vs 75 % in 40–69 years) but a higher prevalence in younger vs. older non-Māori women (70 % in 20–29 years vs 49 % in 40–69 years); the difference in the age-specific patterns of infection for HPV16/18 was not significant either when considering confirmed CIN2 alone (p = 0.09) or CIN3 alone (p = 0.22). Conclusions The overall prevalence of vaccine-included types in CIN2/3 was similar in Māori and non-Māori women, implying that the long-term effects of vaccination will be similar in the two groups. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1034-5) contains supplementary material, which is available to authorized users.