International experience on screening and national screening program in Kazakhstan
The prevalence of noncommunicable diseases. Risk factors around the world that require a comprehensive response from the health system. Measures to combat the epidemic of noncommunicable diseases. National program of screening preventive examinations.
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International experience on screening and national screening program in Kazakhstan
Zh.Ye. Battakova, G.Zh. Tokmurziyeva,
T.K. Saydamarova, Sh.Z. Abdrakhmanova,
Анализ международного опыта показал длительный характер распространенности неинфекционных заболеваний и, объединяющих их, общих факторов риска во всем мире, требующий комплексных ответных мер со стороны системы здравоохранения, принятие которых должно стать долгосрочной целью всех стран. За последние годы Казахстан инвестировал Национальную скрининговую программу для решения стратегической цели в борьбе с эпидемией неинфекционных заболеваний, ставшей одной из ключевых в Государственной программе развития здравоохранения Республики Казахстан «Саламатты Казахстан» на 2011-2015 годы.
Ключевые слова: международный опыт, скрининг, Национальная скрининговая программа, профилактический осмотр, динамической наблюдение, информирование.
disease screening prophylactic
Zh.Ye. Battakova1, G.Zh. Tokmurziyeva2, T.K. Saydamarova, Sh.Z. Abdrakhmanova3, A.A. Akimbayeva3
1Doctor of Medical Sciences, professor, 2Doctor of Medical Sciences, 3Master of medicine, National Centre for Problems of Healthy Lifestyle Development under the Ministry of Health and Social Development of the Republic of Kazakhstan, Almaty city
International experience has shown long-term nature of noncommunicable diseases and integrating them common risk factors in the whole world that requires a comprehensive response by the health system, the adoption of which should be the long-term objective of all countries. In recent years Kazakhstan invested the National screening program for the solution of strategic objectives in the fight against the epidemic of non-communicable diseases, which has become one of the key in the State Program of Healthcare Development of the Republic of Kazakhstan “Salamatty Kazakhstan” for 2011-2015.
Keywords: international experience; screening; breast cancer screening; cervical cancer screening; colorectal cancer screening; national screening program.
Noncommunicable diseases, or NCDs, are the leading cause of death in the world. NCDs kill more than 38 million people each year. About three quarters of these NCD deaths occurred in low- and middle-income countries. The four main types of noncommunicable diseases are cardiovascular diseases (as heart attacks and stroke), cancer, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. Premature NCD deaths can be significantly reduced through government policies tackling behavioral risk factors and universal health care coverage [1,2].
Screening is an integral a health care system and is important in the prevention and control of noncommunicable diseases. It is known that screening - is a preventive public health strategy to distinguish risk factors and disease in clinically asymptomatic individuals in the population. The purpose of screening is to detect of diseases or disorders at an early stage of development, for timely treatment of patients, improving the quality of life, dynamic monitoring and prevention of disability and death [3-8].
Europe has long-term practice and established guidelines in national population screening. We have reviewed the experience of competitive European countries with high socio-economic development on existing practice of preventive screenings, in particular with regard to cervical cancer, breast cancer and colon cancer [8-14].
In Austria people aged 19-40 years are invited every three years, and over 40 years old - every two years are invited to precautionary check-up. Women over 40 years old have possibility to pass mammography every two years and people over 50 years old are informed about intestinal cancer. In addition, every Austrian over 19 years of age has the right to pass free voluntary routine check-up once a year. Women are invited to pass general gynecological examination with a sear test on a yearly basis.
Belgium. The program of population screening for cervical cancer is in force since 1994. Women between ages of 25-64 every three years are called on to have a Pap smear. According to certain analysis, the cervical cancer screening coverage of the target population in Flanders was 82.3% before 1998. In 2000 a national campaign for breast cancer screening was initiated. Screening centers are responsible for determining the target group, invitations for women between age of 50-69, second reading, data registration and sending the report for referring physician.
Germany has a national screening program for breast cancer, cervical cancer and colorectal cancer for individuals with social health insurance. Opportunistic screening for breast cancer is widespread. For breast cancer screening women of 50-69 years of age are invited regularly. The target groups, frequency of screening and type of tests are indentified for cervical cancer and colorectal cancer, as well as prostate cancer screening.
Ireland. The National Cervical Screening Program invites women aged 25-60 years to register in the program for free cervical smear test. Irish National breast cancer screening program, BreastCheck, is developed for early detection and treatment of breast cancer. The program is available for all women with referral from general practitioner.
Spain. Cervical cancer screening with cytology test is proposed to women of 35 years old and over. Since 1990 breast cancer detection program is implementing. The age of the target population varies by regions, it is between 45-50-64 / 69 years of age. Free mammography is offered every two years and additional tests are also provided if needed.
United Kingdom. The National Cancer Screening Program offers cervical cancer screening for women aged 25-49 years every three years and women aged 50 - 64 years -every five years. In Scotland cervical cancer screening is offered to women from 21-60 age group. National breast cancer screening program is for women aged 50 -70 years old who are invited to have mammography every three years. Men and women between 60 and 74 are offered screening for bowel cancer every two years.
Finland. Screening for cervical cancer is performed from the beginning of the 1960s. Every five years women at the age of 25-30-60 years are invited to screening. Population-based screening for breast cancer works since 1987.Women aged 50-59 years are invited for screening every two years. Colorectal cancer screening is offered for people aged 60-69 with biannual faecal occult blood test as a primary test.
In Sweden, cervical cancer screening is carried out since 1960s. The recommended norms of screening for women aged 23-50 is once in a three year period, for those aged 51-60 is once in a five year period. For early detection of breast cancer mammography screening is performed among women between age of 40-74. Guidelines recommend for adults begin their colorectal cancer screenings at age of 50. Screening test for colorectal cancer is faecal occult blood test followed by colonoscopy if required.
Taking into account international experience, WHO recommendations and current screening concepts in the Republic of Kazakhstan the Ministry of Health and Social Development in 2008 introduced a national screening program [15-18].
Screening in the Republic of Kazakhstan is based on data from the Register of population on territorial principal and performed in outpatient primary health care settings. Planning the target group size for preventive examinations is based from 70% and more of the officially registered in Statistics Committee target population. The target group consists of males and / or females, specific age groups at the greatest risk of developing certain diseases. Patients being on dispensary registration with identified disease and with severe somatic pathology as well as those refused to participate in the screening program are excluded from the target group.
National Healthcare Development Program “Salamatty Kazakhstan” for 2011-2015 provides further expansion of the national screening program by increasing the list of nosology [15-18]. The main screening characteristics are presented in Table 1.
Table 1. Screening in Kazakhstan: basic characteristics
Screening for cardiovascular diseases and diabetes are offered to people aged 25-70, from the age of 25 -every five years, then from the age of 40- every two years. Every two years the population is screened for glaucoma at the age of 40-70. For women the mammography is recommended to do every two years at the age of 50-60 and every five years the cytology smear test for cervical cancer for those at the age of 30-60. Screening for colorectal cancer with faecal occult blood test is offered for people at the age of 50-70. Endoscopic examination for early detection of cancer of the esophagus and the stomach is implementing at the age of 50-60 years every two years. The prostate-specific antigen test for detection of prostate cancer is recommended to have at the age of 50-66 every fourth year. Also, the National Screening program provides screening for liver cancer: patients with cirrhosis have the liver ultrasound performed with Alpha-Fetoprotein Blood Test, a computed tomography or magnetic resonance imaging to those patients is offered as additional tests for medical reasons.
It should be noted that the scope of screening tests and further examination with consultation of specialists are strictly regulated. Screening is a part of the state-guaranteed health care and free of charge, conducting on a voluntary basis. People participating in the screening program have the right to: get information on the diseases screened and about the screening procedure; go free examination within the required scope; get consultation of a specialist according to an algorithm of screening; dynamic monitoring and treatment according to the diagnosis and treatment protocols; obtain information about the results of their screening; in case of unexpected adverse (side) effects / complications during screening procedure - to get the proper medical care within the guaranteed free health care. At the same time, the following responsibilities for population exist: regularly and in timely manner to pass the required tests; clearly fulfill the requirements for preparing to the screening procedures, to know the advantages and disadvantages of screening.
National Centre for problems of healthy lifestyle development under the Ministry of Health and Social Development of the Republic of Kazakhstan is the coordinator and working body for analysis, monitoring, evaluating and reporting on the implementation of the National screening program. A large number of health care organizations is involved in the screening program. An expert working group on the screening was established among the number of specialized research organizations, such as the Scientific Research Institute of Cardiology and Internal Diseases, Kazakh Research Institute of Oncology and Radiology, Kazakh Research Institute of Eye Diseases, Scientific Center of Pediatrics and Pediatric Surgery, Research Center of Obstetrics, Gynecology and Perinatology. The expert working group is a body to control implementation and evaluation of effective national screening programs and identify areas for further research. The working group reports to the Ministry of Health and Social Development of the Republic of Kazakhstan and is an important central point for reference and all screening related issues, this experience can serve as an important model for other countries.
Implementation of the national screening program at the beginning faced low population awareness and an informational campaign was carried out to ensure coverage of target population. Audio and video clips with famous people of the country were rotated as well as informational and educational means, a poster on the route of a patient, address notice for invitation to screening were developed and distributed.
Some results of the National Screening Program are presented in Figure 1.
Figure 1.The percentage of specific conditions and diseases identified among the examined target population during the screening program by years in the Republic of Kazakhstan
Since 2008, screening preventive examinations for early detection of cardiovascular diseases for three year period (2008-2010) identified 509 591 cases of coronary heart disease and hypertension, which were accounted for 10% of the examined population. Screening for cervical cancer and breast cancer for the same period (2008-2010) revealed 83349 and 124052 cases respectively of precancerous lesions and cancer which were accounted for 5% and 10% of the examined target population respectively.
Since 2011, a list of nosology for screening preventive examinations was expanded, and therefore, the number of screening increased almost threefold, from 2,705,846 in 2008 to 7,119,648 in 2013. Screening for the early detection of noncommunicable diseases in the period from 2011 to 2013 revealed 25,274 cases (0.3%) of diabetes; 15776 cases of glaucoma (0.3%); 3216 cases of precancerous lesions and colorectal cancer (0.1%).
When comparing the results of screening of urban and rural residents, it should be noted that coverage by screening of rural population was less when compared with the urban one up to 12%. Detection rate indicates that there is a tendency to under-identification of non-communicable diseases among the rurals.
Thus, international experience on screening shows the long history of screening programs in the North Europe and that the benefits from Screening programs are evident as early accurate diagnosis and intervention lead to a better prognosis. At this stage treatment can be less radical and the health care resources could be saved.
Kazakhstan's experience shows that to achieve efficiency and good results of screening programs an accurate register of outpatients is required for reliable formation of target groups, to maintain adequate systems of recall and follow-up of patients. Along with the constant understandable information support to raise awareness on the National Screening Program among the population, and increase the level of joint responsibility of patients for their health through the media, employers and legal regulation, the more attention has to be given to evaluation of screening, constant training of health professionals, quality control and monitoring main outcome indicators.
It is necessary to take into account the disparity in geography, population density, climatic conditions, migration, etc., and therefore, the creation of the availability of screening in different regions of the Republic of Kazakhstan and to the different socio-economic groups. A wider use of effective tool - the mobile medical complexes and health trains, available in all regions of the republic, is another point in addressing inequality in the screening.
Providing further dynamic follow-up as well as the need to engage patients in the processes of disease management and development of Health Schools in primary health care organizations are useful tools in secondary prevention of noncommunicable diseases followed by screening.
1. World Health Organization, Global status report on noncommunicable diseases 2014, World Health Organization, Geneva, Switzerland, 2014.
2. Alwan A, Maclean DR, Riley LM, d'Espaignet ET, Mathers CD, et al. Monitoring and surveillance of noncommunicable diseases: progress and capacity in highburden countries. The Lancet Chronic Diseases Series. 2010; 376:1861-1868.
3. Thorner RM, Remein QR.Principles and Procedures in the Evaluation of Screening for Disease. PHS publication no. 846. Public Health Monograph no. 67.Washington: Public Health Service. 1961.
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6. Strong K, Wald N, Miller A, Alwan A. Current concepts in screening for noncommunicable disease: World Health Organization Consultation Group Report on methodology of noncommunicable disease screening. J Med Screen 2005; 12:12-19.
7. Chamberlain Jocelyn M (1984). Which prescriptive screening programmes are worthwhile? Journal of Epidemiology and Community Health, 38:270-277.
8. Walter W. Holland, Susie Stewart, Cristina Masseria. Policy brief. Screening in Europe. Denmark: WHO Regional Office for Europe, 2006; 76р.
9. Communication from the commission to the European parliament, the council, the European economic and social committee and the committee of the regions on action against cancer: European partnership. Commission of the European Communities. Brussels, 24.06.2009 (provisional version) COM(2009) 291/4.
10. David H. Howard, Lisa C. Richardson, Kenneth E. Thorpe. Cancer Screening And Age In The United States And Europe. 10.1377/hlthaff.28.6.1838Health Affairs November/December 2009 vol. 28 no. 6 1838-1847
11. Giordano L, von Karsa L, Tomatis M, Majek O, de Wolf C et al. Mammographic screening programmes in Europe: organization, coverage and participation. J Med Screen. 2012;19 Suppl 1:72-82.
12. Pignone M1, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002 Jul 16;137(2):132-41.
13. Arbyn M1, Van Oyen H. Cervical cancer screening in Belgium. Eur J Cancer. 2000 Nov;36(17):2191-7.
14. Winawer S, Fletcher R, Rex D, Bond J, Burt R. et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology.2003 Feb;124(2):544-60.
15. Battakova Zh.E., Tokmurziyeva G.Zh., Slazhneva T.I., SaydamarovaT.K. National sceening program. J. Actual issues of health promotion, disease prevention and health promotion. 2013; 3: 64-66.
16. Battakova Zh.E., Tokmurziyeva G.Zh, Khaidarova T.S. Intersectoral collaboration and the role of the Ministry of Health in health promotion of the citizens of the Republic of Kazakhstan. J. Actual issues of health promotion, disease prevention and health promotion. 2013; 4: 10-14.
17. Battakova Zh.E., Tokmurziyeva G.Zh, Khaidarova T.S and al. Prevalence of Behavioral Risk Factors Among Adults of Kazakhstan. EurAsian Journal of BioMedicine. 2014;Vol.7:1: 1-6.
18. Battakova Zh.E., Khaidarova T.S. Monitoring and comparative analysis of lifestyle indicators of the population and the prevalence of risk factors for non-communicable diseases among the population of the Republic of Kazakhstan. J. Actual issues of health promotion, disease prevention and health promotion. 2014; 1: 19-26.
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