Policy Brief

Screening in Europe

by

Walter W HollandSusie Stewart

Cristina Masseria

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The designations employed and the presentation of the material in this policy brief do not imply theexpression of any opinion whatsoever on the part of the European Observatory on Health Systems andPolicies or any of its partners concerning the legalstatus of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries. Where the designation“country or area” appears in the headings of tables,it covers countries, territories, cities, or areas. Dottedlines on maps represent approximate border lines forwhich there may not yet be full agreement.

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© World Health Organization 2006, on behalf of the EuropeanObservatory on Health Systems and Policies

All rights reserved. The EuropeanObservatory on Health Systems andPolicies welcomes requests for permission to reproduce or translateits publications, in part or in full (see address on inside back cover).

European Observatory on Health Systems and Policies

Screening in Europe*

The attack on disease must not be meddlesome; the desire to do something must be guided by sure argument that good will come of it.

Gibson AG. The Physician’s Art. Oxford: The Clarendon Press, 1933

INTRODUCTION

The concept of screening in health care – that is, actively seeking to identifya disease or pre-disease condition in individuals who are presumed andpresume themselves to be healthy – grew rapidly during the twentiethcentury and is now widely accepted in most of the developed world. Usedwisely, it can be a powerful tool in the prevention of disease. But it isessential to observe the long-established principles and criteria and resistthe introduction of screening practices that do not meet these requirements.

We begin this summary by outlining the historical background to screeningand by looking at some definitions of the practice based on experience inthe United States and the United Kingdom but relevant more widely. We goon to examine the criteria for screening and its evaluation and the benefitsand disadvantages of the practice. We then consider a number of keyissues that are relevant at all stages and to every type of screening in anycountry. Finally, we look at current screening practices within the EuropeanUnion (EU), using the United Kingdom as a model, before drawing anumber of general conclusions.

Historical background

The benefits of screening for disease prevention were first demonstrated in the 1940s by the use of mass miniature radiography (MMR) for theidentification of individuals with tuberculosis (TB). After the end of theSecond World War, when effective treatment for TB was introduced, the use of MMR became widespread in many western countries, including theUnited States and the United Kingdom.

Policy brief

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* Based on Holland WW, Stewart S (2005). Screening in Disease Prevention: What Works?Oxford: Radcliffe Publishing Ltd in association with The Nuffield Trust and the EuropeanObservatory on Health Systems and Policies.

Gradually the concept of screening began to be considered equallyapplicable to the prevention of other diseases. The United States led theway, and in 1961 Thorner and Remein of the US Public Health Servicepublished the first comprehensive review of the principles of screening.1

In 1968, Wilson and Jungner produced their Principles and Practice ofScreening for Disease, which was published as a World HealthOrganization monograph.2 This remains a landmark contribution to thescreening literature.

In the late 1960s, screening came to the forefront of the health agenda inthe United Kingdom. The Nuffield Provincial Hospitals Trust convened aworking party on screening under the chairmanship of Professor TomMcKeown. The report highlighted two main conclusions.3 First, evaluation often screening procedures had revealed that in six of these, at least some ofthe basic principles and criteria were not being met; second, that theexisting research and administrative framework for screening wasinadequate and needed to be strengthened. The unmanaged introduction ofscreening for cervical cancer, for example, illustrated very clearly the needfor national planning and coordination before any programme could beintroduced into the National Health Service or any other health care system.

In this context, the Ministry of Health created a Joint Standing Committee onScreening in Medical Care but, although this met between 1969 and1980, its terms of reference were purely advisory and its authority andeffectiveness were limited. The establishment in 1996 of the UnitedKingdom National Screening Committee (NSC) filled this planning gap andcreated a mechanism to influence the implementation and evaluation ofeffective national screening programmes and to identify areas for furtherresearch. The NSC reports to ministers and represents an important centralreference point for all considerations of screening in the United Kingdom.4

This provides an important model for other countries.

DEFINITIONS

There have been various definitions of screening over the years and anumber of the most commonly used in the United States and the UnitedKingdom are summarized in Table 1.

Put simply, what we are talking about in screening is seeking to identify adisease or pre-disease condition in apparently healthy individuals. The mostrecent definition from the UK NSC7 introduces the risk to benefit concept,

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acknowledging that screening can harm as well as help – a responseperhaps to the increasing public climate of complaint and litigation. It isimportant also to distinguish between population screening (where peoplethought to be at risk are invited for screening, as in the nationalprogrammes for cancer of the breast and cervix), and opportunisticscreening for prevention or case-finding (where individuals have sought

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Source Definition

US Commission on Screening is the presumptive identification of Chronic Illness unrecognized disease or defect by the application of (1957)5 tests, examinations or other procedures, which can

be applied rapidly. Screening tests sort out apparentlywell persons who apparently have a disease from those who probably do not.

McKeown (1968)3 Screening is medical investigation which does not arise from a patient’s request for advice for a specific complaint.

Wilson and Jungner Mass screening is the large-scale screening of whole(1968)2 population groups. Selective screening is screening

of certain high-risk groups in the population. Multiphasic screening is the administration of two or more screening tests to large groups of people. Surveillance is long-term observation of individual populations. Case-finding is screening of patients already in contact with the health services to detect disease and start treatment. Early disease detection refers to all types of screening.

NSC – First Report Screening is the systematic application of test or (1998)6 inquiry to identify individuals at sufficient risk of a

specific disorder to warrant further investigation or direct preventive action among persons who have not sought medical attention on account of symptoms of that disorder.

NSC – Second Report Screening is a public health service in which (2000)7 members of a defined population, who do not

necessarily perceive that they are at risk of, or are already affected by, a disease or its complications, are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of disease or its complications.

Table 1: Definitions of screening

medical advice for a specific symptom or complaint and opportunity istaken to suggest various other tests, such as the measurement of bloodpressure or cholesterol, appropriate to their age and sex).

CRITERIA FOR SCREENING

The basic criteria to be fulfilled before screening for any condition isintroduced have been stated clearly over many years. They are fundamentalto the integrity of the screening process in any country. They are reproducedin full on the UK National Screening Committee’s web site (www.nsc.nhs.uk),and are summarized in Table 2.

Evaluation must also be an integral part of any screening procedure. In1971, Cochrane and Holland8 suggested seven criteria for evaluation andthese remain as valid today as they were then (Table 3).

BENEFITS AND DISADVANTAGES

The benefits and disadvantages of screening have been fully described overthe years and have been elegantly summarized by Chamberlain9 (Table 4).

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Category Criteria

Condition The condition sought should be an important health problem whose natural history, including development from latent to declared disease, is adequately understood. The condition should have a recognizable latent or early symptomatic stage.

Diagnosis There should be a suitable diagnostic test that is available, safe and acceptable to the population concerned. There should be an agreed policy, based on respectable test findings and national standards, as to whom to regard as patients, and the whole process should be a continuing one.

Treatment There should be an accepted and established treatment or intervention for individuals identified as having the disease or pre-disease condition and facilities for treatment should be available.

Cost The cost of case-finding (including diagnosis and treatment) should be economically balanced in relation to possible expenditure on medical care as a whole.

Table 2: Summary of criteria for screening

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Factor Criteria

Simplicity The test should be simple to perform, easy to interpret and,where possible, capable of use by paramedics and other personnel.

Acceptability Since participation in screening is voluntary, the test must be acceptable to those undergoing it.

Accuracy The test must give a true measurement of the condition or symptom under investigation.

Cost The expense of the test must be considered in relation to the benefits of early detection of the disease.

Repeatability The test should give consistent results in repeated trials.

Sensitivity The test should be capable of giving a positive finding when the individual being screened has the condition being sought.

Specificity The test should be capable of giving a negative finding when the individual being screened does not have the condition being sought.

Table 3: Summary of criteria for evaluation of screening

Benefits Disadvantages

Improved prognosis for some Longer morbidity in cases where prognosis iscases detected unaltered

Less-radical treatment which Overtreatment of questionable abnormalitiescures some early cases

Resource savings Resource costs

Reassurance for those with False reassurance for those with false-negative test results negative results

Anxiety and sometimes morbidity for those with false-positive results

Hazard of screening test itself

Source: Chamberlain.9 Reproduced by kind permission of the author and publisher.

Table 4: Benefits and disadvantages of screening

The benefits are straightforward. Early and accurate diagnosis andintervention will lead to an improved prognosis in some patients. At thisstage treatment may need to be less radical. Scarce health servicesresources will be saved by treating diseases before they progress, and thosewith true-negative test results can be reassured.

The disadvantages are more complex. There will be longer periods ofmorbidity for patients whose prognosis is unchanged and there may beovertreatment of non-serious conditions or abnormalities identified. There arealso resource costs in finding more illness both in terms of the tests themselves,the personnel costs and the subsequent management of whatever is found.There is the unpalatable certainty that some individuals with false-negativeresults will be given unfounded reassurance and that some with false-positive results will experience, at the very least, unnecessary anxiety and,at the worst, inappropriate treatment. Finally, there is the possibility,however remote, of hazard from the screening test itself.

There is a need for balance in the screening debate, between the extremesof enthusiasm and scepticism. Two points are particularly relevant here. The first is that there may be public demand (fuelled by vested interests) forthe introduction of a screening test that does not meet the establishedcriteria; an example of this is in screening for cancer of the prostate wherethe current screening test – prostate-specific antigen (PSA) – does not meetthe criteria for accuracy or specificity. The second point is that the rhetoricbehind the introduction of a screening programme may not match the realityof its implementation in routine practice; this is illustrated in screening fordiabetic retinopathy in Glasgow, Scotland, where retention of staff, non-attendance and over-referral of patients with minor defects are some of thepracticalities creating problems.10

KEY ISSUES IN SCREENINGThere are a number of key issues that are relevant at all stages and in everytype of screening programme in any country, and are closely interrelated.

Genetics

Genetic screening is an area that has developed very rapidly in recentyears with the mapping of the human genome. Many see it as opening upa new era in the prevention, early diagnosis and identification of disease.However, caution is essential.

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The two most frequently cited objectives of screening for a recessive carrierstate, for example, are to reduce the prevalence of the disorder and toinform the reproductive choices of individuals and couples at risk.Information is thus regarded as worthwhile in itself, regardless of thepossibility of prevention or treatment. While this type of screening cancertainly help to evaluate risk and may be appropriate in certain high-riskgroups, if nothing can be done to alter the finding, the need for and use ofsuch information must be very carefully considered. Is it useful to diagnosewithout being able to treat?

The main purpose of genetic screening at present is to prevent rather thantreat disease. In this it differs from much current screening practice and itmust not be allowed to overlook the basic principles and criteria ofscreening. Open debate on the best way forward is urgent and the ethicaland human implications of the use of the human genome must beconsidered and patient autonomy safeguarded.

Information

Few would disagree that clear information about the benefits and harms ofany screening procedure should be available to all individuals invited toparticipate in any programme. In practice, however, this often involvesnothing more than providing a leaflet and possibly offering a briefdiscussion with a health professional with the emphasis on achieving apositive response. This is not enough.

Information provided should be based on results from respectable scientifictrials in a form that is acceptable, accessible and useful to those receivingit. There must be information about the whole screening process, includingfollow-up tests, some of which may be invasive and unpleasant. We shouldalso resist the current tendency towards “disease-mongering”, whereordinary and inevitable life processes, such as shyness and baldness, aretransformed into medical conditions amenable to treatment by those seekingto promote their products.

Information is thus another central concept in modern health care in generaland screening in particular. It must be provided not, as so often in the past,with the purpose of encouraging participation in a programme, but to givea balanced and understandable picture of the options and the possibleoutcomes, with the end-point being truly informed consent (or refusal) toparticipate.

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Economics

Economic aspects of screening have come to the fore in the consideration ofscreening in the last decade. This is partly due to theoretical advances inthe application of economic principles in health services but also because ithas been realized that some screening procedures require large amounts ofresources with little benefit to the population. With the increase in theperception by both policy-makers and the public that stringent criteria mustbe applied before screening procedures are introduced, economic factshave been increasingly demanded in order to try to quantify the costs andbenefits in terms that are more readily understood.

As economic theory has entered the field, it has been increasinglyrecognized that screening is not a universal panacea and that it may alsodo harm. All screening procedures involve the examination and testing oflarge numbers of individuals in order to find the few with an abnormality.There are two main consequences of this.

First, those who undergo screening are often understandably anxious whilewaiting for the result and become even more anxious if they have toundergo further investigation. These further investigations may not be pain-or risk-free and people eventually found to be clear of disease may stillhave a residual anxiety that something may be wrong.

Second, although most screening tests are simple, relatively cheapprocedures in themselves, the actual costs are by no means trivial becauseof the large numbers involved. Some screening tests that are advocated(often by “for-profit” providers) – for example, whole-body scanning – areexpensive. Further investigation of those found to be positive on screening,many of whom will eventually prove negative, is also likely to be expensive.

A screening service provided for one population consumes resources thatwill be unavailable for use elsewhere. Economic approaches maydemonstrate conflicting aspects of policy decisions – for example,increasing efficiency may reduce equity. They may also highlight thediffering perspectives of providers, consumers and industry. In all healthservices, however funded, financial resources are, and will continue to be,insufficient; expert economic analysis and advice must be an integral part ofthe system and must help to guide policy.

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Ethics

Ethical considerations, such as the harm-to-benefit ratio, must be paramountwhenever a screening programme is being put forward for implementation.In all instances there are going to be disadvantages to some members ofthe population screened. All screening examinations are preliminary andwill involve further investigation to verify that those who screen positivereally do have the abnormality and require treatment (true positives), and toeliminate those who screen positive but do not actually have the abnormality(false positives). Those individuals with negative test results will not normallybe tested further, although some of them may actually have the abnormalityin question (false negatives). This obviously has serious implications.

Screening tests, even with all the safeguards, can never be foolproof andare subject to human and technical error and variation so that even withthe most thorough quality assurance mechanisms, mistakes will occur. Inany assessment of screening in a population an assessment has to be madeof the harm-to-benefit ratio.

Any abnormality identified, whether in a national screening programme orin primary care, must be treatable and the investigation itself must notcause harm. Many believe that early diagnosis, particularly of cancer andheart disease, will lead to the possibility of treatment and improvement inprognosis. This is an attractive concept and can lead to a demand for ascreening procedure to be introduced, irrespective of whether it has beenshown that diagnosis guarantees an improved outcome. The belief thatidentifying the presence of a condition equates with the ability to alter itsnatural history may beguile the public but is unfortunately false.

Through advances in technology, the potential for testing – particularly inthe field of genetics – is immense. However, the technical ability to performa screening procedure does not guarantee its ethical acceptability, as manyexperiments in other areas of science and medicine illustrate. More thanever before it is vital that the key principles on which screening should bebased remain in sharp focus.

Audit, evaluation and quality control

In any screening programme, as with any other service programme,adequate steps must be taken to ensure that the original objectives arebeing met and that the methodology meets appropriate standards.

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The ideal method for evaluating a screening programme is the randomizedcontrolled trial in which individuals in a population are allocated, atrandom, either to a group that is screened or to a group that receives onlyits normal medical care. Randomized controlled trials are expensive anddifficult to manage and may also be ethically questionable in situationswhere the control group is denied treatment for the condition in question.Despite this, the UK National Screening Committee will only recommend theintroduction of any new screening programme after assessing the findings ofa properly conducted randomized controlled trial. The Committee alsokeeps all screening programmes under regular review to ensure that theycontinue to perform in the way intended and continue to be effective.

The components of an effectively organized screening programme havebeen described by Hakama11 and are summarized in Box 1.

The importance of maintaining the quality of screening programmes shouldnever be underestimated. Evaluation, audit and quality control should be anintegral part of any screening programme to ensure that it is achieving whatit has set out to do in a way that is acceptable to those involved.

CURRENT SCREENING PROGRAMMES IN THE UNITED KINGDOM

We recommend the following screening programmes at each stage of thelife-cycle based on our experience in the United Kingdom. The situationvaries throughout the EU, as we illustrate in the next section.

Antenatal and neonatal screening*

Two issues should be emphasized in the context of antenatal screening. The first is that care must be taken not to medicalize this usually normalstage of life where most pregnancies have a successful outcome. The secondis that there must be full, balanced and understandable informationavailable for pregnant women and properly trained health professionalswith time to provide and/or explain it. This is important for all pregnantwomen but particularly for those who experience difficulty and defect.

Our recommendations for screening in the antenatal period are summarizedin Table 5.

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* Key references: www.healthforallchildren.co.uk; www.nelh.nhs.uk/screening/child

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• The target population should be identified.

• Individuals in the population who are to be screened need to be identified.

• All those eligible for screening should be encouraged to attend – for example,by issuing a personal invitation, and offering suitable timing of screeningexaminations to suit the needs of those involved.

• There should be adequate premises, equipment and staff to ensure that thescreening examination is done under pleasant circumstances and is acceptableto those attending.

• There should be an appropriate, satisfactory method of ensuring the maintenance of the best standards of the test(s) by:

i initial and continuing training of the personnel conducting the test(s);ii demonstration (by appropriate records) of the maintenance standards of

equipment used in the examination – for example, calibration of X-raymachines in mammography;

iii routine checks of the validity of the tests performed – for example, random duplicate measurements for biochemistry, cytology, and reading of X-rays.

• There should be adequate and appropriate facilities for the diagnosis andtreatment of any individual found to require this. There should be as littledelay as possible between the screening attendance, advice that thescreening test was negative, advice that the screening test result requiredfurther investigation, and referral to the appropriate centre for furtherinvestigation or treatment. A timetable should be established for these differentprocedures and there should be continuous monitoring to ensure that thetime intervals between the various stages are complied with.

• There should be regular checks to ascertain the satisfaction level of thosewho have undergone the screening process – those investigated, thescreen-negatives and those invited who have not participated.

• Finally, regular periodic checks should be made of the records of thescreened individuals to ascertain their adequacy.

Box 1: Components of an effectively organized screening programme

Screening procedures in the neonatal period can be divided into those thatare part of routine screening for all newborn babies either by clinicalexamination or biochemical tests and those procedures for conditions suchas hearing loss that will require separate testing. Our recommendations aresummarized in Table 6.

The UK National Screening Committee aims to produce a singlecoordinated Antenatal and Neonatal Screening Programme throughout thecountry and, while considerable progress has been made, much remains tobe done to improve the organization and equity of services for this lifestage.

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RoutineAnaemiaBlood group and RhD status Blood test Early in pregnancy withHepatitis B effective follow-up for any HIV abnormalities identifiedRisk factors for pre-eclampsiaRubella immunitySyphilis

Asymptomatic bacteriuria Urine test As above

Fetal anomalies Ultrasound and Between 18 and 20 weeksAnencephaly blood test, if with effective follow-upSpina bifida indicated

Chromosome abnormalities Quadruple serum Second trimester withDown syndrome tests, ultrasound effective follow-up

High risk onlyThalassaemia/sickle cell diseaseTay-Sachs disease

Under research reviewDuchenne muscular dystrophyChlamydiaGestational diabetesFragile X syndromeHepatitis CGenital herpesHTLV1Streptococcus B

Table 5: Our recommendations for screening in the antenatal period

Screening and surveillance in childhood and adolescence*

Screening and surveillance (or observation) in childhood are important infollowing up difficulties already identified and in diagnosing disorders forwhich effective treatment is available. It should be a seamless extension ofantenatal and neonatal care and provides the opportunity for establishing abasis for good health in later life with appropriate advice on healthy eating,home and road safety, and immunization. All reasonable steps should betaken at this early stage to promote good health and prevent illness.

Our recommendations for screening in childhood are summarized in Table 7.

Childhood is the time to build on the care given in the antenatal andneonatal periods that should have identified any major problems andinstigated treatment where appropriate. Vigilance to find any abnormalitiesnot previously detected is important, but since the vast majority of children

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Condition Comment

RoutineBloodspotPhenylketonuriaCongenital hypothyroidism Must be properly evaluatedCystic fibrosis In process of introduction for all neonatesSickle cell disease

Physical examinationCongenital heart disease Adequate training programmes in Congenital cataract physical examination must be developedCryptorchism

Congenital dislocation of the hip/ Use of ultrasound as primary screeningdevelopmental dysplasia of the hip test to be evaluatedOther congenital malformations

Other testsHearing impairment Implementation ongoing

Under research reviewBiotinidase deficiencyCongenital adrenal hyperplasiaDuchenne muscular dystrophy

Table 6: Our recommendations for screening in the neonatal period

* Key references: www.healthforallchildren.co.uk; www.nelh.nhs.uk/screening/child

are healthy, the focus should be on laying good foundations formaintenance of that health in the future. The growing problem of childhoodobesity is not at present a matter for screening, although advice on weightcontrol, exercise and healthy eating should be available in primary careand in school. Since weight/height measurements are taken regularly atvarious ages by GPs and in schools, action should be taken on the results totry to improve the diet of children and encourage their participation ingames and exercise rather than submitting them to a “screening” test.

The more deprived and disadvantaged children and those who have recentlyarrived from abroad as refugees or asylum seekers may have missed out onearlier medical and dental checks and strenuous efforts should be made toidentify them to make sure that any omissions or inequities are minimized.

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Condition Comment

Hearing impairment • Follow-up on neonatal programme where indicated

• School entry “sweep” test to continue • Case-finding to identify late onset or

progressive impairment• Investigation of any children with educational

or behavioural problems

Amblyopia and impaired • Orthoptist screening in 4–5-year-olds vision • Attention to be paid to children who miss

this test for any reason

Dental disease • School dental screening mandatory and should continue, but should be kept under research review

• Early contact with dentists to be encouraged• Problems include shortage of dentists and

lack of parental compliance, especially among the more deprived

Congenital hip dysplasia/ • Children identified by neonatal screening to developmental dysplasia of be reviewedthe hip (CHD/DDH) • Parental observations and concerns to be

investigated

Deprived, disadvantaged or • Need to identify such children and instigate socially isolated children screening/case-finding where relevant

Table 7: Our recommendations for screening in childhood

Screening in adolescents and young adults is another crucial area thatneeds to be approached with sensitivity. This is a period of life when formalcontact with the health service is infrequent for most individuals. But it isalso a time when individuals are coping with profound physical andemotional changes and seeking their independence, but often lack theexperience and judgement to use it wisely.

The margins between childhood and adolescence are becoming blurredwith many children appearing to mature earlier, physically, if notemotionally. It is a difficult period of adjustment towards adulthood and onethat is poorly understood, partly due to the difficulties of communication.The focus of screening and surveillance at this sensitive stage should takeaccount of what adolescents and young adults themselves feel they requireand how it can be most effectively provided. Among their main needs are:

• accessible confidential health services;• greater involvement in planning services;• health education that reflects their experiences, especially about drugs

and alcohol;• specialized advice centres for those with drug problems.

The most constructive approach in this age group is opportunistic case-finding in primary and community care with sensitive and confidentialadvice, support and health education provided in a way and at a placethat is acceptable and helpful to young people to enable them moresuccessfully to bridge the difficult gap between childhood and maturity.

The only screening programme that we would consider appropriate inadolescence and early adulthood is the opportunistic programme forChlamydia, as detailed in Table 8.

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Condition Comment

Chlamydia Opportunistic screening of those aged 25 and under who access sexual health services or primary care

Table 8: Our recommendation for screening in adolescence and early adulthood

Screening in adults

Screening in adults is potentially big business. Media interest in health isinsatiable, and anyone who reads the newspapers, watches television orlistens to radio can hardly fail to be aware of the various diseases that maybe lying in wait for them. Of course, it is of benefit if potential healthproblems can be identified early and treated, or at least alleviated. Butsociety must beware of turning health into an obsession and must resist boththe increasing medicalization of life and the growing politicization ofmedicine. Above all, before any further national screening programme isintroduced, it must be clear that the long-established screening criteria aresatisfied and that the evidence base exists.

The national programmes for breast and cervical cancer should becontinued but kept under review with an emphasis on quality control and onproviding balanced and understandable information to enable women tomake a truly informed choice without pressure from health professionals onwhether or not to participate. Efforts must also be made to improvecoverage of those at highest risk.

A national programme of screening for colorectal cancer by faecal occultblood testing in adults aged from 50 to 74 years has been agreed in theUnited Kingdom but it is essential that adequate diagnostic, treatment andfollow-up facilities are in place before it is introduced.

Screening for risk factors of coronary heart disease and stroke should becarried out in the primary care setting with advice, treatment and follow-upas appropriate.

In the case of abdominal aortic aneurysm, it now seems clear thatultrasound screening in men aged 65 years and over would reducemortality from this condition, although the benefit for those aged over 75years has been questioned. As with colorectal cancer, however, nationalimplementation should await the certainty that adequate facilities andresources are available.

In the case of screening for diabetic retinopathy, close attention must bepaid to audit and the need to be absolutely clear about how, when andwhere to screen. Anecdotal evidence from Scotland suggests that the size ofthe problem may have been underestimated and that the reality ofimplementation does not match up to the rhetoric.

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Screening in adults is an area ripe for exploitation from private andcommercial sectors. It is essential that there is respectable scientific evidenceof benefit before any further programmes are introduced. Skrabanek’scontention that “medicine has no mandate to be meddlesome in the lives ofthose who do not need it”12 remains valid.

Our recommendations for screening in adults are summarized in Table 9.

Screening in the elderly

Society is facing a major challenge in how best to maintain health andquality of life in populations where the proportion of people aged over 60years now outnumbers those aged under 16 and the number of individualsaged over 85 is rising.

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Condition Comment

Breast cancer National programme should be continued but kept under close review with emphasis on quality control, staff training and good information.

Cervical cancer National programme should be continued with review of alternative types of tests and of age range of those eligible and frequency of screening. Good information to be a priority.

Colorectal cancer National screening programme by faecal occult blood testing for adults aged 50–74 years.

Abdominal aortic Ultrasound screening of men aged 65 and over aneurysm seems a reasonable proposition provided the

necessary resources are in place.

Diabetic retinopathy National programme of screening for all diabetics aged over 12. It is essential to be quite clear about how, when and where screening should happen to ensure effective implementation.

Risk factors for Weight surveillance/case-finding approach incoronary heart disease primary care.(CHD)/strokeBlood pressureCholesterolSmoking cessation

Table 9: Our recommendations for screening in adults

A system of regular surveillance and case-finding in primary care wouldseem to be the most appropriate form of screening, particularly in thoseaged 75 and over, but the resource implications of this must be confronted.Several simple tests, such as identifying difficulties with sight or hearing orproblems with feet, can make a huge difference to the comfort and qualityof life. Depression is another area where identification and treatment couldimprove well-being. Social and community support are also vital in enablingolder people to enjoy as independent and contented a life as possible.

The emphasis in screening at this stage of life should be on improvingquality of life and preserving function and independence, rather than onproviding “heroic” treatments to prevent mortality.

Our recommendations for screening of the elderly in primary care aresummarized in Table 10.

SCREENING PRACTICE WITHIN THE EUIn this section we review briefly the position on screening in 28 countries,with regard, where relevant, to cervical, breast and colorectal cancers,phenylketonuria, Down syndrome, spina bifida, HIV, TB and Chlamydia.Detailed information on screening in the original 15 countries of the EU canbe found in Annexe 1; information on screening in the New Member Statesand the Candidate Countries of Turkey and Bulgaria is provided in Annexe2.

The screening situation across Europe is generally very different from that inthe United Kingdom because of the differing structures and financing ofhealth services. Few other countries have a single national body to review

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Physical assessment Mental assessment Social assessment

Hypertension Depression Falls Early heart failure Alcohol use Undernutrition Hearing loss Isolation Vision loss Incontinence Lack of physical activity Foot problems Review of medication

Table 10: Our recommendations for screening in the elderly

screening practice and policy, and population registers for recall andfollow-up of patients are also comparatively rare. Screening tends to betargeted at individuals rather than populations and not all countries adhereto the criteria summarized in Table 1. In many countries health serviceprovision is devolved to local or regional government and screeningpractice in different areas can vary widely as a result.

Antenatal screening: Down syndrome and spina bifida

The situation in relation to screening in the antenatal period in the UnitedKingdom has been described in the previous section and summarized inTable 5. Elsewhere in Europe screening at this stage of life seems to focuson Down syndrome and spina bifida.

In Denmark, from September 2004, pregnant women have had the optionof undergoing an examination to indicate risk of Down syndrome and ofhaving a test for spina bifida.

In Finland, participation in the screening of Down syndrome and spina bifidais voluntary. Almost all municipalities offer ultrasonic scanning for pregnancyin weeks 13–14 and 16–19. Amniocentesis and serum screening areprovided for women between 35 and 40 years of age (the age limit dependson the municipality – for example, in Helsinki the age limit is 40 years).

In France, Down syndrome is systematically screened for in prenatalexaminations. A blood test is offered to every pregnant woman.Amniocentesis is systematically offered to women considered to be at risk:mothers aged 38 years or over, those who have had abnormal blood testresults, defects detected in previous pregnancies, or where there arechromosomal anomalies in parents. Spina bifida is detected by ultrasoundin week 17 of pregnancy.

In Greece, pregnant women aged 35 years and over are offeredamniocentesis.

In Italy, guidelines are very vague but a test for Down syndrome isrecommended to all women at risk and for those aged over 35 years. Thetake-up of antenatal screening varies across regions.

In the Netherlands, tests for Down syndrome and spina bifida (triple tests) arerecommended for all women aged over 35 years at three months of pregnancy.

19

In Spain, antenatal screening is performed either in primary care or inhospital. The guidelines for monitoring a normal pregnancy include: triplescreening for Down syndrome and spina bifida, virus serology for hepatitisB, Rh incompatibility, virus serology for rubella and serology for Toxoplasmagondii. Amniocentesis is highly recommended for women over the age of35 years.

In Sweden, all pregnant women are offered one ultrasound scan in thesecond trimester (gestational weeks 15–20) and 97% of women comply.Women aged 35 years or older are given more detailed information by aphysician and are offered amniocentesis routinely.

In Bulgaria, a selective national antenatal screening programme is in place.Amniocentesis is offered free of charge to all pregnant women over 35years of age, to women who already have a child suffering from anycongenital malformation, and to those referred by a genealogist.

In the Czech Republic and Estonia, testing for spina bifida and Downsyndrome is part of basic screening during the prenatal period. Genetictesting is part of routine prenatal care for pregnant women over 37 years ofage and where indicated among younger pregnant women. Twoultrasounds are also part of the routine management of all pregnancies.

In Hungary, ultrasound examination for Down syndrome is carried out inweek 12 of pregnancy.

In Latvia, tests for Down syndrome are provided for pregnant womenconsidered at high risk in weeks 11 and 17 of pregnancy. High-risk groupsinclude women over 35 years of age; father over 45 years of age; one orboth parents previously affected by radiation; or those women who havehad an acute viral infection during the first trimester of pregnancy.

In Lithuania, screening for Down syndrome is performed only on thoseconsidered at risk, or if specifically requested. All pregnant women aged35 and over, those who have previously had babies with congenitalabnormalities, and those who request it are sent to the Human GeneticsCentre for a triple test which is performed during weeks 14–15 ofpregnancy. Routine ultrasound examinations are performed during weeks18–20 and 30–32 of pregnancy.

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Neonatal screening: phenylketonuria

The situation in relation to screening in the antenatal period in the UnitedKingdom has been described in the previous section and summarized inTable 6. The UK Newborn Screening Programme Centre was established in 2002 with a remit to monitor and improve the quality of newbornbloodspot screening procedures and their outcomes for parents and theirbabies.

In France, neonatal examination is routine for neonates. This includes bloodtesting for phenylketonuria, congenital hypothyroidism, adrenal hyperplasia,haemoglobinopathies/sickle cell anaemia and cystic fibrosis.

Screening for phenylketonuria is recommended in all countries belonging tothe EU before May 2004, except Finland, where screening of the nativeFinnish population is not considered necessary (screening is done, however,if both parents are of western European, American, or Jewish, Kurdish orYugoslavian origin). In the new Member States and Candidate Countries,screening for phenylketonuria is recommended in Bulgaria, the CzechRepublic, Estonia, Hungary, Latvia, Lithuania, Slovakia and Slovenia.

Breast cancer

The situation in relation to screening for cancer of the breast in the UnitedKingdom has been described in the previous section and is summarized inTable 9.

In Belgium, based on the directives developed by Europe Against Cancer,the three Communities and the Federal Government signed a protocol, inOctober 2000, to organize and finance a national campaign of breastcancer screening for women aged 50–69 years. The responsibility for thecoordination of the campaign rests with 11 recognized screening centres.There are five centres in Wallonia (one per province), five in Flanders (inthe four Flemish universities and in Bruges) and one in Brussels. Thescreening centres are responsible for making information available to thetarget group, sending out the invitations, retesting where necessary,recording data and reporting to the referring doctor. In Flanders thecampaign started on 15 June 2001, and in Wallonia and Brussels a yearlater.

In Denmark, screening programmes for breast cancer are established intwo of the 14 county councils (Funen and H:S) for women aged 50–69

21

years. These two screening programmes cover 20% of the targetpopulation.

In Finland, under the terms of the Public Health Act, women between theages of 50 and 59 years are invited every two years for breast screening.

In France, screening for breast cancer, previously limited to somedépartements (32 at the end of 2002), has been extended since January2004. Every woman between 50 and 74 years (except for those inGuyana) is invited for a free breast screening every two years. A strategicobjective of the Public Health Act, which came into force in August 2004, is to “reduce the percentage of late-stage breast cancer detected in women,notably by increasing the screening coverage rate up to 80% in womenaged between 50 and 74 years“. The Act calls for specific programmes totarget isolated, disabled or deprived women who might be reluctant toparticipate. This has been partly achieved by the production of audiovisualmaterials for people suffering from visual or hearing deficiencies, and bythe translation of brochures into community languages. Several campaignsat national and local levels are also planned. Patients’ and women’sassociations are involved in this information/distribution effort.

In Ireland, Phase 1 of BreastCheck, a national breast screening programme,started in February 2000 and already offers screening in several areas,with coverage expected to extend nationwide by the end of 2007. Breastscreening outside the BreastCheck programme is available to all women ifthey are referred by a GP.

In Italy, screening policies for breast cancer have been included in thepackage of essential levels of care provided by the national health system(Essential Level of Assistance) by Decree “DPCM 29/11/2001”. All nationalhealth plans have set targets for these areas of prevention. Registers aremanaged at regional level, however, and screening programmes are morewidespread in northern and central Italy. There is usually a system fortargeting and recalling patients, but the target population varies accordingto regional health plans so the position is varied.

In the Netherlands, there is a national programme for breast cancerscreening.

In Spain, since 1990 breast cancer detection programmes have beenimplemented in all Autonomous Communities. The programmes’ target

22

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population varies across regions but in most it includes women aged 50–65years.

In Sweden, national guidelines from the National Board of Health andWelfare recommend mammography screening for early detection of breastcancer for women aged between 40 and 74 years. Examination intervals are18 months for women under 55 years, and 24 months for women over 55.

Among the new Member States, a pilot programme for breast cancerscreening has started in Cyprus and covers women aged 50–69 years.

In Estonia, there is a screening programme for breast cancer, financed andadministered by the Estonian Health Insurance Fund. The target populationis women aged 45–59 years, and the screening interval is three years.

In Hungary, mammography screening was introduced in 2002 for womenaged 45–65 years, and the procedure is repeated biannually with a goodparticipation rate.

In Latvia, screening for cancer is included in the prophylactic programmefor adults and covered through the health care budget. For breast cancer,women aged 50–69 years are recommended to undergo onemammography every two years.

In Slovakia, breast cancer screening is provided by the State and paid forby health insurance companies. The target population is women aged40–60 years and the method is periodic mammography.

Cervical cancer

The situation in relation to screening for cancer of the cervix in the UnitedKingdom has been described in the previous section and is summarized inTable 9.

In Denmark, screening for cervical cancer is available in all 14 countycouncils. Women in the age group 23–59 years are invited to participate,except in Copenhagen, where coverage is limited to those aged 25–45years.

In Belgium, a programme of cervical cancer screening has been runningsince 1994, when the Flemish Government decided to reorient the

23

organization of secondary prevention of cervical cancer according to theEuropean guidelines. The programme targets women aged between 25 and64 years, who are invited for a Pap smear every three years. The programmeis administered and evaluated by the Scientific Institute of Public Health incollaboration with the Communities. Despite scientific support, no formalscreening programme is organized in the French Community.

In Finland, the Public Health Act states that women aged 30–60 yearsshould be invited for screening for cervical cancer every five years.

In France, cervical cancer screening is offered to women aged 25–69 yearsevery three years. A recent study estimated that 35% of women in the targetage group have never, or only rarely, been screened. Targeted messageswill be used to reach these women and coverage could be increased by theparticipation of GPs (96% of Pap tests are currently carried out bygynaecologists). The 48th objective of the Public Health Act of 2004 is “tocontinue the annual 2.5% decrease of cervical cancer incidence, notably byincreasing screening coverage rate to 80% for women aged 25–69 andHPV [human papillomavirus] test utilisation.“

National screening programmes for cervical cancer are available also inGermany (for the statutory health insured) and the Netherlands.

In Italy, screening programmes for cervical cancer are similar to those forbreast cancer. Registers are managed at regional level and screeningpolicies are more widespread in northern and central Italy.

In Ireland, Phase 1 of a National Cervical Screening Programme, whichoffers free cervical screening to women aged 25–60 years in the Mid-Western Health Board (MWHB) area, has recently started.

In Spain, cervical cancer screening through cytology is offered to all womenaged 35 years and over, but there are regional differences. In Catalonia,for example, there is a personalized register of all target individuals(women aged 20–64 years). Cervical cancer screening (Pap smear) isrecommended every three to five years. In the Balearic Islands, screeningfor cervical cancer prevention is opportunistic rather than population-based.

In Sweden, organized cervical cancer screening has been implemented sincethe mid-1960s. Guidelines for recommended screening are every third yearfor women aged 23–50 years and every fifth year for women aged 51–60.

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In Bulgaria, a national strategy for prophylactic cancer screening(2001–2006) was approved in 2000. Given the scarce resources availablefor this strategy, however, it only recommends preventive examinations forcervical cancer as part of regular gynaecological examinations.

In Cyprus, there is a national policy on screening for cervical cancer basedon the population register and covering all women aged 25–65 years.

In Hungary, a gynaecological cervical screening programme was launchedin 2004. It is based on Pap smear testing of all women aged 25–65 yearsevery three years.

In Latvia, women aged 20–35 years are recommended to have anoncological test every three years. For women aged 35–70 years, the test iscarried out annually.

Since July 2004, in Lithuania a cervical cancer prevention programme hasbeen financed by the Compulsory Health Insurance Fund. The programmetargets women aged 30–60 years and screening is performed every threeyears.

In Slovenia, there is a national policy on screening for cervical cancer thatincludes all women between the ages of 25 and 64 years. There is activefollow-up through a central surveillance system, and the screening interval isthree years, after two initial smears over six months have proved negative.

Colorectal cancer

The situation in relation to screening for colorectal cancer in the UnitedKingdom has been described in the previous section and is summarized inTable 9.

In Denmark, a trial for colorectal cancer has started in two of the countycouncils where men and women aged 50–74 years are invited to participate.

In Finland, a pilot project for colorectal cancer screening of people betweenthe ages of 60 and 69 years was introduced in 2004 in severalmunicipalities.

In France, colorectal cancer screening is the 53rd objective of the 2004Public Health Act and is currently the subject of trials in 22 départements.

25

People aged 50–74 years are invited for a faecal occult blood test (FOBT)every two years. If the result is positive, a colonoscopy is carried out. Theprogramme will be assessed shortly to define the national strategy for2007. Initial results showed an increasing rate of participation (up to 50%in some départements) because of active participation by GPs.

HIV screening

In the United Kingdom, HIV screening is offered to all women in the earlystages of pregnancy with clear referral paths for positive cases (Table 5),and is compulsory for blood and organ donors.

Elsewhere in the EU, HIV screening tends to be targeted at vulnerable socialgroups. It is more common among the new Member States and CandidateCountries.

In the Czech Republic, for example, HIV screening is compulsory for donorsof blood, organs or any biological material, and for pregnant women. InEstonia, it is compulsory during pregnancy, on entering the military serviceand for prisoners. In Latvia, the target population includes pregnant women,individuals to be recruited for military service, those involved in the nationalarmed forces and international peace maintenance, and prisoners. InSlovenia, HIV screening is performed on pregnant women, patients with anewly established diagnosis of syphilis, and on all donors of blood ororgans. In Turkey, it is compulsory for blood donors, registered sex workers(once every three months), illegal migrant sex workers, men recruited formilitary service, any patient undergoing a blood test at a public health unit,pregnant women, patients before undergoing surgery and couples intendingto marry.

HIV screening programmes are also offered to all pregnant women inFinland and France, although it is not compulsory. Screening is compulsory,however, for donors of blood, organs, sperm or milk.

Tuberculosis screening

Screening for TB is not at the moment recommended as a nationalprogramme in the United Kingdom although it was originally the earliestscreening programme introduced with successful results.

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Screening for TB is performed in several European countries and particularlyin the new Member States and Candidate Countries. In Hungary, forexample, TB screening is based on a defined population register with asystem for targeting and recalling individuals (aged 18 years and over), onan annual basis. In 2003, 134 fixed and 48 mobile pulmonary screeningstations were operating, and 3 717 518 screening examinations werecarried out (43% of the adult population was screened).

A massive TB screening programme is in place also in Romania. Thousandsof people are screened by X-ray examination: soldiers, recruits, teachers inschools (every year), children entering kindergarten and their parents,couples before marriage and prisoners. All individuals who work in thefood industry or those who are handling food also require an annual X-rayexamination.

In Turkey, there is a national policy for screening, monitoring and treatingTB. This is based on a defined population, which includes primary schoolchildren (between 7 and 11 years of age), registered sex workers (once ayear), and men conducting their compulsory military service (20–41 years).TB screening is also a procedural requirement for all job applicationsassociated with joining any of the existing insurance schemes.

The key points on screening in the European Union are summarized in Box 2.

CONCLUSIONS

On the basis of this brief account, it is evident that screening programmesand practices vary widely across the countries of the EU and will continueto do so for many years to come. This is inevitable given the differingstructures and financing of health services, and differing demographicfeatures of the population. There are, however, key objectives to strive for.These include having one national body per country responsible for practiceand policy, scrupulous adherence to the long-established screening criteria,accurate population registers, greater uniformity of access across differentareas of a given country and across different socioeconomic groups, andsound research evidence on which to base practice.

The wide variation in practice in Europe illustrates the complexity ofscreening. Some lessons, however, stand out:

27

• the need for greater consideration to be paid to the effectiveness ofscreening;

• the need for more attention to be given to evaluating the processes ofscreening;

• above all, an imperative to involve participating individuals in decisionson screening and to give them clear and understandable informationabout what it involves.

Arguably, the most significant development in the screening field in theUnited Kingdom in the last 15 years has been the establishment in 1996 ofthe National Screening Committee (NSC), and this could be used as a modelfor organizing screening in other countries. The NSC now has overallresponsibility for screening policy and for identifying screening proceduresthat should be provided by the National Health Service. It has accepted thelong-established criteria for the assessment of appropriate tests and has beeneffective in both commissioning good quality research where required andin maintaining continuing surveillance and review of existing programmes.

Accurate population registers are essential to facilitate adequate call/recallsystems, which are crucial for the effectiveness of any screening procedure.

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• Antenatal screening programmes for Down syndrome and spina bifida areperformed only in a few countries and are mainly optional. They are oftenonly recommended to women at high risk.

• Neonatal screening for phenylketonuria is systematically recommended inall countries belonging to the EU before May 2004, except Finland.

• Breast cancer screening and cervical cancer screening programmes arerecommended in some European countries.

• HIV screening is more common among the new Member States and threeCandidate Countries and covers specific vulnerable groups, such as pregnant women and blood donors.

• TB screening is performed in a few European countries, especially centraland eastern European countries, such as Hungary, Romania and Turkey.

• Not all the countries follow the basic criteria for screening. A populationregister to allow recall and follow-up of patients is often missing. A singlenational body for reviewing tests and practice is rare.

Box 2: Screening in the EU: key points

Screening must also be adapted to the particular needs of differing localpopulations. There must be rigorous checking of the quality of screeningservices and their evaluation, including medical audit. There should also bea coordinated and measured approach to screening with a gradual roll-outof programmes to ensure effective implementation and to avoid overloadingthe health services.

There remains a need for good research on which to base recommendationsfor screening, but funding is difficult to find. Screening research in theUnited Kingdom is subsumed under the title of Health Services Research butit is expensive to carry out; large numbers of subjects are needed, and ittakes a long time to produce results. Precedence in funding tends to begiven to studies of greater political significance, such as waiting-list targets,where results can be expected more quickly.

Although there is increasing concern with the strength of evidence before aparticular screening test is introduced and greater emphasis on possibleadverse effects, the dilemma as to whether a specific test should beprovided, even if it has not met the criteria, has not been satisfactorilysolved. This can be illustrated by the demand for PSA testing in the UnitedKingdom where the Prostate Cancer Risk Management Programme hasbeen introduced in primary care to provide advice and testing for thosewho request it, rather than providing a national screening programme forwhich there is currently insufficient evidence of benefit.

Challenges

Screening today faces a number of challenges in the EU as elsewhere.

The first of these is the growth of private screening and full-body checks,and the increased demand from the public in the mistaken hope thatscreening will ensure future good health. This trend is currently moreapparent in the United States and the United Kingdom than in Europe as awhole but is likely to spread. A recent survey of screening in the consumermagazine Which? asked two screening experts to give a verdict on theinformation and tests provided by five private full-body screening services.13

They concluded that information provided about the likely benefits, harmsand limitations of the tests was in most cases inadequate, or evenmisleading, and expressed major misgivings about the value of paying forfull-body scans. It was of interest, however, that the two lay peopleinterviewed for the survey were enthusiastic about screening, highlightingthe gap between professional and public perceptions.

29

Screening provided by national health services may not be perfect but it hasbeen introduced on the basis of sound scientific evidence, is subject toongoing scrutiny and provides continuity of care and follow-up. This is notnecessarily the case in the private sector.

Second, we must continue to work on providing honest and comprehensibleinformation about the various programmes and tests, and train or re-trainthose providing it in how to communicate clearly and without bias. It isessential that those invited to participate in screening are able to make aninformed choice and are fully aware of all the implications. This will not beeasy, particularly, for example, with long-established programmes such ascervical cancer screening where in some places it is still perceived thatwomen should agree to screening when invited.

It must also be acknowledged that some of the tests involved are extremelyunpleasant. Faecal occult blood testing for colorectal cancer is relativelysimple and non-invasive; colonoscopy, the next step after a positive result,most certainly is not.

Third, there is still great variability in the take-up of screening betweendifferent geographical areas and different socioeconomic groups. It isworrying that the more affluent members of the population who aregenerally at lower risk are more likely to accept invitations for screening,while those in the more deprived sectors at higher risk do not. Strategies forimproving equity of access must be devised and implemented.

Finally, there is a major task to educate and inform the media and thepublic as to what screening can and cannot do. Screening is not and cannever be a universal remedy but, used selectively and on the basis of soundresearch evidence, it can continue to be a good use of resources. Providedit remains open to constant review and critical evaluation and is capable ofchange in the light of new evidence, screening will remain a powerful toolin the fight against disease and its impact for the foreseeable future.

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REFERENCES

1 Thorner RM, Remein QR (1961). Principles and Procedures in theEvaluation of Screening for Disease. PHS publication no. 846. PublicHealth Monograph no. 67.Washington: Public Health Service.

2 Wilson JMG, Jungner G (1968). Principles and Practice of Screeningfor Disease. Geneva: World Health Organization.

3 McKeown T (ed.) (1968). Screening in Medical Care: Reviewing theEvidence. Oxford: Oxford University Press for the Nuffield ProvincialHospitals Trust.

4 www.nsc.nhs.uk/

5 US Commission on Chronic Illness (1957). Chronic Illness in the US.Vol. I. Prevention of Chronic Illness. Cambridge, Mass: HarvardUniversity Press.

6 Health Departments of the United Kingdom (1998). First Report of theUK National Screening Committee, April.

7 Health Departments of the United Kingdom (2000). Second Report ofthe National Screening Committee, October.

8 Cochrane AL, Holland WW (1971). Validation of screeningprocedures. British Medical Bulletin, 27(1):3–8.

9 Chamberlain Jocelyn M (1984). Which prescriptive screeningprogrammes are worthwhile? Journal of Epidemiology and CommunityHealth, 38:270–277.

10 Wykes WN (2004). Personal communication.

11 Hakama M (1986). Screening for cancer. Scandinavian Journal ofSocial Medicine Supplement, 37:17–25.

12 Skrabanek P (1994). The Death of Humane Medicine. London: SocialAffairs Unit.

13 Health Screening (2004). Which?, 12 August.

31

ANNEXE 1

Screening tables: the EU before May 2004

34

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Tuber

culo

sis

Ow

ing

to th

e re

lativ

ely

low

inci

denc

e of

TB

inA

ustri

a, n

o ge

nera

lpl

an o

n sc

reen

ing

is in

plac

e. U

ntil

2000

, the

gene

ral v

acci

natio

npl

an r

ecom

men

ded

inoc

ulat

ion

agai

nst T

B.N

ow o

nly

spec

ific

risk

grou

ps (e

.g.

hosp

ital e

mpl

oyee

s)ar

e va

ccin

ated

.

HIV

Ther

e is

no

natio

nal p

olic

y on

scr

eeni

ng fo

r H

IV. S

ome

1.2

mill

ion

peop

le in

Aus

tria

have

an

HIV

test

done

ever

y ye

ar, 5

0000

0 of

them

whe

n m

akin

g a

bloo

d do

natio

n.Fo

r pre

vent

ion

of H

IV in

fect

ion,

gen

eral

info

rmat

ion

broc

hure

s en

sure

con

tinui

ty in

the

diss

emin

atio

n of

bas

icin

form

atio

n ab

out t

his

dise

ase.

Tar

get-g

roup

-spec

ific

publ

icat

ions

and

cam

paig

ns a

re a

ddre

ssed

to c

erta

in

age

grou

ps (e

.g. y

oung

peo

ple)

or

peop

le w

ho in

dulg

e in

cer

tain

form

s of

hig

h-ris

k be

havi

our

(peo

ple

who

frequ

ently

cha

nge

sexu

al p

artn

ers,

sex

tour

ists,

pro

stitu

tes

and

thei

r cu

stom

ers)

. The

dut

y of

the

Fede

ral

Min

iste

r of

Hea

lth to

impl

emen

t mea

sure

s to

edu

cate

peo

ple

abou

t HIV

and

the

prev

entio

n of

HIV

infe

ctio

n is

embe

dded

in th

e A

ustri

an A

IDS

Act

, 198

5.

In a

dditi

on to

its

cent

ral i

nfor

mat

ion

activ

ities

, the

hea

lth d

epar

tmen

t sup

ports

the

regi

onal

AID

S he

lp

insti

tutio

ns a

nd a

num

ber

of s

elf-h

elp

insti

tutio

ns. T

he c

ontin

uous

info

rmat

ion

and

cons

ulta

tion

activ

ities

of t

heA

IDS

help

insti

tutio

ns r

ange

from

car

ryin

g ou

t ano

nym

ous

HIV

ant

ibod

y te

sts a

nd a

ssoc

iate

d ad

viso

ry ta

lks,

right

up

to th

e ps

ycho

logi

cal c

are

of H

IV-p

ositi

ve p

eopl

e an

d th

ose

with

full-

blow

n A

IDS.

The

Fede

ral M

inis

try fo

r H

ealth

and

Wom

en p

ublis

hes

statis

tics

on in

cide

nce

and

deat

hs, d

iffer

entia

ted

byris

k gr

oups

and

pro

vinc

es, o

n a

mon

thly

bas

is.

Chla

mydia

No

info

rmat

ion

avai

labl

e.

Aust

ria

Tuber

culo

sis

In th

e Fr

ench

Com

mun

ity a

ll ne

w c

ases

of T

B m

ust

be d

ecla

red

to th

e pr

ovin

cial

hea

lth in

spec

tor.

The

Foun

datio

n fo

r Re

spira

tory

Con

ditio

ns a

ndH

ealth

Edu

catio

n (F

onda

tion

cont

re le

sA

ffect

ions

Res

pira

toire

s et

pou

r l’E

duca

tion

à la

Sant

é: F

ARE

S) p

roce

sses

the

regi

ster

of a

ctiv

eca

ses

of T

B fo

r th

e W

allo

on d

istri

ct a

nd th

e m

etro

polit

an d

istri

ct o

f Bru

ssel

s. In

the

Flem

ish

Com

mun

ity th

e re

cord

ing

is in

the

hand

s of

the

heal

th in

spec

tion

of th

e Pr

even

tive

and

Soci

alH

ealth

Car

e D

ivis

ion.

All

data

are

bro

ught

toge

ther

in th

e Be

lgia

n tu

berc

ulos

is r

egis

ter.

This

pol

icy

is fi

nanc

ed b

y th

e C

omm

uniti

es.

HIV

In B

elgi

um th

ere

are

seve

n A

IDS-

refe

renc

e ce

ntre

s w

ith e

ight

refe

renc

e la

bora

torie

s, r

ecog

nize

d an

d fin

ance

d by

the

fede

ral g

over

nmen

t. O

ne o

f the

ir ta

sks

is to

impl

emen

t co

nfirm

atio

n te

sts o

n se

ra fo

und

posi

tive

at a

det

ectio

n te

st.Si

nce

only

thes

e se

ven

refe

renc

e ce

ntre

s ar

e qu

alifi

ed to

run

thes

e te

sts, t

he re

cord

ing

give

s a

com

plet

e pi

ctur

e of

the

tota

lnu

mbe

r of

per

sons

with

HIV

. The

ref

eren

ce c

entre

s al

so tr

yto

col

lect

bas

ic e

pide

mio

logi

cal f

acts.

For

this

a sta

ndar

dize

dfo

rm is

sen

t to

ever

y do

ctor

who

dia

gnos

es H

IV, r

eque

sting

info

rmat

ion

on s

ex, a

ge, n

atio

nalit

y, p

ossi

ble

man

ner

ofco

ntag

ion

and

clin

ical

sta

ge a

t the

poi

nt o

f dia

gnos

is.

This

reg

istra

tion

is fi

nanc

ed b

y th

e fe

dera

l sta

te a

nd d

ata

are

anal

ysed

by

the

Scie

ntifi

c In

stitu

te o

f Pub

lic H

ealth

.

Chla

mydia

Chl

amyd

iais

one

of t

he o

rgan

ism

sth

at h

ave

to b

e re

porte

d by

the

115

sent

inel

mic

robi

olog

y la

bora

torie

s re

pres

entin

g 59

% o

f all

reco

gniz

edpr

ivat

e or

hos

pita

l mic

robi

olog

y la

bora

torie

s in

200

4. It

mus

t be

repo

rted

to th

e Sc

ient

ific

Insti

tute

of

Publ

ic H

ealth

, whi

ch fo

llow

s th

e tre

nds

in n

umbe

rs o

f iso

late

s of

diff

eren

tor

gani

sms

repo

rted

to th

e ne

twor

k in

ord

er to

car

ry o

ut s

urve

illan

ce o

fin

fect

ious

dis

ease

s. T

his

regi

strat

ion

is fi

nanc

ed b

y th

e fe

dera

l sta

te.

Bel

giu

m

Tabl

e A

1.1

TB,

HIV

, Chl

amyd

ia

35

Tuber

culo

sis

Wor

ld H

ealth

Org

aniz

atio

n (W

HO

) and

the

Inte

rnat

iona

lU

nion

Aga

inst

Tube

rcul

osis

and

Lun

g D

iseas

e (IU

ATLD

), ad

vise

ever

y co

untry

to h

ave

a na

tiona

lpro

gram

me

on tu

berc

ulos

is,

whe

reby

eve

ry c

ase

is r

epor

ted

to th

e au

thor

ities

. In

Den

mar

kca

ses

are

repo

rted

to th

e m

edic

al o

ffice

r of

hea

lth. T

reat

men

tsar

e of

fere

d at

pul

mon

ary

units

, whi

ch e

nsur

e th

at tr

eatm

ent i

sca

rrie

d ou

t, m

edic

atio

n is

take

n as

pre

scrib

ed, a

nd th

at th

epa

tient

is c

ured

. The

sam

e un

its a

lso m

ake

sure

that

the

envi

ronm

ent a

roun

d ev

ery

infe

ctio

us c

ase

is e

xam

ined

clos

ely.

Eve

ry m

embe

r of

the

patie

nt’s

fam

ily is

X-ra

yed

and

Man

toux

teste

d.

In 1

986

the

prev

alen

ce o

f TB

was

the

low

est e

ver

at 2

99ca

ses.

Sin

ce th

en it

has

nea

rly d

oubl

ed, p

rimar

ily d

ue to

imm

igra

tion

from

are

as w

ith a

hig

h pr

eval

ence

. The

re a

reon

ly a

few

rec

orde

d ca

ses

of T

B tra

nsm

itted

from

imm

igra

nts

to n

ativ

e D

anes

.

HIV

Scre

enin

g fo

r H

IV is

oppo

rtuni

stic.

Tes

ts ar

eav

aila

ble,

and

free

of

char

ge, a

t eve

ry G

P su

rger

y an

d at

larg

erho

spita

ls th

roug

hout

the

coun

try, w

here

an

onym

ous

testi

ng a

ndco

unse

lling

are

avai

labl

e.In

form

atio

n ab

out t

hete

sting

opt

ions

is

prom

oted

in h

igh-

risk

popu

latio

ns, e

spec

ially

amon

g th

e ho

mos

exua

lpo

pula

tion.

Chla

mydia

As

with

all

othe

r se

xual

ly tr

ansm

itted

dis

ease

s (S

TDs)

, tes

ting

for

Chl

amyd

iais

offe

red

at e

very

GP

surg

ery

and

at la

rger

hos

pita

ls.W

heth

er th

e pr

esen

t scr

eeni

ng o

ptio

n sh

ould

be

chan

ged

to a

strat

egy

whe

re a

ll yo

ung

peop

le in

the

age

grou

p 16

–25

year

sar

e of

fere

d a

year

ly h

ome

test

is u

nder

con

side

ratio

n. A

hom

ete

st w

ill a

lso b

e of

fere

d to

par

tner

s w

hen

know

n. T

his

strat

egy

isin

tend

ed to

red

uce

the

frequ

ency

of C

hlam

ydia

and

the

num

ber

of u

roge

nita

l inf

ectio

ns, i

nfer

tility

, ect

opic

pre

gnan

cy a

nd c

hron

icab

dom

inal

pai

n. T

he s

trate

gy w

ill b

e co

st-ef

fect

ive

afte

r the

four

thye

ar o

f scr

eeni

ng. B

ecau

se o

f con

cern

s ab

out s

tigm

atiz

atio

n,ho

me

tests

are

gen

eral

ly w

ell a

ccep

ted

by th

e ta

rget

gro

up, w

hosh

ould

hav

e im

med

iate

acce

ss to

info

rmat

ion

and

advi

ce.

All

thre

e di

seas

es a

re b

eing

kep

t und

er s

urve

illan

ce b

y th

e St

ate

Seru

m In

stitu

te. T

he s

cree

ning

tests

and

, if n

eede

d, th

e tre

atm

ent,

are

free

of c

harg

e w

ith c

osts

cove

red

by th

e co

unty

cou

ncils

.

Den

mark

Tuber

culo

sis

The

natio

nal p

olic

y on

scr

eeni

ng fo

r TB

isop

portu

nisti

c i.e

. it i

s ba

sed

on id

entif

ied

case

s. A

phy

sici

an is

res

pons

ible

for

notif

ying

ever

y TB

cas

e to

the

natio

nal r

egis

ter

of

infe

ctio

us d

isea

se a

dmin

iste

red

by th

eN

atio

nal P

ublic

Hea

lth In

stitu

te. T

here

are

abou

t 500

new

TB

case

s in

Fin

land

ann

ually

.

HIV

Scre

enin

g fo

r H

IV fo

r pr

egna

nt w

omen

was

sta

rted

in 1

993.

Exc

ept f

or p

regn

ant w

omen

, the

scr

eeni

ngsy

stem

for

HIV

is o

ppor

tuni

stic.

The

Nat

iona

l Pub

licH

ealth

Insti

tute

mai

ntai

ns a

n H

IV la

bora

tory

, whi

chfo

llow

s, p

redi

cts

and

tries

to p

reve

nt n

ew H

IV c

ases

.In

the

perio

d 19

80–2

003,

162

5 H

IV c

ases

wer

eid

entif

ied

in F

inla

nd. T

he F

inni

sh m

unic

ipal

ities

,w

hich

org

aniz

e an

d fin

ance

mat

erni

ty c

linic

ser

vice

s,or

gani

ze th

e sc

reen

ing

prog

ram

me

for

HIV

for

preg

nant

wom

en.

Chla

mydia

The

natio

nal s

cree

ning

pol

icy

for

Chl

amyd

iais

oppo

rtuni

stic.

Onl

y Fi

nnis

h St

uden

t Hea

lthSe

rvic

es (Y

THS)

org

aniz

e sy

stem

atic

scr

eeni

ngfo

r C

hlam

ydia

for

first-

year

uni

vers

ity s

tude

nts

and

for

stude

nts

mak

ing

gyna

ecol

ogic

al v

isits

.Fo

r fir

st-ye

ar u

nive

rsity

stu

dent

s sc

reen

ing

isun

derta

ken

in c

onju

nctio

n w

ith a

phy

sica

l ex

amin

atio

n. F

inni

sh S

tude

nt H

ealth

Ser

vice

s ar

e fin

ance

d m

ainl

y by

the

Nat

iona

l Soc

ial

Insu

ranc

e In

stitu

te (K

ELA

in F

inni

sh) a

nd s

tude

nts.

Finla

nd

36

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

No

info

rmat

ion

avai

labl

e.

HIV

HIV

scr

eeni

ng is

sys

tem

atic

and

com

pulso

ry fo

rbl

ood,

org

an, s

perm

or m

ilk d

onor

s. It

issy

stem

atic

ally

sug

geste

d in

pre

nupt

ial a

ndpr

enat

al e

xam

inat

ions

and

ofte

n to

peo

ple

unde

rgoi

ng s

urgi

cal p

roce

dure

s.If

som

eone

wish

es to

ben

efit

from

HIV

sc

reen

ing,

ther

e ar

e tw

o po

ssib

ilitie

s:1.

Atte

ndan

ce a

t spe

cial

cen

tres

(Con

sulta

tions

de D

épist

age

Ano

nym

e et

Gra

tuit:

CD

AG

),w

here

tests

are

free

and

ano

nym

ous.

The

reis

at le

ast o

ne c

entre

per

”de

partm

ent”

.2.

Con

sulta

tion

with

a G

P or

spe

cial

ist, w

how

ill p

resc

ribe

an H

IV te

st. T

he te

st is

perfo

rmed

in a

labo

rato

ry a

nd fu

lly

reim

burs

ed.

Chla

mydia

In 2

003,

the

Min

istry

of H

ealth

ask

ed th

e N

atio

nal A

genc

y fo

r Eva

luat

ion

in H

ealth

Car

e(A

NA

ES) t

o ev

alua

te th

e op

portu

nity

to s

et u

p a

natio

nal p

olic

y fo

r Chl

amyd

iasc

reen

ing.

AN

AES

reco

mm

ende

d th

e ad

optio

n of

an

oppo

rtuni

stic

strat

egy

for s

cree

ning

, tar

getin

g th

epo

pula

tion

at ri

sk in

cen

tres

for b

irth

plan

ning

and

edu

catio

n (C

entre

s de

pla

nific

atio

n et

d’

éduc

atio

n fa

mili

ale)

, in

cent

res

for f

ree

and

anon

ymou

s sc

reen

ing

(CD

AG

), in

ant

i-ven

erea

ldi

seas

es d

ispen

sarie

s (D

ispen

saire

s an

ti-vé

nérie

ns:D

AV),

in c

entre

s fo

r abo

rtion

, and

in

cent

res

for m

othe

r and

chi

ld c

are.

Chl

amyd

iasc

reen

ing

shou

ld b

e of

fere

d to

mal

es a

ndfe

mal

es u

nder

the

age

of 3

0 w

ho a

re s

exua

lly a

ctiv

e, w

ho h

ave

chan

ged

sexu

al p

artn

er in

the

last

12 m

onth

s, o

r who

se p

artn

er m

ay b

e in

fect

ed w

ith a

sex

ually

tran

smitt

ed d

iseas

e.Pa

rticu

lar a

ttent

ion

shou

ld b

e gi

ven

to p

eopl

e w

ho d

o no

t hav

e re

gula

r con

tact

with

the

heal

th c

are

syste

m.

AN

AES

also

reco

mm

ende

d pi

lot s

tudi

es in

gen

eral

pra

ctic

e to

eva

luat

e th

e pr

eval

ence

of

the

Chl

amyd

iain

fect

ion,

and

to a

ctiv

ely

prom

ote

the

use

of c

ondo

ms

in th

e ge

nera

l pop

ulat

ion.

The

redu

ctio

n of

Chl

amyd

iapr

eval

ence

(and

oth

er S

TDs)

is on

e of

the

100

obje

ctiv

es o

f the

Publ

ic H

ealth

Act

of A

ugus

t 200

4, b

ut th

e m

eans

of a

chie

ving

this

goal

are

not

des

crib

ed.

France

Tuber

culo

sis

The

Infe

ctio

us D

iseas

esA

ct o

f 200

0 ha

s m

odifi

ed th

e ta

rget

grou

ps fo

r TB

scre

enin

g.Te

ache

rs a

nd m

any

othe

r pro

fess

iona

lgr

oups

dea

ling

with

the

publ

ic a

re n

o lo

nger

rout

inel

y sc

reen

ed,

whi

le e

lder

ly p

eopl

em

ovin

g to

an

insti

tutio

n,an

d as

ylum

see

kers

,ar

e no

w s

cree

ned.

HIV

and C

hla

mydia

Ther

e is

no n

atio

nal p

olic

y on

scr

eeni

ng fo

r HIV

or C

hlam

ydia

. Cas

e-fin

ding

for H

IV o

r Chl

amyd

iain

fect

ions

is p

aid

for b

y sta

tuto

ryhe

alth

insu

ranc

e in

the

pres

ence

of i

ndic

ativ

e co

mpl

aint

s or

sym

ptom

s. S

cree

ning

is e

ncou

rage

d in

pre

gnan

cy a

nd re

com

men

ded

in“r

isk g

roup

s” b

y pr

ofes

siona

l gui

delin

es b

ut is

sub

ject

to th

e de

cisio

n of

the

phys

icia

n an

d pa

tient

(“op

portu

nisti

c”).

With

rega

rd to

HIV

ther

e is

a na

tiona

l pol

icy

not t

o en

cour

age

testi

ng, b

ut to

focu

s on

pra

ctic

al p

rote

ctio

n m

essa

ges

(con

dom

s, ri

sk-

pron

e sit

uatio

ns, n

egot

iatio

n sk

ills,

as

wel

l as

solid

arity

with

thos

e af

fect

ed).

Man

y ot

her c

ount

ries

use

both

vol

unta

ry c

ouns

ellin

g an

dte

sting

stra

tegi

es. T

he G

erm

an a

nd D

utch

pub

lic e

duca

tion

syste

ms,

for e

xam

ple,

enc

oura

ge v

olun

tary

cou

nsel

ling

and

are

silen

t abo

utte

sting

to tr

y to

avo

id a

redu

ctio

n in

saf

e be

havi

our.

For t

he s

ame

reas

on, t

estin

g w

as e

ven

proa

ctiv

ely

disc

oura

ged

amon

g ho

mos

exua

lsin

the

early

and

mid

-199

0s. I

n ge

nera

l, w

ritte

n ed

ucat

ion

mat

eria

ls ar

e pr

ovid

ed a

nd b

alan

ce te

sting

is re

com

men

ded

if lo

ng-te

rm

partn

ers

wan

t a c

hild

or w

ant t

o ch

oose

ano

ther

con

trace

ptiv

e. T

here

is e

xten

sive

info

rmat

ion

abou

t tes

t val

idity

, tes

t cha

ract

erist

ics,

the

win

dow

per

iod

and

reco

mm

enda

tions

for s

uppo

rt an

d fu

ture

beh

avio

ur.

HIV

and

Chl

amyd

iaw

ere

neve

r def

ined

as

“sex

ually

-tran

smitt

able

infe

ctio

ns”

(STI

s) in

a le

gal s

ense

sin

ce th

is w

ould

hav

e m

eant

unt

il19

99 th

at le

gal o

ptio

ns to

per

form

com

pulso

ry te

sting

and

trea

tmen

t cou

ld h

ave

been

app

lied

to “

non-

com

plia

nt”

STI p

atie

nts

unde

rtre

atm

ent o

r to

“pro

misc

uous

peo

ple

susp

ecte

d of

spr

eadi

ng th

e di

seas

e”. T

he In

fect

ious

Dise

ases

Act

of 2

000

abol

ished

the

1956

com

pulso

ry re

gula

tions

for a

ll ST

Is, w

hich

, in

prac

tice,

had

rare

ly b

een

appl

ied.

Ger

many

Tabl

e A

1.1

con

t.

37

Tuber

culo

sis

Acc

ordi

ng to

Pre

siden

tial D

ecre

e /

GN

G 2

62A

/195

0,th

e re

porti

ng o

f TB

in G

reec

e is

com

pulso

ry. C

ases

shou

ld b

e re

porte

d w

ithin

one

wee

k of

dia

gnos

is b

y th

e cl

inic

ians

in c

harg

e. N

atio

nal h

ospi

tals

prov

ide

the

tube

rcul

osis

bul

letin

and

ask

the

patie

nt to

fill

in a

ll th

ere

leva

nt in

form

atio

n co

ncer

ning

the

statu

s an

d se

verit

y of

his

or

her

dise

ase.

Th

e In

tern

atio

nal U

nion

Aga

inst

Tube

rcul

osis

and

Resp

irato

ry D

isea

ses

(IUA

LATD

) and

WH

O h

ave

laun

ched

gui

delin

es to

pro

mot

e an

ti-tu

berc

ulos

isca

mpa

igns

in fa

vour

of v

acci

ne p

rogr

amm

es. E

mph

asis

is p

lace

d on

the

vacc

inat

ion

of th

e fo

llow

ing

high

-risk

grou

ps:

•im

mig

rant

s;

•ne

onat

es w

hose

mot

hers

hav

e be

en in

fect

ed w

ithH

IV;

•ch

ildre

n w

ith M

anto

ux (–

) (ne

gativ

e), a

nd a

fam

ilym

embe

r w

ith r

ecog

nize

d tu

berc

ulos

is;

•Ro

m p

eopl

e.In

acc

orda

nce

with

the

WH

O g

uide

lines

(WH

O/W

ER 2

004,

79:

25–4

0), M

embe

rs a

re in

vite

dto

dev

elop

a m

onito

ring

and

eval

uatio

n sy

stem

for

reco

rdin

g TB

cas

es a

nd c

olle

ctin

g re

liabl

eep

idem

iolo

gica

l dat

a.

A s

igni

fican

t red

uctio

n in

rec

orde

d ca

ses

of T

B is

obse

rved

in G

reec

e, in

com

paris

on w

ith th

e re

st of

the

EU M

embe

r St

ates

. In

2002

Gre

ece

mai

ntai

ned

one

ofth

e lo

wer

rat

es a

mon

g EU

cou

ntrie

s w

ith 6

.6 c

ases

per

100

000

peop

le, w

hile

the

EU a

vera

ge w

as 1

1.55

.

HIV

In G

reec

e se

vera

l pol

icie

s ha

ve b

een

impl

emen

ted

to c

ontro

l, m

onito

ran

d pr

even

t the

HIV

epi

dem

ic. T

he H

elle

nic

Cen

tre fo

r In

fect

ious

Dis

ease

Con

trol (

KEEL

) is

resp

onsi

ble

for

HIV

/AID

S ca

se r

epor

ting

and

has

esta

blis

hed

a re

liabl

e m

onito

ring

netw

ork

of n

ine

AID

SLa

bora

torie

s Re

fere

nce

Cen

tres

and

17 H

IV/A

IDS

clin

ics

in p

ublic

and

priv

ate

hosp

itals.

A

IDS

case

rep

ortin

g w

as im

plem

ente

d in

Gre

ece

in 1

984.

It is

anon

ymou

s, c

onfid

entia

l and

man

dato

ry b

y la

w A

1/61

22/1

9-9-

1986

. The

firs

t tw

o ch

arac

ters

of t

he n

ame

as w

ell a

s th

e pa

tient

’sda

te o

f birt

h ar

e us

ed a

s pe

rson

al id

entif

iers

to p

reve

nt d

uplic

atio

n.Th

e re

porti

ng o

f HIV

cas

es w

as in

itial

ly im

plem

ente

d in

Gre

ece

in19

98. I

t is

anon

ymou

s, c

onfid

entia

l and

man

dato

ry b

y la

wB1

/529

5/7-

8-19

98. T

he n

ew s

urve

illan

ce s

yste

m fo

r m

onito

ring

HIV

infe

ctio

n w

as im

plem

ente

d at

Eur

opea

n le

vel i

n Ja

nuar

y 19

99.

KEEL

is r

espo

nsib

le fo

r co

llect

ing

and

mon

itorin

g da

ta o

n H

IV a

ndot

her

infe

ctio

us d

isea

ses.

Rep

ortin

g is

obl

igat

ory

and

all h

ospi

tals

and

heal

th c

entre

s ar

e ob

liged

to r

epor

t tre

ated

cas

es. K

EEL

pres

ents

the

colle

cted

info

rmat

ion

ever

y si

x m

onth

s. A

pre

-spec

ified

sta

ndar

dfo

rmat

is u

sed

in o

rder

to e

nsur

e ho

mog

enei

ty o

f the

rep

orte

d da

ta.

Acc

ordi

ng to

the

“Hal

f-Yea

r” e

ditio

n of

KEE

L (3

0 Ju

ne 2

004)

, the

num

ber

of H

IV p

ositi

ve p

erso

ns (i

nclu

ding

AID

S ca

ses)

rep

orte

d in

Gre

ece

over

the

first

half

of 2

004,

was

esti

mat

ed to

be

6923

cas

es,

and

arou

nd 2

21 w

ere

new

HIV

infe

ctio

ns. T

he p

erce

ntag

e of

men

repo

rting

HIV

infe

ctio

n w

as o

n av

erag

e 4

times

hig

her

than

that

of

wom

en.

Dat

a on

new

ly d

iagn

osed

HIV

infe

ctio

ns s

houl

d be

inte

rpre

ted

with

cau

tion

beca

use

they

may

not

rep

rese

nt in

cide

nce

and

beca

use

they

dep

end

heav

ily o

n va

ryin

g pa

ttern

s of

HIV

testi

ng a

nd re

porti

ng.

Chla

mydia

Ther

e ar

e no

dat

aav

aila

ble

on C

hlam

ydia

in G

reec

e. O

n th

e ba

sis

of s

ever

al in

terv

iew

sco

nduc

ted

by o

ur te

am a

tth

e U

nive

rsity

of A

then

sw

ith o

ffici

als

at th

eM

inis

try o

f Hea

lth a

ndKE

EL, i

t was

rep

orte

d th

atKE

EL is

in th

e pr

oces

s of

deve

lopi

ng a

reg

istry

of

sexu

ally

and

com

mun

icab

le d

isea

ses

incl

udin

g C

hlam

ydia

,kn

own

as S

exua

llyC

omm

unic

able

Dis

ease

sSu

rvei

llanc

e.

The

aim

is to

dev

elop

am

onito

ring

syste

m fo

rC

hlam

ydia

, fin

ance

dex

clus

ivel

y by

KEE

L.

A p

ilot p

roje

ct is

des

igne

dan

d w

ill b

e im

plem

ente

din

the

near

futu

re a

t the

And

reas

Syg

ros

Hos

pita

lin

Ath

ens

as w

ell a

s at

the

Aph

rodi

siac

Hos

pita

lin

The

ssal

onic

a.

Gre

ece

38

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

Ther

e is

a T

B va

ccin

atio

n pr

ogra

mm

e, th

eBC

G in

ject

ion,

whi

ch is

adm

inis

tere

d to

all

child

ren

in Ir

elan

d in

the

first

few

mon

ths

oflif

e. It

is n

ot o

ppor

tuni

stic.

HIV

The

Dep

artm

ent o

f Hea

lth a

nd C

hild

ren

intro

duce

d a

polic

y of

vo

lunt

ary

ante

nata

l HIV

scr

eeni

ng in

Irel

and

in A

pril

1999

. As

part

ofth

is p

rogr

amm

e, H

IV s

cree

ning

is o

ffere

d to

all

wom

en w

ho a

ttend

for

ante

nata

l ser

vice

s.

Chla

mydia

No

natio

nal s

cree

ning

pol

icy.

Chla

mydia

Rout

ine

scre

enin

g fo

r as

ympt

omat

icin

fect

ion

is r

ecom

men

ded

for

adol

esce

nt w

omen

who

are

sex

ually

activ

e an

d fo

r w

omen

at h

igh

risk

of in

fect

ion.

How

ever

, thi

s is

left

to lo

cal h

ealth

aut

horit

ies

and,

ul

timat

ely,

to th

e de

cisi

on o

f in

divi

dual

doc

tors

.

Irel

and

Tuber

culo

sis

With

the

intro

duct

ion

of th

e de

cree

of 2

9Ju

ly 1

998,

all d

iagn

osed

cas

es o

f TB

and

myc

obac

terio

sis

mus

tbe

not

ified

to th

e he

alth

aut

horit

ies.

Scr

eeni

ng is

carr

ied

out a

t reg

iona

l lev

el. F

or e

xam

ple,

the

ASR

of E

mili

a Ro

mag

na h

as d

evel

oped

sof

twar

e fo

rm

onito

ring

and

surv

eilla

nce

of T

B. D

urin

g 20

03,

314

case

s of

TB

in th

e ad

ult p

opul

atio

n (o

ver

14ye

ars

old)

wer

e re

porte

d in

this

reg

ion,

of w

hich

25%

wai

ted

for

a m

onth

bef

ore

cont

actin

g a

doct

or, a

nd 5

0% h

ad a

del

ay in

dia

gnos

is g

reat

erth

an tw

o m

onth

s.

HIV

Rece

ntly,

the

Min

istry

of H

ealth

has

esta

blis

hed

a N

atio

nal

Com

mis

sion

for

HIV

(“C

omm

issi

one

Naz

iona

le p

er la

lotta

cont

ro l’

AID

S“) w

hich

is in

tend

ed to

dev

ise

educ

atio

nal a

ndpr

even

tive

strat

egie

s an

d to

pro

mot

e co

ntin

uing

edu

catio

nfo

r doc

tors

in th

e fie

ld o

f inf

ectio

us d

iseas

es. T

he c

omm

issio

nw

ill a

lso m

onito

r th

e sp

read

of H

IV b

oth

at n

atio

nal a

ndin

tern

atio

nal l

evel

, with

par

ticul

ar e

mph

asis

on

high

-risk

ca

tego

ries.

It w

ill p

rom

ote

and

mon

itor

rese

arch

in H

IV a

ndau

dit t

he le

vel o

f car

e pr

ovid

ed fo

r H

IV p

atie

nts.

Mor

eove

r,th

e co

mm

issi

on w

ill u

pdat

e gu

idel

ines

for

certa

in ty

pes

oftre

atm

ent a

nd v

erify

DG

Rs ta

riffs

for

infe

ctio

us d

isea

ses.

Italy

Tuber

culo

sis

No

info

rmat

ion

avai

labl

e.H

IV a

nd C

hla

mydia

Ther

e is

no

natio

nal s

cree

ning

pro

gram

me

for

HIV

or

Chl

amyd

ia. H

owev

er:

•al

l pre

gnan

t wom

en c

an u

nder

go a

n H

IV te

st as

par

t of a

nten

atal

and

pos

tnat

al s

cree

ning

;•

the

loca

l pub

lic h

ealth

age

ncie

s (G

GD

s) a

re in

cha

rge

of H

IV te

sting

of s

peci

fic r

isk

grou

ps.

How

ever

, the

GG

Ds

have

set

up

volu

ntar

y H

IV s

cree

ning

for

men

and

wom

en in

hig

h-ris

k gr

oups

(hom

osex

uals,

drug

add

icts,

pro

stitu

tes)

.

Net

her

lands

Tabl

e A

1.1

con

t.

39

Tuber

culo

sis

Scre

enin

g is

opp

ortu

nisti

c. N

eona

tes

are

vacc

inat

ed. A

ll TB

-rela

ted

serv

ices

are

finan

ced

by th

e na

tiona

l hea

lth s

ervi

ce(in

divi

dual

s ar

e ex

empt

from

any

sor

t of

paym

ent).

Chi

ldre

n in

con

tact

with

TB

patie

nts

are

give

n tre

atm

ent.

Som

e ty

pes

of T

B ar

e w

ithin

the

syste

m o

fco

mpu

lsory

not

ifica

tion

of d

isea

se.

HIV

Scre

enin

g is

opp

ortu

nisti

c. N

otifi

catio

n of

HIV

beca

me

com

pulso

ry in

200

4. D

rugs

for

AID

Spa

tient

s ar

e fu

lly r

eim

burs

ed b

y th

e sta

te; p

atie

nts

are

exem

pted

from

use

r ch

arge

s in

the

NH

S; b

utH

IV-p

ositi

ve p

atie

nts

pay

for

drug

s ou

tside

hos

pita

l. Th

ere

are

guid

elin

es fo

r te

sting

pre

gnan

tw

omen

, with

the

aim

of i

mpr

ovin

g de

tect

ion

and

early

trea

tmen

t.

Chla

mydia

Scre

enin

g is

opp

ortu

nisti

c. C

hlam

ydia

is n

ot

spec

ially

targ

eted

in th

e na

tiona

l pro

gram

mes

, but

is tr

eate

d w

ithin

the

grou

p of

sex

ually

tran

smitt

eddi

seas

es. S

cree

ning

is u

sual

ly d

one

thro

ugh

the

Pap

test,

with

gui

delin

es o

n fre

quen

cy o

f tes

ting.

Th

ere

is n

o po

pula

tion

regi

ster

to a

llow

for

targ

etin

g an

d re

calli

ng p

atie

nts,

nor

do

curr

ent

info

rmat

ion

syste

ms

allo

w fo

r th

at.

Port

ugal

Tuber

culo

sis

Regi

onal

gov

ernm

ents

have

res

pons

ibili

ty fo

r TB

con

trol a

ndpr

even

tion

prog

ram

mes

. Gui

delin

es w

ere

prov

ided

in a

co

nsen

sus

docu

men

t on

TB p

reve

ntio

n an

d co

ntro

l. Th

isdo

cum

ent o

utlin

es th

e ne

ed fo

r co

oper

atio

n be

twee

n th

eM

inist

ry o

f Hea

lth a

nd th

e D

epar

tmen

ts of

Hea

lthof

the

regi

onal

gov

ernm

ents

in o

rder

to c

reat

e a

prac

tical

and

effic

ient

net

wor

k fo

r con

trol a

nd p

reve

ntio

n of

TB.

In 1

995,

with

the

crea

tion

of th

e na

tiona

l Net

wor

k fo

r Ep

idem

iolo

gica

lSu

rvei

llanc

e, r

espi

rato

ry tu

berc

ulos

is w

as in

clud

ed in

the

natio

nal r

egis

try o

f com

pulso

ry n

otifi

catio

n di

seas

es. I

n 20

02al

l typ

es o

f TB

wer

e in

clud

ed in

the

regi

stry.

In 1

996

only

82%

of t

he A

uton

omou

s C

omm

uniti

es h

ad d

evel

oped

are

gion

al p

rogr

amm

e fo

r TB

pre

vent

ion

and

cont

rol.

Alth

ough

TB n

otifi

catio

n is

obl

igat

ory,

in 1

999

only

78%

of t

he c

ases

dete

cted

in Z

arag

oza

wer

e ac

tual

ly r

egis

tere

d, a

nd th

ispe

rcen

tage

var

ied

from

45%

in V

alen

cia

in 1

990–

1993

to94

.5%

in C

aste

llon

in 1

997–

1999

.

HIV

Resp

onsib

ility

for A

IDS

is sh

ared

bet

wee

n th

e ce

ntra

lgo

vern

men

t and

the

Aut

onom

ous

Com

mun

ities

,al

thou

gh th

e M

inis

try o

f Hea

lth is

the

key

spon

sor

ofth

e N

atio

nal P

lan

Aga

inst

AID

S (th

e fir

st on

e w

asap

prov

ed in

199

7, a

nd w

as fo

llow

ed b

y a

new

one

in 2

001)

. A m

ultis

ecto

ral a

ppro

ach

(com

mun

itypa

rtici

patio

n, c

oord

inat

ion

of c

entra

l/re

gion

al/l

ocal

adm

inist

ratio

n, in

terd

iscip

linar

y ap

proa

ch),

strat

egie

sof

pro

ven

effe

ctiv

enes

s an

d eq

uity

(hum

an r

ight

s,to

lera

nce

and

solid

arity

; equ

al o

ppor

tuni

ties

and

non-

disc

rimin

atio

n; r

educ

tion

of v

ulne

rabi

lity)

are

som

e of

the

prin

cipl

es g

over

ning

the

New

Pla

n(2

001–

2005

). A

ctio

n in

this

are

a is

dire

cted

tow

ards

bet

ter k

now

ledg

e an

d an

alys

is of

the

real

ityof

the

epid

emic

; the

dev

elop

men

t of p

reve

ntio

n pr

ogra

mm

es (i

nfor

mat

ion

cam

paig

ns, n

eedl

eex

chan

ge, p

reve

ntio

n of

sex

ual t

rans

mis

sion

,m

etha

done

sub

stitu

tion

prog

ram

mes

); tra

inin

g an

d su

ppor

t pro

gram

mes

for

heal

th c

are

staff;

re

com

men

datio

ns o

n tre

atm

ent;

scre

enin

g, e

tc.

Chla

mydia

Ther

e is

no

spec

ific

Chl

amyd

iasc

reen

ing

prog

ram

me.

How

ever

, the

cont

rol a

nd p

reve

ntio

n of

sex

ually

trans

mitt

ed d

isea

ses

is in

clud

edam

ong

the

obje

ctiv

es o

f the

HIV

infe

ctio

n an

d A

IDS

Mul

tisec

tora

lPl

an 2

001–

2005

. “I

nten

sify

act

iviti

es fo

r pr

even

tion,

early

dia

gnos

is a

nd tr

eatm

ent o

fin

fect

ions

ass

ocia

ted

with

dru

g us

e,he

patit

is, t

uber

culo

sis

and

STD

s, a

sw

ell a

s H

IV, f

rom

hea

lth c

entre

s an

ddr

ug a

buse

trea

tmen

t ser

vice

s”(“

Prev

entio

n in

intra

veno

us d

rug

user

s”, H

IV In

fect

ion

and

AID

SM

ultis

ecto

ral P

lan

2001

–200

5).

“Offe

r co

mpr

ehen

sive

car

e to

wom

en th

at in

clud

es e

arly

det

ectio

nof

STD

s (h

erpe

s, C

hlam

ydia

and

HPV

) and

cer

vica

l can

cer”

Spain

40

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

Som

e ex

ampl

es o

f reg

iona

l TB

cont

rol a

nd p

reve

ntio

n pr

ogra

mm

es:

The

Dep

artm

ent o

f Hea

lth o

f Cas

tilla

y L

eón

has

deve

lope

d a

prog

ram

me

for

prev

entio

n an

d co

ntro

l of

TB (1

999)

. It d

efin

es th

e ta

rget

pop

ulat

ion

(peo

ple

with

cl

inic

al h

isto

ry c

ompa

tible

with

TB;

rel

ativ

es a

nd p

eopl

e w

hoha

ve b

een

in c

onta

ct w

ith T

B pa

tient

s; h

igh-

risk

popu

latio

n),

the

obje

ctiv

e (to

red

uce

TB p

reva

lenc

e by

200

7) a

nd th

eac

tions

to b

e ta

ken.

Th

e TB

con

trol a

nd p

reve

ntio

n pr

ogra

mm

e of

the

Dep

artm

ent o

f Hea

lth o

f Val

enci

a gi

ves

resp

onsi

bilit

y fo

r TB

dete

ctio

n to

pub

lic h

ealth

pro

fess

iona

ls in

prim

ary

care

set

tings

.Th

ese

agen

cies

aim

to a

ctiv

ely

cont

rol h

igh-

risk

popu

latio

ns(H

IV in

fect

ed, d

rug

addi

cts,

pris

oner

s an

d in

stitu

tiona

lized

men

tally

ill,

imm

igra

nts,

the

polic

e fo

rce

and

med

ical

pe

rson

nel).

Tre

atm

ent i

s pr

ovid

ed b

y sp

ecia

lists.

Pub

lic h

ealth

adm

inis

tratio

n is

res

pons

ible

for

regi

stry,

info

rmat

ion

and

heal

th k

now

ledg

e in

itiat

ives

.

HIV

Rece

ntly,

AID

S pa

tient

s w

ere

incl

uded

in th

e gr

oup

whi

ch p

ays

a re

duce

d ch

arge

for

med

icin

es.

The

HIV

tests

can

be

carr

ied

out i

n Sp

ain

free

ofch

ange

and

con

fiden

tially

thro

ugho

ut th

e N

atio

nal

Hea

lth S

yste

m.

Sinc

e 19

83 th

ere

has

been

a N

atio

nal H

IVRe

gistr

y an

d si

nce

the

end

of th

e 19

80s

all

Aut

onom

ous

Com

mun

ities

hav

e ha

d th

eir

own

Regi

onal

HIV

Reg

istry

. H

IV s

urve

illan

ce c

onsi

sts o

f per

iodi

c su

rvey

sai

med

at r

epre

sent

ativ

e gr

oups

of t

he g

ener

al

popu

latio

n as

wel

l as

targ

et p

opul

atio

n gr

oups

as

defin

ed in

the

HIV

Infe

ctio

n an

d A

IDS

Mul

tisec

tora

l Pla

n 20

01–2

005

(ado

lesc

ents

and

youn

g pe

ople

, int

rave

nous

dru

g us

ers,

com

mer

cial

sex

wor

kers

, hom

osex

uals,

wom

en, p

rison

ers,

imm

igra

nts

and

ethn

ic m

inor

ities

).

Chla

mydia

In 1

990

a C

hlam

ydia

scre

enin

gpr

ogra

mm

e w

as im

plem

ente

d in

the

Fam

ily P

lann

ing

Cen

tre “

Mig

uel

Serv

et”

in L

a C

oruñ

a. T

he m

ain

obje

ctiv

e of

the

prog

ram

me

was

tore

duce

the

prev

alen

ce o

f Chl

amyd

iain

the

area

(at t

hat t

ime

the

prev

alen

cera

te a

mon

g w

omen

was

5.1

%).

Spec

ific

aim

s in

clud

ed th

e re

duct

ion

of th

e pr

eval

ence

by

50%

dur

ing

the

first

year

(199

0–19

91) a

nd th

en b

yan

add

ition

al 5

0% d

urin

g th

e ne

xttw

o ye

ars

(199

2–19

93) t

o re

ach

apr

eval

ence

rat

e of

1.2

–1.3

%.

Spain

con

t.

Tabl

e A

1.1

con

t.

41

Tuber

culo

sis

Ther

e is

no

natio

nal s

cree

ning

pro

gram

me

for

TB.

In S

wed

en, g

ener

al v

acci

natio

n ce

ased

in 1

975,

and

sin

ce th

en c

hild

ren

have

been

pro

tect

ed b

y m

eans

of t

arge

ted

actio

n. In

eve

ry c

ase

of T

B, a

n an

alys

is o

fth

e in

fect

ion

is c

arrie

d ou

t for

sur

vey

purp

oses

, and

chi

ldre

n w

ho h

ave

com

e in

tocl

ose

cont

act w

ith th

e sic

k pe

rson

are

vac

cina

ted.

Vac

cina

tion

is al

so re

com

men

ded

for

all c

hild

ren

of im

mig

rant

s fro

m c

ount

ries

whe

re T

B is

mor

e pr

eval

ent t

han

inSw

eden

, as

wel

l as

for

child

ren

trave

lling

to s

uch

coun

tries

, and

thos

e w

ho w

ill b

eliv

ing

in c

lose

con

tact

with

the

loca

l pop

ulat

ion.

All

asyl

um s

eeke

rs a

re a

lso o

ffere

d PP

D te

sting

at t

heir

first

heal

th c

heck

-up,

as

are

preg

nant

wom

en if

thei

r hi

story

sug

gests

that

they

mig

ht b

e co

nsid

ered

at r

isk.

The

Nat

iona

l Boa

rd o

f Hea

lth a

nd W

elfa

re r

elea

sed

guid

elin

es in

199

0 on

pr

even

tive

mea

sure

s co

ncer

ning

TB

but t

hese

are

cur

rent

ly u

nder

rev

isio

n.

HIV

and C

hla

mydia

Nat

iona

l stra

tegi

es fo

r th

e en

tire

area

of h

ealth

and

sex

ualit

y ar

epr

esen

tly la

ckin

g an

d w

ill b

e de

velo

ped

by th

e N

atio

nal I

nstit

ute

ofPu

blic

Hea

lth. I

n ad

ditio

n, w

ork

has

been

initi

ated

on

esta

blis

hing

an

actio

n pl

an fo

r th

e pr

even

tion

of u

nwan

ted

preg

nanc

ies.

This

is b

ased

on

prev

entiv

e w

ork

carr

ied

out u

nder

pro

visi

ons

ofth

e C

omm

unic

able

Dis

ease

s A

ct, t

he H

ealth

and

Med

ical

Ser

vice

sA

ct a

nd th

e pu

blic

hea

lth p

olic

y of

the

Nat

iona

l Ins

titut

e of

Pub

licH

ealth

with

res

pect

to H

IV a

nd S

TIs,

as

wel

l as

with

in th

e fra

mew

ork

of v

ario

us r

egio

nal/

loca

l pro

gram

mes

.C

urre

ntly,

scr

eeni

ng fo

r C

hlam

ydia

and

HIV

is o

ppor

tuni

stic

with

preg

nant

wom

en b

eing

offe

red

tests

, as

are

thos

e di

spla

ying

ris

kbe

havi

ours

.

Swed

en

Tuber

culo

sis

No

natio

nal s

cree

ning

pro

gram

me.

H

IV a

nd C

hla

mydia

HIV

testi

ng is

offe

red

to w

omen

in e

arly

pre

gnan

cy. T

estin

g is

com

pulso

ry fo

r bl

ood

and

orga

n do

nors

.O

ppor

tuni

stic

scre

enin

g fo

r C

hlam

ydia

is o

ffere

d to

thos

e ag

ed 2

5 an

d un

der

who

acc

ess

sexu

al h

ealth

ser

vice

sor

prim

ary

care

.

United

Kin

gdom

42

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rTh

ere

are

two

maj

or s

yste

ms

in p

lace

with

reg

ard

to s

cree

ning

for

the

abov

e-m

entio

ned

form

s of

can

cer.

Ever

y A

ustri

an o

ver

the

age

of 1

9 is

ent

itled

to a

ttend

a v

olun

tary

pre

caut

iona

ry c

heck

-up

once

a y

ear,

free

of c

harg

e. T

his

exam

inat

ion

cons

ists

of a

sta

ndar

d pa

rt fo

r bo

th s

exes

(blo

od te

st, u

rine

test,

sto

ol te

st,cl

inic

al e

xam

inat

ion

of th

e bo

dy in

clud

ing

the

brea

st an

d th

e re

ctum

, per

sona

l ses

sion

with

the

doct

or) a

nda

gyna

ecol

ogic

al p

art f

or w

omen

con

sisti

ng o

f a g

ener

al g

ynae

colo

gica

l exa

min

atio

n an

d a

smea

r te

st.

In 2

002

abou

t 1 m

illio

n pr

ecau

tiona

ry c

heck

-ups

at a

cos

t of a

bout

€62

mill

ion

wer

e ca

rrie

d ou

t. O

nem

illio

n ch

eck-

ups

corr

espo

nd to

13.

6% o

f all

thos

e el

igib

le. O

f the

se, 6

5% w

ere

mal

e an

d 35

% fe

mal

e.

The

conc

ept o

f the

pre

caut

iona

ry c

heck

-up

is c

urre

ntly

bei

ng r

evis

ed. B

esid

es s

ome

new

exa

min

atio

ns,

the

mai

n fo

cus

of th

e “V

orso

rgeu

nter

such

ung

– N

eu”

lies

in h

ealth

y lif

esty

le a

dvic

e. In

ord

er to

incr

ease

pa

rtici

patio

n in

the

prec

autio

nary

che

ck-u

p an

invi

tatio

n pr

ogra

mm

e (C

all/

Reca

ll Sc

hem

e) is

pla

nned

.Pe

ople

bet

wee

n 19

and

40

will

get

an

invi

tatio

n ev

ery

thre

e ye

ars,

and

thos

e ov

er 4

0 ev

ery

two

year

s.Pe

ople

ove

r 50

will

be

info

rmed

abo

ut in

testi

nal c

ance

r, an

d w

omen

ove

r 40

abo

ut th

e po

ssib

ility

of

havi

ng a

mam

mog

raph

y ev

ery

two

year

s.Be

side

s th

e pr

ecau

tiona

ry c

heck

-up,

wom

en a

re a

sked

to a

ttend

a g

ynae

colo

gica

l rou

tine

cont

rol

appo

intm

ent o

n a

year

ly b

asis

whe

n a

smea

r te

st is

car

ried

out.

Cur

rent

ly th

ere

is n

o ca

ll an

d re

call

syste

m e

stabl

ishe

d bu

t thi

s is

bei

ng d

evel

oped

.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aIn

the

cour

se o

f the

“A

ustri

an E

arly

-reco

gniti

onpr

ogra

mm

e fo

r inh

erite

d m

etab

olic

diso

rder

s”ev

ery

new

born

chi

ld is

scr

eene

d fo

r PK

U.

Ther

e is

no

univ

ersa

l com

pulso

ry s

yste

m o

fsc

reen

ing

for

Dow

n sy

ndro

me

in p

lace

.Ph

ysic

ians

are

obl

iged

to in

form

an

expe

ctan

tm

othe

r ab

out t

he p

ossi

bilit

y of

vol

unta

rysc

reen

ing

for

the

cond

ition

.Th

e po

ssib

le in

corp

orat

ion

of s

cree

ning

fo

r D

own

synd

rom

e an

d ot

her

pren

atal

exam

inat

ions

into

the

mot

her-c

hild

pas

s is

curr

ently

und

er d

iscu

ssio

n.

Ther

e is

no

syste

mat

ic s

cree

ning

for

spin

abi

fida.

Aust

ria

Cer

vica

l ca

nce

rA

pro

gram

me

of c

ervi

cal c

ance

r sc

reen

ing

has

been

run

ning

sin

ce 1

994

whe

n th

e Fl

emis

hG

over

nmen

t dec

ided

to re

orie

nt th

e or

gani

zatio

nof

sec

onda

ry p

reve

ntio

n of

cer

vica

l can

cer

acco

rdin

g to

Eur

opea

n gu

idel

ines

. Sin

ce th

en,

early

det

ectio

n of

cer

vica

l can

cer

has

mov

edgr

adua

lly fr

om th

e str

ictly

opp

ortu

nisti

c to

mor

eor

gani

zed

scre

enin

g. It

targ

ets

wom

enbe

twee

n th

e ag

es o

f 25

and

64, w

ho a

re

invi

ted

to h

ave

a Pa

p sm

ear

take

n on

ce e

very

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBa

sed

on th

e di

rect

ives

dev

elop

ed b

y Eu

rope

Aga

inst

Can

cer,

the

Com

mun

ities

and

the

fede

ral

gove

rnm

ent s

igne

d a

prot

ocol

on

25 O

ctob

er20

00 to

org

aniz

e an

d fin

ance

, on

a na

tiona

lsc

ale,

a c

ampa

ign

of b

reas

t can

cer

scre

enin

g fo

r w

omen

bet

wee

n th

e ag

es o

f 50

and

69.

The

fede

ral g

over

nmen

t pay

s fo

r th

e ra

diol

ogic

alco

sts. T

he o

rgan

izat

iona

l cos

ts ar

e pa

id b

y th

eC

omm

uniti

es. T

he r

espo

nsib

ility

for

coor

dina

ting

the

cam

paig

n is

giv

en to

rec

ogni

zed

scre

enin

g

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aTh

e de

tect

ion

of P

KU fa

lls u

nder

the

Com

mun

ities

’pr

ogra

mm

e of

mas

s sc

reen

ing

of c

onge

nita

lm

etab

olic

dis

orde

rs. T

he C

omm

uniti

es fi

x th

eco

nditi

ons

whi

ch th

e ce

ntre

s fo

r th

e de

tect

ion

ofco

ngen

itally

met

abol

ic d

evia

tions

mus

t ful

fil. N

orm

ally

a bl

ood

sam

ple

is ta

ken

on th

e fif

th d

ay a

fter

birth

.D

own

synd

rom

e: d

urin

g pr

egna

ncy,

at l

east

thre

eul

traso

und

exam

inat

ions

can

be

reim

burs

ed b

yna

tiona

l hea

lth in

sura

nce.

Thi

s is

usu

ally

car

ried

out

as a

rou

tine

exam

inat

ion

to fo

llow

the

norm

al

Bel

giu

m

Tabl

e A

1.2

Cer

vica

l can

cer,

brea

st c

ance

r, co

lore

ctal

can

cer,

PKU

, Dow

n sy

ndro

me

and

spin

a bi

fida

43

Cer

vica

l ca

nce

rth

ree

year

s. T

he p

rogr

amm

e is

adm

inis

tere

dan

d ru

n by

the

Scie

ntifi

c In

stitu

te o

f Pub

licH

ealth

in c

olla

bora

tion

with

the

Com

mun

ities

.D

espi

te s

cien

tific

sup

port,

no

form

al s

cree

ning

prog

ram

me

is o

rgan

ized

in th

e Fr

ench

Com

mun

ity. A

ccor

ding

to th

e 20

01 h

ealth

inte

rvie

w s

urve

y, 7

0% o

f wom

en b

etw

een

25an

d 64

had

a P

ap s

mea

r ta

ken

in th

e pr

evio

us th

ree

year

s. N

ew s

cree

ning

met

hods

will

be

eval

uate

d by

the

Scie

ntifi

cIn

stitu

te o

f Pub

lic H

ealth

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rce

ntre

s. E

leve

n sc

reen

ing

cent

res

have

bee

nid

entif

ied:

five

in W

allo

nia

(one

per

pro

vinc

e),

five

in F

land

ers

(in th

e fo

ur F

lem

ish

univ

ersi

ties

and

one

in B

ruge

s) a

nd o

ne in

Bru

ssel

s. T

hesc

reen

ing

cent

res

are

resp

onsi

ble

for

iden

tifyi

ngth

e ta

rget

gro

up, s

endi

ng in

vita

tions

, the

sec

ond

read

ing,

rec

ordi

ng o

f dat

a an

d fo

r re

porti

ng to

the

refe

rrin

g do

ctor

. In

Flan

ders

the

cam

paig

nsta

rted

on 1

5 Ju

ne 2

001;

and

in W

allo

nia

and

Brus

sels,

in J

une

2002

.Th

ere

is n

o sp

ecifi

c go

vern

men

t pol

icy

onsc

reen

ing

for

colo

n an

d re

ctal

can

cer.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

ade

velo

pmen

t of t

he fe

tus.

Bet

wee

n w

eeks

10

and

14of

pre

gnan

cy a

spe

cific

ultr

asou

nd in

to a

bnor

mal

accu

mul

atio

n of

liqu

id in

the

neck

of t

he fo

etus

can

be c

ondu

cted

. On

the

basi

s of

this

res

earc

h, D

own

synd

rom

e ca

n be

iden

tifie

d. T

he p

rese

nce

of a

ch

rom

osom

al a

bnor

mal

ity c

an o

nly

be c

onfir

med

by

an

addi

tiona

l tes

t suc

h as

an

amni

ocen

tesi

s.Th

ese

form

s of

ant

enat

al d

iagn

osis

are

onl

y of

fere

dto

cou

ples

with

an

incr

ease

d ris

k.Sp

ina

bifid

a ca

n al

so b

e de

tect

ed d

urin

g th

epr

egna

ncy

thro

ugh

a bl

ood

test,

an

ultra

soun

d or

an

am

nioc

ente

sis.

Bel

giu

m c

ont.

Cer

vica

l ca

nce

rTh

ere

is n

ow (a

rec

ent d

evel

opm

ent)

afre

e sc

reen

ing

prog

ram

me

in e

very

one

of th

e co

untry

’s 14

cou

nty

coun

cils.

The

prog

ram

mes

are

bas

ed o

n th

e re

gion

s’po

pula

tion

regi

sters

use

d fo

r ca

ll an

dre

call.

Wom

en a

re in

vite

d fo

r a

Pap

smea

r ev

ery

third

yea

r by

thei

r G

P.Ty

pica

lly, t

wo

rem

inde

r le

tters

are

sen

tif

no a

ppoi

ntm

ent h

as b

een

mad

e af

ter

the

first

lette

r. W

omen

age

d 23

–59

are

invi

ted,

exc

ept i

n C

open

hage

n co

unty

coun

cils

whe

re th

e in

vita

tion

is ex

tend

edon

ly to

thos

e ag

ed 2

5–45

. Som

eco

unty

cou

ncils

are

also

targ

etin

gw

omen

age

d 60

–74.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSc

reen

ing

prog

ram

mes

for

brea

st ca

ncer

are

esta

blis

hed

in tw

o of

the

14 c

ount

y co

unci

ls(F

unen

and

H:S

). Th

ese

cove

r 20

% o

f the

popu

latio

n. In

thos

e ar

eas

wom

en a

ged

50–6

9 ar

e in

vite

d fo

r sc

reen

ing.

The

re h

asbe

en c

onsi

dera

ble

deba

te o

n br

east

canc

ersc

reen

ing

in D

enm

ark

with

som

e co

unty

co

unci

ls ar

guin

g th

at th

e ev

iden

ce o

f ben

efit

is in

conc

lusi

ve.

Col

on a

nd r

ecta

l can

cer:

a te

am o

fex

perts

from

the

Nat

iona

l Boa

rd o

f Hea

lthha

s re

com

men

ded

scre

enin

g fo

r co

lore

ctal

canc

er a

nd a

tria

l is

taki

ng p

lace

in tw

o of

the

coun

ty c

ounc

ils. M

en a

nd w

omen

age

d50

–74

are

invi

ted

to p

artic

ipat

e an

d th

ese

rvic

e is

free

.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aEv

ery

child

bor

n in

Den

mar

k is

offe

red

a ro

utin

e ex

amin

atio

nfo

r PK

U. T

he e

xam

inat

ion

is m

ade

via

a bl

ood

test

carr

ied

out i

n th

e fir

st w

eek

afte

r th

e ch

ild is

bor

n, w

hich

mak

es th

edi

seas

e pr

even

tabl

e. It

is th

e re

spon

sibi

lity

of th

e m

idw

ife to

ensu

re th

at th

e te

st is

car

ried

out o

n th

e ch

ild’s

fifth

day

of l

ife(in

pra

ctic

e th

is is

don

e be

twee

n da

ys 4

and

10)

, reg

ardl

ess

of w

heth

er th

e ch

ild is

del

iver

ed a

t hom

e or

whe

ther

the

mot

her

has

been

dis

char

ged

from

hos

pita

l. Th

e sa

me

test

is u

sed

tosc

reen

for

low

ered

met

abol

ism

. D

own

synd

rom

e an

d sp

ina

bifid

a: in

Sep

tem

ber

2004

The

Nat

iona

l Boa

rd o

f Hea

lth c

hang

ed th

e gu

idel

ines

on

embr

yodi

agno

stics

from

aut

omat

ic s

elec

tion

crite

ria (e

.g. a

ge),

to

indi

vidu

al c

hoic

e. P

regn

ant w

omen

are

giv

en th

e op

tion

of a

nex

amin

atio

n th

at in

dica

tes

a ris

k of

Dow

n sy

ndro

me,

as

wel

las

a te

st fo

r sp

ina

bifid

a. T

here

will

also

be

mor

e in

form

atio

nav

aila

ble

on h

elp

and

supp

ort.

Den

mark

44

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Cer

vica

l ca

nce

rSc

reen

ing

for

cerv

ical

can

cer

was

sta

rted

at th

e be

ginn

ing

ofth

e 19

60s.

Acc

ordi

ng to

the

Publ

ic H

ealth

Act

, wom

enag

ed 3

0–60

yea

rs a

re c

alle

dev

ery

fifth

yea

r fo

r sc

reen

ing.

The

Finn

ish

mun

icip

aliti

es a

rere

spon

sibl

e fo

r or

gani

zing

and

finan

cing

scr

eeni

ng a

nd th

eFi

nnis

h ca

ncer

org

aniz

atio

nsha

ve p

ropo

sed

that

it s

houl

dbe

ext

ende

d to

incl

ude

25-y

ear-o

ld w

omen

. In

2003

,a

tota

l of 1

57 c

ervi

cal c

ance

rca

ses

wer

e fo

und.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aSc

reen

ing

of P

KU fo

r the

nat

ive

Finn

ish p

opul

atio

n is

not c

onsid

ered

nec

essa

ry.

If bo

th th

e m

othe

r an

d fa

ther

are

of w

este

rn E

urop

ean,

Am

eric

an, o

r e.

g.Je

wis

h, K

urd

or Y

ugos

lav

orig

in, a

PKU

test

is p

erfo

rmed

on

neon

ates

. Pa

rtici

patio

n in

the

scre

enin

g of

Dow

n sy

ndro

me

is v

olun

tary

. Alm

ost a

llm

unic

ipal

ities

offe

r ul

traso

und

scan

ning

in w

eeks

13–

14 a

nd 1

6–19

of

preg

nanc

y. A

mni

ocen

tesi

s an

d se

rum

scr

eeni

ng is

pro

vide

d to

wom

enbe

twee

n 35

and

40

year

s of

age

(the

age

lim

it de

pend

s on

the

mun

icip

ality

,e.

g. in

Hel

sink

i the

age

lim

it is

40

year

s)In

mun

icip

aliti

es w

hich

offe

r sc

reen

ing,

all

preg

nant

wom

en in

the

age

cate

gory

are

invi

ted

for

the

test.

Pa

rtici

patio

n in

spi

na b

ifida

scr

eeni

ng is

vol

unta

ry. A

lmos

t all

mun

icip

aliti

esof

fer

ultra

soun

d sc

anni

ng in

wee

ks 1

3–14

and

16–

19 o

f pre

gnan

cy.

Finla

nd

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSc

reen

ing

for

brea

st ca

ncer

was

in

trodu

ced

in 1

987.

Acc

ordi

ng to

the

Publ

ic H

ealth

Act

wom

en b

etw

een

the

ages

of5

0 an

d 59

are

cal

led

ever

yse

cond

yea

r fo

r sc

reen

ing.

The

Fin

nish

mun

icip

aliti

es a

re r

espo

nsib

le fo

ror

gani

zing

and

fina

ncin

g th

is s

cree

ning

.Th

e Fi

nnis

h ca

ncer

org

aniz

atio

ns h

ave

prop

osed

that

it s

houl

d be

ext

ende

d to

incl

ude

the

age

grou

p 60

–69.

In 2

003,

3779

bre

ast c

ance

r ca

ses

wer

e fo

und.

A p

ilot p

roje

ct fo

r sc

reen

ing

for

colo

nan

d re

ctal

can

cer

in m

en a

nd w

omen

aged

60–

69 w

as in

trodu

ced

in 2

004

inse

vera

l mun

icip

aliti

es.

Cer

vica

l ca

nce

rC

ance

r sc

reen

ing

strat

egie

s ar

e an

impo

rtant

part

of th

e N

atio

nal C

ance

r Pla

n im

plem

ente

din

200

3 fo

r th

e 20

02–2

006

perio

d.N

atio

nal t

echn

ical

gro

ups

have

bee

n cr

eate

dto

dev

elop

scr

eeni

ng p

rogr

amm

es. C

ervi

cal

canc

er s

cree

ning

is o

ffere

d to

wom

en a

ged

25–6

9 ev

ery

thre

e ye

ars.

The

par

ticip

atio

nra

te, e

stim

ated

in fi

ve r

egio

ns, i

s 25

%, a

ndth

e pl

an ta

rget

s ar

e 80

%. T

he F

renc

hN

atio

nal A

genc

y fo

r A

ccre

dita

tion

and

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBr

east

canc

er s

cree

ning

, pre

viou

sly li

mite

d to

som

e dé

parte

men

ts(3

2 at

the

end

of 2

002)

, has

bee

n ex

tend

edna

tionw

ide

sinc

e 1

Janu

ary

2004

(exc

ept f

or G

uyan

a): e

very

wom

an a

ged

betw

een

50 a

nd 7

4 is

invi

ted

for

a fre

e br

east

scre

enin

g ev

ery

two

year

s. B

reas

t scr

eeni

ng p

rogr

amm

es in

Fran

ce a

re a

dmin

iste

red

by m

anag

emen

t tea

ms

in e

ach

dépa

rtem

ent,

whi

ch s

ends

invi

tatio

ns to

targ

eted

wom

en.

Brea

st ca

ncer

scr

eeni

ng is

per

form

ed m

ainl

y by

inde

pend

ent

prof

essi

onal

s (9

0% o

f scr

eeni

ngs)

and

join

tly fi

nanc

ed b

yge

nera

l cou

ncils

and

hea

lth in

sura

nce

fund

s.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aD

own

synd

rom

e is

sys

tem

atic

ally

sou

ght i

npr

enat

al e

xam

inat

ions

. A b

lood

test

isof

fere

d to

eve

ry p

regn

ant w

oman

.A

mni

ocen

tesi

s is

sys

tem

atic

ally

offe

red

topa

tient

s at

ris

k: m

othe

rs a

ged

38 o

r ol

der,

thos

e w

ith a

“po

sitiv

e” b

lood

test,

or

inw

hom

a d

efec

t has

bee

n de

tect

ed in

apr

evio

us p

regn

ancy

, and

whe

re th

ere

isev

iden

ce o

f a c

hrom

osom

al d

efec

t in

pare

nts.

The

cos

t of t

he b

lood

test

is

France

Tabl

e A

1.2

con

t.

45

Cer

vica

l ca

nce

rEv

alua

tion

in H

ealth

(AN

AES

) ass

esse

d th

ebe

nefit

s of

the

Hum

an p

apill

oma

viru

s (H

PV)

test

and

did

not r

ecom

men

d its

sys

tem

atic

use

in a

ssoc

iatio

n w

ith th

e Pa

p te

st.H

owev

er, t

he H

PV te

st w

as in

clud

ed in

the

prof

essi

onal

s’ fe

e sc

hedu

le in

Dec

embe

r20

03 a

nd h

as b

een

reim

burs

ed in

cas

es o

fsu

spic

ious

Pap

test

resu

lts s

ince

Jan

uary

2004

. A r

ecen

t stu

dy e

stim

ated

that

35%

of

wom

en a

ged

25–6

9 ha

ve n

ever

, or

rare

ly,ha

d a

Pap

test.

Tar

gete

d m

essa

ges

will

be

used

to r

each

thes

e w

omen

and

the

upta

keof

Pap

tests

cou

ld b

e in

crea

sed

by th

epa

rtici

patio

n of

GPs

(96%

of P

ap te

sts a

recu

rren

tly c

arrie

d ou

t by

gyna

ecol

ogis

ts).

Bre

ast

cance

r, c

olo

rect

al ca

nce

rC

ance

r sc

reen

ing

exam

inat

ions

are

exe

mpt

ed fr

om th

e us

ers’

parti

cipa

tion

of €

1.C

olor

ecta

l can

cer

scre

enin

g ha

s be

en th

e su

bjec

t of t

rials

in 2

2 dé

parte

men

ts. P

relim

inar

y m

easu

res

wer

e ne

eded

tore

solv

e pr

oble

ms

rela

ted

to th

e pa

ymen

t of p

hysi

cian

s an

d to

the

posta

l tra

nspo

rting

of H

emoc

cult®

tests

. In

this

prog

ram

me,

men

and

wom

en a

ged

50 to

74

are

invi

ted

ever

y tw

o ye

ars

for

a fa

ecal

occ

ult b

lood

test

(FO

BT).

If th

is is

pos

itive

, aco

lono

scop

y w

ill b

e ca

rrie

d ou

t. Th

e pr

ogra

mm

e w

ill b

e ev

alua

ted

at th

e en

d of

200

5 to

def

ine

the

natio

nal s

trate

gyfo

r 20

07 (t

his

is th

e 53

rdob

ject

ive

of th

e Pu

blic

Hea

lth A

ct

of 2

004)

. The

firs

t res

ults

show

ed a

n in

crea

sing

rat

e of

pa

rtici

patio

n (u

p to

50%

in s

ome

dépa

rtem

ents)

than

ks to

stron

g pa

rtici

patio

n by

GPs

. The

tria

l inc

lude

s a

com

para

tive

asse

ssm

ent o

f tw

o te

sts (H

emoc

cult

II® v

ersu

s M

agstr

eam

).

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

are

imbu

rsed

by

soci

al s

ecur

ity if

car

ried

out b

etw

een

the

15th

and

the

18th

wee

ksof

pre

gnan

cy. T

he p

atie

nt h

as to

sig

n a

cons

ent f

orm

. Am

nioc

ente

sis

is a

lso

reim

burs

ed.

Neo

nata

l exa

min

atio

ns a

re r

outin

e fo

rne

wbo

rns

and

incl

ude

bloo

d te

sting

for

PKU,

cong

enita

l hyp

othy

roid

ism

, adr

enal

hype

rpla

sia,

hae

mog

lobi

nopa

thie

s/si

ckle

cell

anae

mia

, and

cys

tic fi

bros

is.

Spin

a bi

fida

is d

etec

ted

by u

ltras

ound

in w

eek

17 o

f pre

gnan

cy.

France

con

t.

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rTh

ere

is a

nat

iona

l pro

gram

me

for

brea

st ca

ncer

, cer

vica

l can

cer

and

colo

rect

al c

ance

r fo

r SH

I-ins

ured

indi

vidu

als.

Priv

ate

heal

th in

sure

rs w

ill p

ay fo

r op

portu

nisti

c sc

reen

ing.

Opp

ortu

nisti

c sc

reen

ing

for

brea

st ca

ncer

use

d to

be

wid

ely

prac

tised

. Bre

ast c

ance

r sc

reen

ing

has

been

rec

ently

reo

rgan

ized

tow

ards

a s

yste

mat

ic s

cree

ning

pro

gram

me,

at l

east

in w

omen

age

d 50

–69

who

are

invi

ted

regu

larly

. The

scr

eeni

ng is

sub

ject

ed to

tigh

t, ev

iden

ce-b

ased

qua

lity

assu

ranc

e m

easu

res.

The

scre

enin

g pr

ogra

mm

e is

org

aniz

ed s

epar

atel

y fro

m th

e di

seas

e m

anag

emen

t pro

gram

me

for

(the

treat

men

t of)

brea

st ca

ncer

, int

rodu

ced

in 2

003.

Fo

r ce

rvic

al a

nd c

olor

ecta

l can

cer

as w

ell a

s pr

osta

te c

ance

r di

rect

ives

of j

oint

com

mitt

ees

defin

e th

eta

rget

gro

ups,

the

scre

enin

g in

terv

al a

nd ty

pe o

f int

erve

ntio

n th

at is

pai

d fo

r by

SH

I. D

irect

ives

also

sp

ecify

qua

lity

assu

ranc

e re

quire

men

ts fo

r ph

ysic

ians

who

see

k re

imbu

rsem

ent f

rom

sic

knes

s fu

nds.

Th

ose

insu

red

are

enco

urag

ed to

par

ticip

ate

via

heal

th jo

urna

ls an

d ce

lebr

ity-le

d ca

mpa

igns

, but

are

not

invi

ted

indi

vidu

ally.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aPK

Ute

sting

is p

art o

f the

rou

tine

neon

atal

exam

inat

ions

for

babi

es a

nd is

fina

nced

by S

HI.

Ther

e ar

e na

tiona

l scr

eeni

ng p

olic

ies

for

preg

nanc

y w

ithin

SH

I, bu

t as

yet t

here

are

no s

peci

fic n

atio

nal s

cree

ning

pol

icie

s fo

rD

own

synd

rom

eor

spi

na b

ifida

. Tes

ting

for

Dow

n sy

ndro

me

and

spin

a bi

fida,

as

part

of tw

o ul

traso

unds

for

case

-find

ing

durin

g pr

egna

ncy,

is p

aid

for

by S

HI.

Ger

many

46

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rTh

ere

is n

o na

tiona

l pol

icy

on s

cree

ning

for

cerv

ical

can

cer,

brea

st ca

ncer

or

colo

n an

dre

ctal

can

cer

in G

reec

e. T

here

hav

e be

en s

ever

al s

pora

dic

initi

ativ

es d

evel

oped

by

the

Ant

i-Can

cer

Soci

ety

but t

here

is n

o w

ell-d

efin

ed a

nd s

peci

fic p

olic

y fo

r sc

reen

ing.

We

have

cond

ucte

d in

terv

iew

s w

ith:

1. M

inis

try o

f Hea

lth a

nd S

ocia

l Sol

idar

ity2.

KEE

L3.

Ant

i-Can

cer

Soci

ety

(non

gove

rnm

enta

l org

aniz

atio

n).

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aIn

Gre

ece

the

prev

alen

ce o

f PKU

has

bee

n es

timat

ed a

t 1pe

r 77

00 c

hild

ren

in 2

002.

PKU

can

be

diag

nose

d ea

rly in

the

neon

atal

per

iod.

Dow

n sy

ndro

me:

pre

gnan

t wom

en a

re a

sked

to u

nder

goa

bloo

d te

st an

d th

ose

over

35

year

s of

age

are

offe

red

anam

nioc

ente

sis.

N

o in

form

atio

n is

ava

ilabl

e fo

r sp

ina

bifid

a.

Gre

ece

Cer

vica

l ca

nce

rPh

ase

1 of

a N

atio

nal C

ervi

cal

Scre

enin

g Pr

ogra

mm

e of

fers

free

cerv

ical

scr

eeni

ng to

wom

en a

ged

25–6

0 ye

ars

in th

e M

id-W

este

rnH

ealth

Boa

rd a

rea

who

are

invi

ted

to r

egis

ter

with

the

prog

ram

me.

Th

e Iri

sh C

ervi

cal S

cree

ning

Prog

ram

me

(ICSP

) aim

s to

ens

ure

that

wom

en o

n th

e re

giste

r ar

ein

vite

d by

lette

r, ov

er a

five

-yea

rsc

reen

ing

perio

d, to

atte

nd fo

r a

free

cerv

ical

sm

ear

test.

Wom

enw

ho h

ave

neve

r ha

d a

prog

ram

me

smea

r ca

n co

ntac

t one

of t

he IC

SPRe

giste

red

Smea

rtake

rs (d

octo

rsan

d nu

rses

) to

disc

uss

havi

ng a

free

smea

r te

st.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBr

eastC

heck

is Ir

elan

d’s

natio

nal b

reas

t scr

eeni

ng p

rogr

amm

e. T

he a

imof

the

prog

ram

me

is th

e ea

rly d

etec

tion

and

treat

men

t of b

reas

t can

cer

in w

omen

who

sho

w n

o sy

mpt

oms

of th

e di

seas

e. P

hase

1 s

tarte

d in

Febr

uary

200

0 an

d is

in o

pera

tion

in th

e H

ealth

Ser

vice

Exe

cutiv

e(H

SE) E

aste

rn A

rea,

HSE

Mid

land

Are

a an

d H

SE N

orth

Eas

tern

Are

as.

In F

ebru

ary

2003

, the

Min

iste

r fo

r H

ealth

and

Chi

ldre

n an

noun

ced

the

exte

nsio

n of

Bre

astC

heck

in th

e ea

st to

cou

ntie

s W

exfo

rd, K

ilken

nyan

d C

arlo

w. S

cree

ning

sta

rted

in W

exfo

rd in

Mar

ch 2

004

and

in C

arlo

win

Apr

il 20

05. I

t is

expe

cted

to fo

llow

in K

ilken

ny in

ear

ly 2

006.

In M

ay 2

005

the

min

iste

r an

noun

ced

plan

s fo

r th

e de

velo

pmen

t of a

furth

er tw

o Br

eastC

heck

clin

ics

to c

over

the

sout

hern

and

wes

tern

regi

ons

of Ir

elan

d. It

is e

xpec

ted

to b

e av

aila

ble

natio

nally

tow

ards

the

end

of 2

007.

Brea

st sc

reen

ing

outsi

de th

e Br

eastC

heck

pro

gram

me

is a

vaila

ble

toal

l wom

en if

they

are

ref

erre

d by

a G

P. It

is in

clud

ed w

ithin

out

patie

ntpu

blic

hos

pita

l ser

vice

s an

d w

omen

are

not

cha

rged

for

scre

enin

g if

refe

rred

by

a G

P. In

priv

ate

hosp

itals,

they

hav

e to

pay

for

the

serv

ice.

Col

orec

tal c

ance

r is

not c

urre

ntly

scr

eene

d fo

r in

the

gene

ral p

opul

atio

nin

Irel

and.

Cer

tain

indi

vidu

als

are,

how

ever

, mor

e at

ris

k an

d m

ayre

ques

t to

be s

cree

ned.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aA

Nat

iona

l New

born

Scr

eeni

ngPr

ogra

mm

e w

as in

stiga

ted

in Ir

elan

d in

1966

with

initi

al s

cree

ning

for

phen

ylke

tonu

ria.

Scre

enin

g te

sts fo

r D

own

synd

rom

e an

dsp

ina

bifid

aar

e no

t offe

red

rout

inel

y bu

ton

ly in

cas

es c

onsi

dere

d to

be

at h

igh

risk.

Irel

and

Tabl

e A

1.2

con

t.

47

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rSc

reen

ing

polic

ies

for

thes

e di

seas

es h

ave

been

incl

uded

in th

e pa

ckag

e of

ess

entia

l lev

els

of c

are

prov

ided

by th

e SS

N (L

EA) b

y D

ecre

e “D

PCM

29/

11/2

001”

. All

Nat

iona

l Hea

lth P

lans

hav

e se

t tar

gets

for t

hese

are

asof

pre

vent

ion.

Reg

iste

rs a

re m

anag

ed a

t reg

iona

l lev

el. I

n th

e pa

st, th

ey w

ere

ofte

n sta

rted

inde

pend

ently

and

only

sub

sequ

ently

inse

rted

into

reg

iona

l hea

lth p

lans

. Scr

eeni

ng p

olic

ies

are

mor

e w

ides

prea

d in

north

ern

and

cent

ral I

taly.

The

re is

usu

ally

a s

yste

m fo

r ta

rget

ing

and

reca

lling

pat

ient

s al

thou

gh th

e ta

rget

popu

latio

n va

ries

acco

rdin

g to

reg

ion.

In U

mbr

ia, f

or b

reas

t can

cer,

the

targ

et p

opul

atio

n in

clud

es w

omen

aged

50–

59; f

or c

ervi

cal c

ance

r 25

–64,

for

colo

rect

al c

ance

r w

omen

and

men

age

d 50

–59.

Each

yea

r, th

ere

are

270

000

new

can

cer

case

s, w

ith 1

5000

0 de

aths

. Can

cer

is th

e se

cond

larg

est

caus

e of

dea

th a

nd in

cide

nce

is c

onsta

ntly

incr

easi

ng. S

ince

200

0, th

e go

vern

men

t has

ado

pted

a s

erie

s of

mea

sure

s ai

med

at p

rom

otin

g th

e w

ides

prea

d an

d un

iform

ado

ptio

n of

scr

eeni

ng p

olic

ies

at n

atio

nal l

evel

.Th

e m

ain

rece

nt p

olic

ies

are

the

follo

win

g:•

The

Budg

et (F

inan

cial

) Law

for t

he y

ear 2

001

(“Le

gge

Fina

nzia

ria”

art.

85) s

et e

xem

ptio

ns fr

om c

o-pa

ymen

t(ti

cket

) mam

mog

raph

ic e

xam

s (o

ne e

very

two

year

s fo

r wom

en a

ged

45–6

9); c

ervi

cal-v

agin

al c

ytol

ogic

alex

amin

atio

ns (o

ne e

very

thre

e ye

ars

for w

omen

age

d 25

–-69

); co

lono

scop

y (e

very

five

yea

rs, f

or m

en a

ndw

omen

age

d ov

er 4

5 an

d th

e po

pula

tion

defin

ed a

s at

risk

by

Min

istry

of H

ealth

dec

rees

). •

In 2

004

an a

gree

men

t bet

wee

n th

e sta

te a

nd th

e re

gion

s w

as s

igne

d th

at in

clud

es in

the

PPA

(Pia

no d

iPr

even

zion

e A

ttiva

) can

cer s

cree

ning

, as

defin

ed b

y th

e EU

Par

liam

ent r

esol

utio

n, a

s on

e of

the

four

stra

tegi

cta

rget

s.

•La

w n

.138

(pub

lishe

d in

the

Offi

cial

Bul

letin

– G

.U. –

on

26/5

/200

4) a

rt. 2

bis,

con

tain

s a

com

mitm

ent t

ocl

ose

the

gap

betw

een

the

targ

et p

opul

atio

n an

d th

e sc

reen

ed p

opul

atio

n, a

lloca

ting

€50

mill

ion

for t

his

targ

et.

•Th

e D

epar

tmen

t of H

ealth

is s

trivi

ng to

impl

emen

t an

effe

ctiv

e ca

ncer

scr

eeni

ng a

nd in

form

atio

n pr

ogra

mm

eat

nat

iona

l lev

el.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aEa

ch r

egio

n ha

s its

ow

n re

gula

tions

.A

nten

atal

scr

eeni

ng is

rec

omm

ende

d by

doct

ors

to w

omen

at r

isk.

Pre

gnan

t wom

enge

t rou

tine

ultra

soun

d ex

amin

atio

ns (a

t afre

quen

cy w

hich

var

ies

betw

een

regi

ons)

but g

enet

ic te

sting

is u

sual

ly o

ffere

d on

ly to

wom

en a

t ris

k.

Ther

e is

no

natio

nal p

olic

y. T

here

are

five

spec

ializ

ed s

pina

bifi

da c

entre

s in

Ital

yth

at p

rom

ote

info

rmat

ion

and

prev

entio

n.

Italy

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rTh

ere

is a

nat

iona

l pol

icy

on s

cree

ning

for

cerv

ical

and

bre

ast c

ance

r, bu

t not

for

colo

rect

alca

ncer

. The

se tw

o pr

ogra

mm

es (c

ervi

cal a

nd b

reas

t can

cer)

are

base

d on

a d

efin

ed p

opul

atio

nof

wom

en; t

heir

addr

esse

s ar

e ta

ken

from

the

mun

icip

al p

opul

atio

n re

giste

rs. P

aym

ent i

s ba

sed

on th

e Ex

cept

iona

l Med

ical

Exp

ense

s A

ct (A

WBZ

) (w

hich

is a

uni

vers

al s

ocia

l hea

lth in

sura

nce

sche

me)

and

the

prog

ram

mes

are

elig

ible

for

all w

omen

in th

e de

fined

age

gro

up.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aPK

U: t

here

are

blo

od te

sts fo

r al

l new

born

chi

ldre

n in

the

first

wee

k af

ter

birth

.D

own

synd

rom

e an

d sp

ina

bifid

a: a

trip

le te

st is

av

aila

ble

for

all w

omen

ove

r 35

afte

r th

ree

mon

ths

ofpr

egna

ncy.

Pay

men

t is

base

d on

the

Exce

ptio

nal

Med

ical

Exp

ense

s A

ct (A

WBZ

).

Net

her

lands

48

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Cer

vica

l ca

nce

rSc

reen

ing

is o

ppor

tuni

stic.

The

re a

re g

uide

lines

for

wom

en to

take

yea

rly s

mea

r te

sts. N

atio

nal P

rogr

am o

f Pre

vent

ion

and

Con

trol t

o O

ncol

ogy

Dise

ases

targ

ets

for s

cree

ning

of c

ervi

cal

canc

er, b

reas

t can

cer

and

colo

n an

d re

ctal

can

cer

are

60%

of

the

targ

et p

opul

atio

n by

201

0. C

ance

r pa

tient

s ar

e ex

empt

edfro

m th

e pa

ymen

t of u

ser

char

ges;

ther

e ar

e no

cha

rges

for

hosp

ital t

reat

men

t; an

d dr

ugs

for

canc

er tr

eatm

ent a

re to

tally

reim

burs

ed b

y th

e sta

te. N

ever

thel

ess,

can

cer

patie

nts

mig

ht p

ayfo

r co

nsum

ptio

n of

oth

er d

rugs

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSc

reen

ing

is o

ppor

tuni

stic

and

is d

etec

ted

mos

tly th

roug

h m

amm

ogra

phy.

The

re a

regu

idel

ines

for

wom

en to

take

yea

rlym

amm

ogra

phy.

Scre

enin

g fo

r co

lore

ctal

can

cer

isop

portu

nisti

c. T

here

is n

o na

tiona

l pol

icy

for

this

type

of c

ance

r.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aSc

reen

ing

for

PKU

and

Dow

n sy

ndro

me

isco

mpu

lsory

for

neon

ates

in th

e fir

st w

eek

of li

fe; t

hese

tests

are

free

of c

harg

e.

We

have

no

info

rmat

ion

on s

pina

bifi

da.

Port

ugal

Cer

vica

l ca

nce

rC

ervi

cal c

ance

r sc

reen

ing

thro

ugh

cyto

logy

is o

ffere

d to

all

wom

en a

ged

35 a

nd o

ver.

It is

fina

nced

by

publ

icin

sura

nce.

In th

e Ba

lear

ic Is

land

s ce

rvic

al

canc

er s

cree

ning

is o

ppor

tuni

stic.

In C

atal

onia

, the

re is

a p

erso

naliz

edre

giste

r of

all

targ

et in

divi

dual

s(w

omen

age

d 20

–64)

. Cer

vica

l can

cer

scre

enin

g (P

apan

icol

au te

chni

que)

isre

com

men

ded

ever

y th

ree

to fi

ve y

ears

.A

mon

g th

e m

ain

obje

ctiv

es o

f the

Nav

arre

Hea

lth P

lan

2001

–200

5 ar

eth

ose

rela

ted

to e

arly

det

ectio

n of

cerv

ical

can

cer,

brea

st ca

ncer

and

colo

rect

al c

ance

r. Th

e ce

rvic

al c

ance

rpr

ogra

mm

e is

bas

ed o

n oc

casi

onal

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSi

nce

1990

bre

ast c

ance

r de

tect

ion

prog

ram

mes

hav

ebe

en im

plem

ente

d in

all

Aut

onom

ous

Com

mun

ities

.Th

e pr

ogra

mm

es’ t

arge

t pop

ulat

ion

varie

s ac

ross

regi

ons.

In m

ost o

f the

reg

ions

the

targ

et p

opul

atio

nin

clud

es w

omen

age

d 50

–64/

5. In

thre

e A

uton

omou

sC

omm

uniti

es th

e ta

rget

pop

ulat

ion

is e

xten

ded

to a

llw

omen

bet

wee

n th

e ag

es o

f 45

and

69 (M

adrid

,N

avar

re a

nd V

alen

cia)

. In

Cat

alon

ia a

nd M

urci

aw

omen

bet

wee

n 50

and

69

can

bene

fit fr

om th

e pr

ogra

mm

e. In

Cas

tilla

y L

eón

the

prog

ram

me

cove

rsw

omen

age

d 45

–64/

5. T

he to

tal t

arge

t pop

ulat

ion

in20

03 r

ose

to 3

869

662

and

97.3

% w

ere

actu

ally

cove

red

by th

e pr

ogra

mm

es. F

ree

mam

mog

raph

y is

prov

ided

eve

ry tw

o ye

ars,

as

wel

l as

addi

tiona

l med

ical

and

labo

rato

ry e

xam

inat

ions

whe

n ne

eded

. La

ck o

f kno

wle

dge

and

soci

al a

ccep

tanc

e m

ake

the

dete

ctio

n of

col

orec

tal c

ance

r un

com

mon

. The

re a

repi

lot s

cree

ning

pro

gram

mes

in C

atal

onia

. The

via

bilit

y

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aTh

ere

are

neon

atal

scr

eeni

ng p

rogr

amm

es fo

ren

docr

ine-

met

abol

ic d

isea

ses

(PKU

and

hyp

othy

roid

ism

)in

all

Aut

onom

ous

Com

mun

ities

. The

se p

rogr

amm

essta

rted

in 1

968

in G

rana

da a

nd w

ere

impl

emen

ted

inBa

rcel

ona

and

Mad

rid a

few

yea

rs la

ter.

Sinc

e th

e19

80s

thes

e pr

ogra

mm

es h

ave

been

ext

ende

d to

the

rest

of th

e A

uton

omou

s C

omm

uniti

es. T

oday

the

neon

atal

scre

enin

g pr

ogra

mm

es c

over

pra

ctic

ally

100

% o

fne

onat

es. T

he r

ecom

men

datio

n is

to o

btai

n bl

ood

from

babi

es b

etw

een

the

5th

and

the

10th

day

of b

irth.

Th

e an

alys

es a

re c

ondu

cted

in a

ny o

f the

20

Clin

ical

and

Mol

ecul

ar G

enet

ics

Labo

rato

ries.

A

nten

atal

scr

eeni

ng is

per

form

ed in

prim

ary

care

se

tting

s or

in h

ospi

tals.

The

gui

delin

es fo

r m

onito

ring

ano

rmal

pre

gnan

cy in

clud

e a

serie

s of

tests

to d

etec

t ce

rtain

pat

holo

gies

, suc

h as

trip

le s

cree

ning

for

Dow

nsy

ndro

me

and

spin

a bi

fida,

the

O’S

ulliv

an te

st fo

rdi

abet

es, v

irus

sero

logy

for

hepa

titis

B, t

ests

for

Stre

ptoc

occu

s

Spain

Tabl

e A

1.2

con

t.

49

Cer

vica

l ca

nce

rsc

reen

ing

of th

e at

-risk

pop

ulat

ion

and

calli

ng o

f hig

h-ris

k in

divi

dual

s. T

hepl

an a

lso e

nvis

ages

the

deve

lopm

ent

of a

pro

gram

me

for

prev

entio

n an

dea

rly d

etec

tion

of c

olor

ecta

l can

cer.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rof

regi

onal

scr

eeni

ng p

rogr

amm

e is

still

to b

e ev

alua

ted.

The

prop

osed

scr

eeni

ng p

rogr

amm

e in

clud

es th

ree

type

s of

tests

(rec

tal e

xplo

ratio

n, tr

ansr

ecta

l eco

grap

hy,

and

pros

tate

-spec

ific

antig

en te

st) fo

r in

divi

dual

s ag

ed50

– 69

that

sho

uld

be p

erfo

rmed

eve

ry fi

ve to

ten

year

s.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aag

alac

tiae,

Rh

inco

mpa

tibili

ty, v

irus

sero

logy

for r

ubel

la,

and

sero

logy

for T

oxop

lasm

a go

ndii.

The

trip

le s

cree

ning

(a b

lood

test

that

mea

sure

s al

pha-

feto

prot

ein,

hum

anch

orio

nic

gona

dotro

pin

and

unco

njug

ated

estr

iol)

is

perfo

rmed

on

all p

regn

ant w

omen

. Am

nioc

ente

sis

ishi

ghly

rec

omm

ende

d fo

r w

omen

ove

r 35

.

Spain

con

t.

Cer

vica

l ca

nce

rO

rgan

ized

cer

vica

l can

cer

scre

enin

g ha

s be

en

impl

emen

ted

in S

wed

ensi

nce

the

mid

-196

0s.

A m

arke

d de

clin

e in

ce

rvic

al c

ance

r in

cide

nce

coul

d be

attr

ibut

ed to

the

start

of s

cree

ning

.Sq

uam

ous

cell

carc

inom

aha

s de

clin

ed b

y 60

%,

whe

reas

ade

noca

rcin

oma

has

incr

ease

d.

Abo

ut 9

5000

0Pa

pani

cola

ou (P

ap)

smea

rs a

re ta

ken

annu

ally.

Onl

y 31

% o

f the

sm

ears

are

take

n in

the

orga

nize

dsc

reen

ing

prog

ram

me.

A

s of

199

8, th

egu

idel

ines

for

reco

mm

ende

d sc

reen

ing

are:

eve

ry th

ird y

ear,

for

Bre

ast

cance

r, c

olo

rect

al ca

nce

rM

amm

ogra

phy

scre

enin

g is

car

ried

out f

or e

arly

det

ectio

n of

brea

st ca

ncer

, acc

ordi

ng to

the

Nat

iona

l Gui

delin

es fr

om th

eN

atio

nal B

oard

of H

ealth

and

Wel

fare

, a g

over

nmen

t age

ncy.

Scre

enin

g w

omen

in th

e ag

e gr

oup

40–7

4 w

ith m

amm

ogra

phy

can

redu

ce th

e ris

k of

mor

talit

y fro

m b

reas

t can

cer.

Effe

cts

vary

with

age

and

are

gre

ates

t for

wom

en a

ged

50–6

9. M

edic

alex

amin

atio

n w

ith m

amm

ogra

phy

is r

ecom

men

ded

for

this

age

grou

p th

roug

hout

the

natio

n.Fo

r w

omen

age

d 70

–74

the

effe

cts

are

cons

ider

ed to

be

good

and

an in

crea

sing

dem

and

can

be e

xpec

ted.

The

refo

re, i

t is

cost-

effe

ctiv

e to

offe

r sc

reen

ing

to th

is a

ge g

roup

as

wel

l. D

etai

ls m

ust

be a

djus

ted

to lo

cal c

ondi

tions

.Fo

r w

omen

age

d 40

–49

the

posi

tive

effe

cts

outw

eigh

oth

er

cons

ider

atio

ns, e

ven

if cu

rren

t inf

orm

atio

n is

unc

lear

as

to th

e ris

kof

sid

e-ef

fect

s an

d ov

ertre

atm

ent.

The

low

inci

denc

e of

can

cer

mea

ns th

at th

e ab

solu

te g

ain

is le

ss c

ompa

red

to o

lder

age

grou

ps; t

his

is c

ompe

nsat

ed fo

r by

the

fact

that

you

nger

wom

enha

ve m

ore

life-

year

s to

gai

n. S

cree

ning

with

mam

mog

raph

y is

,th

eref

ore,

rec

omm

ende

d al

so fo

r th

ese

wom

en. T

he fo

rm a

ndsc

ope

shou

ld b

e de

term

ined

in a

ccor

danc

e w

ith lo

cal c

ondi

tions

.Ex

amin

atio

n te

chni

que,

pro

ject

ions

and

inte

rval

s sh

ould

be

indi

vidu

ally

ada

pted

to th

e w

oman

’s br

east

tissu

e ch

arac

ter,

curre

nt

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aG

ener

al s

cree

ning

for

PKU

was

intro

duce

d in

Sw

eden

in 1

965.

A b

lood

sam

ple

is ta

ken

from

all

neon

ates

on

the

third

day

afte

r de

liver

y an

d an

alys

ed fo

r ph

enyl

alan

ine.

Eve

n ch

ildre

n bo

rn a

t hom

e or

abr

oad

are

incl

uded

in th

e sc

reen

ing

whe

reve

r po

ssib

le. I

f PKU

is s

uspe

cted

the

defin

itive

dia

gnos

is is

ach

ieve

d by

anal

ysis

of t

he b

lood

leve

l of a

min

o ac

ids

and

the

urin

ele

vel o

f pte

rines

. In

som

e ca

ses

gene

ana

lysi

s is

also

carr

ied

out i

n or

der

to d

etec

t the

gen

e fo

r ph

enyl

ala-

nine

hydr

oxyl

ase.

Scre

enin

g fo

r Dow

n sy

ndro

me:

ultr

asou

nd e

xam

inat

ion

durin

g pr

egna

ncy

was

intro

duce

d ne

arly

25

year

s ag

o.

All

preg

nant

wom

en a

re o

ffere

d on

e ul

traso

und

scan

in th

e se

cond

trim

este

r (g

esta

tiona

l wee

ks 1

5–20

) and

the

offe

r is

acc

epte

d by

97%

of w

omen

. Mid

wiv

es w

ithsp

ecia

l tra

inin

g in

ultr

ason

ogra

phy

usua

lly p

erfo

rm th

eex

amin

atio

n. A

ims

of th

e ro

utin

e ul

traso

und

are

to: e

stim

ate

gesta

tiona

l age

, loc

aliz

e th

e pl

acen

ta, s

cree

n fo

r mul

tiple

preg

nanc

ies

and

dete

ct s

truct

ural

mal

form

atio

ns.

All

preg

nant

wom

en a

re a

lso g

iven

info

rmat

ion

(by

the

mid

wiv

es) o

n th

e po

ssib

ility

of h

avin

g an

am

nioc

ente

sispe

rform

ed in

ord

er to

det

ect c

hrom

osom

al a

bnor

mal

ities

Swed

en

50

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Cer

vica

l ca

nce

r23

–50

and

ever

y fif

th y

ear

for

thos

e ag

ed 5

1–60

. H

owev

er, h

ealth

car

e in

Swed

en is

org

aniz

ed b

yau

tono

mou

s co

untie

s an

dth

ere

are

abou

t 30

diffe

rent

regi

onal

aut

onom

ous

cerv

ical

can

cer

scre

enin

gpr

ogra

mm

es in

Sw

eden

.Fo

r ab

out 8

0% o

fSw

eden

, com

pute

rized

files

of o

rgan

ized

and

spon

tane

ous

Pap

smea

rus

age

by e

ach

indi

vidu

alar

e co

llect

ed, b

ut th

ese

files

are

not

com

bine

d to

gene

rate

nat

ionw

ide

data

on s

cree

ning

usa

ge a

ndar

e no

t use

d fo

r lin

kage

with

can

cer

regi

strie

s to

dete

rmin

e w

heth

er th

esc

reen

ing

has

the

desi

red

effe

cts

of r

educ

ing

inci

denc

e of

, and

mor

talit

yfro

m, c

ervi

cal c

ance

r.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rm

edic

atio

n et

c. In

oth

er c

ases

18

mon

ths

for

wom

en u

nder

55

and

24 m

onth

s fo

r w

omen

ove

r 55

is r

ecom

men

ded.

For

high

dia

gnos

tic a

ccur

acy,

dou

ble

chec

king

of m

amm

ogra

ms

is r

ecom

men

ded.

How

ever

, in

the

near

futu

re n

ew e

lect

roni

cde

vice

s m

ay b

e av

aila

ble

to s

uppo

rt th

is p

roce

ss, w

hich

has

to b

ead

juste

d ac

cord

ingl

y.Th

e N

atio

nal H

ealth

Act

sta

tes

that

the

qual

ity o

f hea

lth c

are

shou

ld b

e sy

stem

atic

ally

dev

elop

ed a

nd im

prov

ed fo

r sa

fety

. Th

e N

atio

nal B

oard

of H

ealth

and

Wel

fare

has

issu

ed r

egul

atio

nsan

d ge

nera

l adv

ice

on q

ualit

y as

sura

nce

syste

ms

in h

ealth

car

e.Th

ese

regu

latio

ns a

pply

to s

cree

ning

with

mam

mog

raph

y.In

the

expe

rt re

port

indi

cato

rs a

re d

efin

ed a

nd c

urre

nt th

resh

old

valu

es a

re g

iven

for

qual

ity c

riter

ia.

If a

publ

ic h

ealth

ser

vice

del

egat

es th

e ta

sk o

f im

plem

entin

g a

scre

enin

g pr

ogra

mm

e w

ith m

amm

ogra

phy

to a

sec

onda

rypr

ovid

er, t

he d

eleg

atin

g he

alth

ser

vice

mus

t be

assu

red

that

the

prov

ider

follo

ws

thes

e re

gula

tions

.A

utho

rizat

ion

is r

equi

red

from

the

Nat

iona

l Rad

iatio

n Pr

otec

tion

Insti

tute

(SSI

) for

all

faci

litie

s ut

ilizi

ng io

nizi

ng r

adia

tion.

Ther

e is

no

natio

nal s

cree

ning

pro

gram

me

for

colo

rect

al c

ance

rin

Sw

eden

. The

Nat

iona

l Boa

rd o

f Hea

lth a

nd W

elfa

re a

re c

urre

ntly

wor

king

on

new

gui

delin

es fo

r co

lore

ctal

can

cer,

brea

st ca

ncer

and

canc

er o

f the

pro

state

pla

nned

for

publ

icat

ion

in 2

006.

Faec

al o

ccul

t blo

od te

st, s

igm

oido

scop

y an

d co

lono

scop

y ha

ve a

llbe

en c

onsi

dere

d as

scr

eeni

ng te

sts fo

r co

lore

ctal

can

cer.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

ain

the

fetu

s. F

oeta

l scr

eeni

ng fo

r ch

rom

osom

al

abno

rmal

ities

is p

rimar

ily a

imed

at d

etec

ting

Dow

n sy

ndro

me

(bei

ng th

e m

ost c

omm

on o

ne).

Wom

en a

ged

35 o

r ol

der

are

give

n m

ore

deta

iled

info

rmat

ion

(by

a ph

ysic

ian)

on

this

subj

ect a

nd ro

utin

ely

offe

red

amni

ocen

tesi

s.

Scre

enin

g m

etho

ds a

vaila

ble

on r

eque

st bu

t not

ro

utin

ely

used

are

:•

Firs

t trim

este

r se

rum

scr

eeni

ng w

ith a

naly

sis

ofPA

PP-A

and

β-H

CG

are

bio

chem

ical

met

hods

of

estim

atin

g th

e ris

k of

the

foet

us h

avin

g D

own

synd

rom

e.•

Seco

nd tr

imes

ter

mat

erna

l ser

um a

naly

ses

ofal

pha-

feto

prot

ein

(AFP

), H

CG

and

unc

onju

gate

des

triol

and

inhi

bin-

A le

vels.

Scre

enin

g fo

r sp

ina

bifid

a: T

he S

wed

ish

Regi

stry

ofC

onge

nita

l Mal

form

atio

nsw

as s

tarte

d in

196

4 as

a tr

ial

and

esta

blis

hed

in 1

965.

In 1

999

a sp

ecia

l rep

ortin

gsy

stem

was

sta

rted

to in

clud

e fe

tuse

s w

ith c

onge

nita

lm

alfo

rmat

ions

.The

aim

is to

con

tinuo

usly

follo

w th

ede

velo

pmen

t of s

erio

us c

onge

nita

l mal

form

atio

ns a

ndqu

ickl

y to

det

ect c

hang

es in

the

occu

rren

ce o

f diff

eren

tm

alfo

rmat

ions

. Ser

ious

con

geni

tal m

alfo

rmat

ions

are

repo

rted

with

in s

ix m

onth

s af

ter

birth

. The

re a

re a

bout

1700

rep

orts

a ye

ar.

Swed

en c

ont.

Tabl

e A

1.2

con

t.

51

Cer

vica

l ca

nce

rN

atio

nal C

ervi

cal C

ance

r Pr

ogra

mm

e:ce

rvic

al s

cree

ning

is o

ffere

d to

wom

enag

ed 2

5–49

eve

ry th

ree

year

s an

d to

thos

e ag

ed 5

0–64

eve

ry fi

ve y

ears

. It i

sof

fere

d to

thos

e ag

ed 6

5+ o

nly

if th

eyha

ve n

ever

bee

n sc

reen

ed o

r if

they

have

pre

viou

sly h

ad a

sus

pect

res

ult.

The

age

grou

p fo

r ce

rvic

al s

cree

ning

in S

cotla

nd is

21–

60.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rN

atio

nal B

reas

t Can

cer S

cree

ning

Pro

gram

me:

wom

en a

ged

50–7

0 ar

e in

vite

d fo

r m

amm

ogra

phy

ever

y th

ree

year

s.W

omen

ove

r 70

can

be

scre

ened

on

requ

est.

As

a re

sult

of p

ilot s

tudi

es, a

nat

iona

l pro

gram

me

ofsc

reen

ing

by fa

ecal

occ

ult b

lood

test

for

colo

rect

al c

ance

rha

s be

en a

gree

d fo

r m

en a

nd w

omen

age

d 60

–69

ever

ytw

o ye

ars.

Impl

emen

tatio

n is

cur

rent

ly b

eing

pla

nned

and

scr

eeni

ngw

ill b

e in

trodu

ced

in p

hase

s sta

rting

in A

pril

2006

.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aTh

ere

are

rout

ine

neon

atal

blo

odsp

ot s

cree

ning

tests

for

PKU

, CH

, CF

and

sick

le c

ell d

isea

se.

Dow

n sy

ndro

me:

qua

drup

le s

erum

tests

and

ultra

soun

d ar

e ca

rrie

d ou

t in

the

seco

ndtri

mes

ter

of p

regn

ancy

.Sp

ina

bifid

a: u

ltras

ound

scr

eeni

ng ta

kes

plac

e be

twee

n 18

and

20

wee

ks o

f pre

gnan

cyw

ith b

lood

test

if in

dica

ted.

United

Kin

gdom

ANNEXE 2

Screening tables: New Member Statesand Candidate Countries

54

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

Giv

en th

e in

crea

sing

pre

vale

nce

of c

ases

of

TB in

the

last

10–1

5 ye

ars

(the

TB m

orbi

dity

rate

has

dou

bled

in o

nly

eigh

t yea

rs; f

rom

25.1

in 1

000

0 in

199

0 to

50.

0 in

100

000

in 1

998)

, the

Min

istry

of H

ealth

dev

elop

ed a

Nat

iona

l Pro

gram

me

for

Prev

entio

n, E

arly

Dia

gnos

is a

nd T

reat

men

t of T

uber

culo

sis

(200

0–20

03) i

n 20

00. A

mon

g th

e go

als

ofth

is p

rogr

amm

e is

ear

ly T

B di

agno

sis.

Fluo

rogr

aphi

c ch

eck-

ups

of p

opul

atio

ns a

t ris

k(p

eopl

e liv

ing

in r

egio

ns w

ith T

B m

orbi

dity

rate

s hi

gher

than

the

coun

try a

vera

ge; p

rison

s;ps

ychi

atric

and

com

mun

ity e

stabl

ishm

ents,

etc.

) hav

e be

en in

trodu

ced.

The

pro

gram

me

isal

so c

onsid

erin

g th

e de

velo

pmen

t of a

com

mon

com

pute

rized

sys

tem

for

regi

sterin

g al

l new

TB c

ases

and

the

resu

lts o

f the

ir tre

atm

ent.

The

rela

tive

succ

ess

of th

is p

rogr

amm

e is

ev

iden

t fro

m th

e fa

ct th

at th

e TB

inci

denc

era

te in

Bul

garia

has

dec

lined

slig

htly

ove

r th

ela

st fe

w y

ears

and

rem

aine

d be

low

50

in10

000

0 pe

ople

(48.

8 an

d 47

.8 in

100

000

peop

le in

200

1 an

d 20

02, r

espe

ctiv

ely)

.A

new

Nat

iona

l Tub

ercu

losi

s C

ontro

lPr

ogra

mm

e (2

004–

2006

) has

bee

n in

pla

cesi

nce

2004

. Thi

s ne

w p

rogr

amm

e se

t som

esp

ecifi

c qu

antit

ativ

e ob

ject

ives

(des

crib

edab

ove)

and

is fu

lly fi

nanc

ed b

y th

e N

atio

nal

Hea

lth In

sura

nce

Fund

.

HIV

A N

atio

nal P

rogr

amm

e fo

r Pr

even

tion

and

Con

trol o

f HIV

and

oth

er s

exua

lly tr

ansm

itted

dise

ases

(200

1–20

07) h

as b

een

in p

lace

sin

ce 2

001.

It is

not

opp

ortu

nisti

c. T

he m

ain

obje

ctiv

es, b

road

ly d

efin

ed, o

f thi

s pr

ogra

mm

e ar

e:•

to e

stabl

ish

the

basi

s fo

r a

stead

y pr

oces

s of

era

dica

ting

the

fact

ors

that

con

tribu

teto

the

spre

ad o

f HIV

, pay

ing

spec

ial a

ttent

ion

to th

e vu

lner

able

gro

ups

of th

e po

pula

tion;

•to

ens

ure

a to

lera

nt a

nd s

uppo

rtive

soc

ial e

nviro

nmen

t and

acc

ess

to h

ealth

car

efo

r th

ose

suffe

ring

from

HIV

or

sexu

ally

tran

smitt

ed d

isea

ses;

•to

redu

ce th

e ris

k of

tran

smitt

ing

HIV

and

oth

er b

lood

-bor

ne in

fect

ions

by

intro

duci

nggo

od m

edic

al p

ract

ices

and

sta

ndar

ds a

ccor

ding

to th

e di

rect

ives

of W

HO

and

the

Euro

pean

Cou

ncil.

The

prog

ram

me

is no

t uni

form

thro

ugho

ut th

e co

untry

. Nin

etee

n of

the

27 m

unic

ipal

ities

cont

ain

the

high

est p

erce

ntag

es o

f the

targ

et p

opul

atio

n: 9

0% o

f the

intra

veno

us d

rug

addi

cts;

67%

of t

he p

rosti

tute

s; 5

0% o

f the

gyp

sy m

inor

ity; a

nd 6

7% o

f you

ng p

eopl

e(6

6% o

f tho

se in

sec

onda

ry e

duca

tion

and

82%

of t

hose

in u

nive

rsity

edu

catio

n).

The

prog

ram

me

clas

sifie

s th

e m

unic

ipal

ities

in th

ree

grou

ps:

1.si

x m

unic

ipal

ities

with

hig

her

risk

expo

sure

, whe

re th

e pr

ogra

mm

e co

ver

all f

our

vuln

erab

le g

roup

s in

the

popu

latio

n (in

trave

nous

dru

g ad

dict

s, p

rosti

tute

s, th

egy

psy

min

ority

, and

you

ng p

eopl

e);

2.th

ree

mun

icip

aliti

es w

here

the

prog

ram

me

cove

rs th

ree

of th

e fo

ur v

ulne

rabl

egr

oups

(int

rave

nous

dru

g ad

dict

s, p

rosti

tute

s, a

nd y

oung

peo

ple)

; 3.

ten

mun

icip

aliti

es w

here

the

prog

ram

me

cove

rs o

nly

one

of th

e fo

ur v

ulne

rabl

egr

oups

.Th

e pr

ogra

mm

e is

fina

nced

by

the

Glo

bal F

und

to fi

ght A

IDS,

TB

and

mal

aria

. Th

e fin

anci

al c

ontri

butio

n re

ceiv

ed fr

om th

e Fu

nd a

mou

nts

to U

S$ 6

894

270

for

the

perio

d 20

03–2

005.

How

ever

, mos

t of t

he te

sts fo

r de

tect

ion

of H

IV o

r ot

her

sexu

ally

tran

smitt

ed d

isea

ses

are

paid

dire

ctly

by

the

patie

nts.

The

re is

one

ON

G th

at p

rovi

des

HIV

tests

free

of

char

ge.

Chla

mydia

Chl

amyd

iais

not e

xplic

itly

men

tione

d in

the

abov

e pr

ogra

mm

es.

No

othe

r in

form

atio

n is

avai

labl

e.

Bulg

ari

a

Tabl

e A

2.1

TB,

HIV

, Chl

amyd

ia

55

Tuber

culo

sis

Non

eH

owev

er, n

on-E

U c

itize

ns g

oing

to w

ork

in C

ypru

s fro

m A

sia

(Sri

Lank

a, In

dia,

Pak

ista

n, T

haila

nd, e

tc.)

and

easte

rn E

urop

ear

e te

sted.

In a

dditi

on, a

ll ci

vil s

erva

nts

mus

t hav

e a

ches

t X-ra

y up

on a

ppoi

ntm

ent t

o th

e ci

vil s

ervi

ce. I

n th

e ca

se o

f for

eign

wor

kers

, the

ir po

tent

ial e

mpl

oyer

bea

rs th

e fu

ll co

st, w

hile

for

civi

l ser

vant

s th

e co

st is

cov

ered

by

the

state

.

HIV

Non

eChla

mydia

Non

e

Cypru

s

Tuber

culo

sis

TB is

not

ifiab

le b

y la

w w

ith tw

o lin

ked

syste

ms

– th

e re

giste

r of

tube

rcul

osis

and

a la

bora

tory

not

ifica

tion-

base

d in

form

atio

n sy

stem

for b

acill

ary

tube

rcul

osis.

Any

pat

ient

pre

sent

ing

with

hea

lth p

robl

ems

and

diag

nose

d w

ith T

B ha

s to

be n

otifi

ed. D

ata

are

reta

ined

with

in th

e sy

stem

follo

win

g cl

assi

ficat

ion

rule

s.H

ealth

car

e w

orke

rs in

TB

setti

ngs,

TB

labo

rato

ry p

erso

nnel

, stu

dent

s en

terin

gm

edic

al s

choo

ls an

d pr

isone

rs a

re re

gula

rly s

cree

ned

for T

B (T

ST –

tube

rcul

osis

skin

test)

. BC

G v

acci

natio

n is

obl

igat

ory

and

child

ren

are

scre

ened

by

TST

atag

e 11

. If t

hey

pres

ent a

neg

ativ

e re

sult,

they

are

rev

acci

nate

d. M

igra

nts

inas

ylum

cam

ps a

re s

cree

ned

at e

ntry

with

TST

. The

re is

a li

mite

d pr

ogra

mm

efo

r sc

reen

ing

hom

eles

s pe

ople

, with

ince

ntiv

es (X

-ray

scre

enin

g fo

r ac

tive

TB).

TB s

cree

ning

is p

aid

for

by h

ealth

insu

ranc

e. R

ules

for

TB c

ontro

l req

uire

reca

ll of

pat

ient

s an

d pe

rson

s in

con

tact

with

TB

acco

rdin

g to

spe

cific

rul

es.

Ther

e is

a s

et o

f leg

al in

strum

ents

cont

rolli

ng T

B sc

reen

ing.

HIV

Scre

enin

g fo

r H

IV is

ver

y co

mpl

ex w

ith a

set

of

lega

l ins

trum

ents

cont

rolli

ng H

IV s

cree

ning

.Th

ere

is o

blig

ator

y sc

reen

ing

in c

ases

incl

uded

in s

peci

fic ru

les.

Vol

unta

ry s

cree

ning

is a

cces

sible

for a

nyon

e w

ho w

ants

it (in

cer

tain

circ

umsta

nces

adm

itted

by

law

it c

an b

e an

onym

ous)

.Sc

reen

ing

is c

ompu

lsory

for

dono

rs o

f blo

od,

orga

ns o

r any

bio

logi

cal m

ater

ial,

and

for

preg

nant

wom

en. A

ny s

uch

scre

enin

g is

pai

dfo

r by

hea

lth in

sura

nce.

Som

e fo

reig

n co

untri

esre

quire

HIV

testi

ng b

efor

e en

try a

nd in

suc

hca

ses

the

cost

of th

e te

st is

the

resp

onsi

bilit

y of

the

indi

vidu

al c

once

rned

.

Chla

mydia

Tests

for

Chl

amyd

iaar

edo

ne o

nly

as a

par

t of

the

diag

nosti

c pr

oces

s in

indi

vidu

al c

ases

. The

reis

no

spec

ific

scre

enin

gsc

hem

e.

Cze

ch R

epublic

Tuber

culo

sis

Non

eH

IVH

IV te

sting

is c

ompu

lsory

dur

ing

preg

nanc

y, w

hen

ente

ring

mili

tary

ser

vice

,an

d fo

r pr

ison

ers.

Chla

mydia

Testi

ng fo

r C

hlam

ydia

is c

ompu

lsory

dur

ing

preg

nanc

y.

Esto

nia

56

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

Scre

enin

g ba

sed

on a

def

ined

pop

ulat

ion

regi

ster

with

a s

yste

m fo

r ta

rget

ing

and

reca

lling

indi

vidu

als

(age

d 18

+, o

n a

year

lyba

sis)

ope

rate

s on

ly fo

r TB

. In

2003

134

fixed

and

48

mob

ile p

ulm

onar

y sc

reen

ing

statio

ns w

ere

oper

atin

g an

d 3

717

518

scre

enin

gs w

ere

carr

ied

out (

43%

of t

head

ult p

opul

atio

n w

ere

scre

ened

).

HIV

Opp

ortu

nisti

c sc

reen

ing

for

HIV

is a

lso a

vaila

ble.

Targ

eted

scr

eeni

ng fo

r H

IV in

fect

ion

is a

sub

prog

ram

me

of th

e N

PHP.

Incr

easi

ng

volu

ntar

y te

sting

bas

ed o

n in

form

ed c

onse

nt a

mon

g hi

gh-ri

sk g

roup

s an

d re

-intro

duci

ngan

onym

ous

HIV

testi

ng c

ombi

ned

with

cou

nsel

ling

are

plan

ned.

Enf

orci

ng th

e le

gally

regu

late

d m

anda

tory

hea

lth e

xam

inat

ion

(incl

udin

g H

IV te

sting

) of s

exua

l wor

kers

isal

so a

mon

g th

e ac

tions

pla

nned

in th

e su

b-pr

ogra

mm

e “P

reve

ntin

g A

IDS”

of t

he N

PHP.

Scre

enin

g te

sts a

re p

aid

for

by th

e N

atio

nal I

nsur

ance

Fun

d (N

IF) i

f the

y ar

e ca

rrie

dou

t in

accr

edite

d in

stitu

tions

.

Chla

mydia

Opp

ortu

nisti

csc

reen

ing

for

Chl

amyd

iais

avai

labl

e.

Hungary

Tabl

e A

2.1

con

t.

Tuber

culo

sis

WH

O T

B co

ntro

l stra

tegy

form

ed th

e ba

sis

for

a N

atio

nal T

uber

culo

sis

Con

trol P

rogr

amm

e ai

med

at d

iagn

osis

, tre

atm

ent a

nd p

reve

ntio

n.TB

dia

gnos

is w

orks

on

two

leve

ls: G

Ps p

rovi

de a

nnua

l exa

min

atio

nsof

thei

r pa

tient

s (p

assi

ve r

ecog

nitio

n); c

heck

-up

of a

ny c

onta

cts

and

patie

nt h

igh-

risk

grou

ps, s

uch

as p

rison

ers

and

imm

igra

nts

(act

ive

reco

gniti

on).

Patie

nt r

ecal

l is

base

d on

the

TB p

atie

nt r

egis

ter

– pa

tient

s ar

eex

amin

ed tw

o ye

ars

afte

r re

cove

ry.

The

Stat

e A

genc

y of

TB

and

Lung

Dise

ases

of L

atvi

a (S

ATLD

) man

age

the

Latv

ian

Nat

iona

l TB

Prog

ram

me,

initi

ated

in 1

995,

bef

ore

the

rest

of th

e fo

rmer

Sov

iet U

nion

follo

win

g th

e W

HO

DO

TS s

trate

gy (D

irect

lyO

bser

ved

Trea

tmen

t Sho

rt-co

urse

). By

199

9, n

early

95%

of t

hepo

pula

tion

was

cov

ered

by

DO

TS w

ith a

72%

cur

e ra

te (W

HO

glo

bal

targ

et o

f 85%

). La

tvia

was

the

only

cou

ntry

in th

e re

gion

per

form

ing

larg

e-sc

ale

treat

men

t of M

DR-

TB p

atie

nts

acco

rdin

g to

WH

O’s

DO

TS-

Plus

stra

tegy

, with

200

–250

pat

ient

s an

nual

ly b

eing

trea

ted

with

dru

gsfu

nded

by

the

Latv

ian

gove

rnm

ent.

The

SATL

D is

a tr

eatm

ent,

teac

hing

and

rese

arch

faci

lity

with

trai

ning

in a

ll as

pect

s of

TB

man

agem

ent

and

cont

rol,

incl

udin

g ro

le o

f PH

C, l

abor

ator

ies

and

surv

eilla

nce.

HIV

Prog

ram

me

for

Limiti

ng th

e Sp

read

of H

IV/A

IDS

in L

atvi

a20

03–2

007

(pre

viou

sly H

IV/A

IDS

spre

ad c

ontro

l stra

tegy

inLa

tvia

199

9–20

03).

Prio

ritie

s ar

e: H

IV p

reve

ntio

n am

ong

inje

ctin

gdr

ug u

sers

; tre

atm

ent a

nd s

uppo

rt fo

r pe

ople

livi

ng w

ith H

IV a

ndA

IDS;

HIV

infe

ctio

n sp

read

con

trol a

mon

g yo

ung

peop

le.

Two

maj

or p

roje

cts

supp

ort t

he c

ontro

l of H

IV in

fect

ion:

co

ordi

nate

d su

ppor

t for

you

ng p

eopl

e’s

heal

th in

Lat

via;

and

un

iform

sec

onda

ry p

reve

ntio

n bu

ildin

g fo

r int

rave

nous

dru

g us

ers.

A

IDS

Prev

entio

n C

entre

: epi

dem

iolo

gica

l mon

itorin

g an

d pr

even

tion

mea

sure

s.Lia

ises

with

the

Euro

pean

AID

S M

onito

ring

Cen

tre a

ndad

here

s to

the

requ

irem

ents

of U

NA

IDS

and

the

Euro

pean

Uni

onan

d is

inte

grat

ed in

to E

uroH

IV p

rogr

amm

e.Ta

rget

gro

ups

for

scre

enin

g:•

HIV

infe

cted

per

sons

and

AID

S pa

tient

s;•

preg

nant

wom

en;

•m

ilita

ry r

ecru

its;

•th

ose

invo

lved

in th

e na

tiona

l arm

ed fo

rces

and

inte

rnat

iona

lpe

ace

mai

nten

ance

.

Chla

mydia

Ther

e is

no

spec

ific

prog

ram

me

for

scre

enin

g of

Chl

amyd

ia.

Latv

ia

57

Tuber

culo

sis

Ther

e is

a n

atio

nal p

olic

y of

sel

ectiv

e te

sts fo

r TB

. Te

sts a

re p

erfo

rmed

on

peop

le w

ith p

rolo

nged

cou

gh

synd

rom

e or

clin

ical

ly s

uspe

ct s

ympt

oms,

usin

g m

icro

scop

ican

alys

is o

f exp

ecto

ratio

n (D

OT

prog

ram

me)

. Te

sts a

re fi

nanc

ed b

y th

e sta

te s

ickn

ess

fund

.

HIV

Ther

e is

a n

atio

nal p

olic

y on

HIV

scr

eeni

ng.

Tests

are

per

form

ed o

n pe

ople

with

clin

ical

AID

Ssy

mpt

oms,

peo

ple

from

hig

h-ris

k gr

oups

and

on

preg

nant

wom

en.

Tests

are

fina

nced

by

the

state

sic

knes

s fu

nd.

Chla

mydia

Ther

e is

no

natio

nal s

cree

ning

pol

icy

for

Chl

amyd

ia. T

ests

are

perfo

rmed

oppo

rtuni

stica

llyac

cord

ing

to c

linic

alsy

mpt

oms

and

are

paid

for

by th

epa

tient

.

Lith

uania

Tuber

culo

sis

In M

alta

, TB

inci

denc

e is

low

bec

ause

of s

cree

ning

, act

ive

surv

eilla

nce

and

cont

rol s

trate

gies

fund

eden

tirel

y by

the

publ

ic h

ealth

car

e sy

stem

. Th

e Sc

hool

Med

ical

Ser

vice

that

form

s pa

rt of

the

Prim

ary

Hea

lth C

are

Dep

artm

ent o

ffers

TB

scre

enin

g w

ith M

anto

ux a

nd B

CG

vac

cina

tion

to a

ll sc

hool

chi

ldre

n at

12–

13 y

ears

of a

ge.

The

Che

st U

nit o

f the

Dep

artm

ent o

f Pub

lic H

ealth

scr

eens

ille

gal i

mm

igra

nts

to M

alta

for

TB w

ith a

Man

toux

test.

Obj

ectiv

es a

re to

iden

tify

activ

e TB

dis

ease

at a

n ea

rly s

tage

, to

give

cur

ativ

e tre

atm

ent

and

to p

reve

nt tr

ansm

issi

on o

f dis

ease

.Be

caus

e of

ver

y po

or c

ompl

ianc

e w

ith th

e TB

pre

vent

ive

treat

men

t by

imm

igra

nts,

it is

now

bei

ngof

fere

d to

imm

igra

nt s

choo

lchi

ldre

nan

d to

thos

e im

mig

rant

s w

ith a

bnor

mal

che

st X-

rays

whe

re fi

ndin

gsar

e co

nsist

ent w

ith o

ld T

B. A

ny im

mig

rant

who

wish

es to

be

teste

d fo

r TB

infe

ctio

n an

d of

fere

d pr

even

tive

treat

men

t can

do

so. P

reve

ntiv

e tre

atm

ent i

s of

fere

d an

d ca

n be

ref

used

by

the

patie

nt.

Patie

nts

with

act

ive

tube

rcul

osis

are

giv

en tr

eatm

ent f

ree

of c

harg

e. T

reat

men

t is

supe

rvis

ed d

aily

by

a nu

rse

to m

ake

sure

that

it is

take

n pr

oper

ly a

nd r

egul

arly

(DO

T pr

ogra

mm

e).

HIV

Opp

ortu

nisti

c sc

reen

ing

for

HIV

is o

ffere

d w

ithin

the

publ

ic h

ealth

ser

vice

.It

is u

sual

ly c

arrie

dou

t thr

ough

the

ante

-na

tal o

r gy

naec

olog

ycl

inic

s or

thro

ugh

the

geni

to-u

rinar

y cl

inic

.Pr

e- a

nd p

ost-t

est

coun

selli

ng is

also

give

n as

par

t of t

hese

rvic

e.

Chla

mydia

At p

rese

nt M

alta

does

not

car

ry o

utor

gani

zed

scre

enin

gfo

r C

hlam

ydia

. Sc

reen

ing

is

carr

ied

out o

nly

onsy

mpt

omat

ic c

ases

.A

ll te

sting

is d

one

usin

g PC

R (R

oche

Am

picl

or).

Malta

Tuber

culo

sis

For

over

30

year

s th

e nu

mbe

r of

the

new

TB

case

s in

Pol

and

has

been

dec

reas

ing1

; abo

ut 5

% o

f yea

rlym

orbi

dity

. Dur

ing

1991

–199

3 an

incr

ease

in n

ewin

fect

ions

was

obs

erve

d, s

imila

r to

that

obs

erve

d in

othe

r co

untri

es o

f the

cen

tral a

nd e

aste

rn E

urop

ean

regi

on. I

t is

bein

g ex

plai

ned

by th

e tra

nsfo

rmat

ion

HIV

Hea

lth a

nd s

ocia

l pro

blem

s re

late

d to

HIV

/AID

S ne

cess

itate

d th

e es

tabl

ishm

ent

of a

n in

stitu

tion

at n

atio

nal l

evel

to id

entif

y pr

oble

ms,

pro

pose

sol

utio

ns a

ndco

ordi

nate

diff

eren

t act

iviti

es. S

uch

an in

stitu

tion

was

esta

blis

hed

in 1

992

as a

part

of th

e of

fice

of N

atio

nal S

anita

ry In

spec

tion.

In 2

000,

the

natio

nal o

ffice

sfo

r th

e co

ordi

natio

n of

AID

S pr

even

tion

beca

me

the

Nat

iona

l Cen

tre fo

r A

IDS.

This

insti

tutio

n is

dire

ctly

sub

ordi

nate

to th

e M

inis

try o

f Hea

lth a

nd p

lays

the

Chla

mydia

No

info

rmai

onav

aila

ble

Pola

nd

1O

blig

ator

y va

ccin

atio

n ag

ains

t BC

G w

as in

trodu

ced

In P

olan

d in

195

5

58

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

cris

is. I

n th

e fir

st pe

riod

of c

hang

es th

ere

appe

ared

a ra

pid

– 20

% to

30%

– d

ecre

ase

in p

rodu

ctio

n an

din

com

e of

the

popu

latio

n, in

crea

se in

mig

ratio

ns a

ndpa

ralle

l HIV

infe

ctio

ns. I

n co

mpa

rison

with

cou

ntrie

sbe

long

ing

to th

e EU

bef

ore

May

200

4, th

ein

cide

nce

of T

B in

Pol

and

is s

till t

wic

e as

hig

h.

In th

e tre

atm

ent o

f TB

in P

olan

d, th

e W

HO

DO

TSstr

ateg

y is

use

d. T

here

is a

spe

cial

cen

tral i

nstit

ute

for

orga

nizi

ng a

nd m

onito

ring

TB tr

eatm

ent –

the

Insti

tute

for T

uber

culo

sis a

nd L

ung

Dise

ases

in W

arsa

w,

with

sev

eral

bra

nche

s el

sew

here

. The

Cen

tral

Regi

ster

of P

eopl

e w

ith T

uber

culo

sis

also

mon

itors

th

e tre

atm

ent o

f pat

ient

s.

HIV

mai

n ro

le in

: sha

ping

the

state

pol

icy

on H

IV/A

IDS

prev

entio

n an

d tre

atm

ent,

anal

ysin

g th

e ep

idem

iolo

gica

l situ

atio

n in

this

field

, and

info

rmat

ion

and

train

ing

activ

ities

. Its

mai

n cu

rren

t tas

k is

coo

rdin

atin

g w

ork

on th

e im

plem

enta

tion

of

the

Nat

iona

l Pro

gram

me

for

HIV

Pre

vent

ion

and

Car

e fo

r Pe

ople

Liv

ing

with

HIV

/AID

S. T

he N

atio

nal C

entre

for

AID

S is

also

the

cont

act p

oint

for

nong

over

nmen

tal o

rgan

izat

ions

(NG

Os)

, whi

ch a

re o

ffere

d su

ppor

t and

fin

anci

al h

elp,

exp

erie

nce,

edu

catio

n, p

rofe

ssio

nal a

dvic

e an

d co

nsul

tatio

n.H

elp

and

supp

ort i

s of

fere

d al

so to

indi

vidu

als

livin

g w

ith H

IV/A

IDS,

to e

nsur

epr

even

tion

and

educ

atio

n in

this

are

a.

Scre

enin

g fo

r HPV

viru

s is

avai

labl

e fo

r wom

en li

ving

with

HIV

. An

HIV

-pos

itive

wom

an h

as th

e sa

me

right

to b

ecom

e a

mot

her

as a

ny o

ther

wom

an.2

If a

wom

an in

this

situ

atio

n co

nsci

ously

dec

ides

to b

ecom

e a

mot

her,

she

is u

nder

the

care

of t

he In

stitu

te o

f Mot

her

and

Chi

ld fo

r th

e w

hole

pre

gnan

cy a

nd h

asan

acc

ess

to a

ntire

trovi

ral (

ARV

) tre

atm

ent f

or v

ertic

al in

fect

ions

. The

re e

xists

api

lot p

rogr

amm

e of

test-

tube

inse

min

atio

n w

ith c

lean

spe

rm.

Chla

mydia

No

info

rmai

onav

aila

ble

Pola

nd c

ont.

Tabl

e A

2.1

con

t.

2N

ow th

e tre

atm

ent i

s pr

ovid

ed to

aro

und

70 c

oupl

es li

ving

with

HIV

who

wou

ld li

ke to

hav

e a

heal

thy

child

.

Tuber

culo

sis

Ther

e is

a m

assi

ve T

B sc

reen

ing

prog

ram

me

in p

lace

. Tho

usan

ds o

f peo

ple

are

scre

ened

by

X-ra

y ex

amin

atio

n: c

hild

ren

ente

ring

kind

erga

rten

and

thei

rpa

rent

s, s

oldi

ers

and

recr

uits,

teac

hers

in s

choo

ls ev

ery

year

, cou

ples

bef

ore

mar

riage

, pris

oner

s. A

ll w

orke

rs in

the

food

indu

stry,

or

thos

e w

ho a

re

hand

ling

food

, nee

d to

hav

e a

year

ly X

-ray

exam

inat

ion

as w

ell a

s al

l new

empl

oyee

s (c

osts

are

born

e by

em

ploy

er in

thes

e ca

ses)

. M

arry

ing

coup

les

and

pare

nts

and

thei

r ki

nder

garte

n ch

ildre

n ha

ve to

cove

r th

e co

st of

the

ches

t X-ra

y th

emse

lves

.

HIV

Testi

ng fo

r H

IV is

vol

unta

ry w

ithth

e gu

aran

tee

of c

onfid

entia

lity.

Pr

egna

nt w

omen

, pat

ient

s w

ithST

Is an

d TB

pat

ient

s ha

ve e

asy

acce

ss to

HIV

testi

ng a

nd

coun

selli

ng.

The

Nat

iona

l Stra

tegy

on

HIV

-A

IDS

2004

–200

7 de

velo

ps

Chla

mydia

Scre

enin

g fo

r C

hlam

ydia

is c

urre

ntly

oppo

rtuni

stic.

The

Nat

iona

l Stra

tegy

for

the

Prev

entio

n an

d C

ontro

l of S

exua

lTr

ansm

itted

Infe

ctio

ns r

ecom

men

dsth

at s

ympt

oms

of C

hlam

ydia

shou

ldbe

trea

ted,

bei

ng c

heap

er th

an th

ela

bora

tory

test.

How

ever

, the

inte

ntio

n

Rom

ania

59

Tuber

culo

sis

The

natio

nal T

B co

ntro

l pro

gram

me

was

intro

duce

d in

200

0. N

ow m

ore

focu

sed

scre

enin

g is

taki

ng p

lace

with

wel

l-def

ined

pop

ulat

ions

, for

exa

mpl

e,et

hnic

com

mun

ities

with

a h

igh

TB in

cide

nce,

pris

oner

s, in

stitu

tiona

lized

peo

ple,

etc.

Thi

s sc

reen

ing

also

incl

udes

spu

tum

sm

ear

bact

erio

logi

cal e

xam

inat

ion.

The

Nat

iona

l Stra

tegy

for

TB c

ontro

lis

chal

leng

ing

the

scre

enin

g pr

ogra

mm

ede

scrib

ed a

bove

as

an in

effe

ctiv

e on

e, r

ecom

men

ding

the

revi

sion

of t

hesc

reen

ing

polic

y.

Cur

rent

ly a

n ev

alua

tion

of th

e pe

riod

2001

–200

5 is

taki

ng p

lace

with

the

supp

ort o

f WH

O a

nd th

e G

loba

l Fun

d to

Fig

ht A

IDS,

Tub

ercu

losis

and

Mal

aria

.

HIV

furth

er th

e in

itiat

ives

from

the

prev

ious

stra

tegy

of 2

000–

2003

and

aim

s to

mak

e H

IV te

sting

and

coun

selli

ng a

vaila

ble

tode

fined

vul

nera

ble

popu

latio

nssu

ch a

s co

mm

erci

al s

ex w

orke

rs,

pris

oner

s, s

treet

chi

ldre

n,

insti

tutio

naliz

ed c

hild

ren,

trav

ellin

gco

mm

uniti

es a

nd s

o on

.

Chla

mydia

is to

intro

duce

a s

cree

ning

stra

tegy

afte

r co

nduc

ting

a pi

lot s

urve

y on

Chl

amyd

iasc

reen

ing

for

wom

enun

der

25 w

ho h

ave

not b

een

preg

nant

and

who

are

at r

isk

ofde

velo

ping

STI

s. T

he r

esul

ts of

the

pilo

t sho

uld

lead

to th

e de

velo

pmen

tof

a c

ost-e

ffect

ive

scre

enin

g str

ateg

y.

Rom

ania

con

t.

Tuber

culo

sis

Slov

akia

has

a n

atio

nal p

olic

y on

scr

eeni

ng fo

r TB

. The

re is

a N

atio

nal T

Bre

giste

r es

tabl

ishe

d in

198

8, to

not

ify a

ll ca

ses.

Targ

et g

roup

s ar

e:•

new

born

bab

ies

• c

hild

ren

at a

ge 6

•im

mig

rant

s•

pris

oner

s•

olde

r pe

ople

livi

ng in

ret

irem

ent h

omes

.A

ll co

sts a

re la

id b

y th

e he

alth

insu

ranc

e co

mpa

nies

.

HIV

Slov

akia

has

a n

atio

nal p

olic

y on

scre

enin

g fo

r H

IV. T

here

is a

Nat

iona

l HIV

reg

iste

r, bu

t the

re is

curr

ently

no

targ

etin

g of

at-r

isk

grou

ps.

All

costs

are

pai

d by

the

heal

th in

sura

nce

com

pani

es.

Chla

mydia

Slov

akia

has

no

natio

nal s

cree

ning

polic

y fo

r C

hlam

ydia

.So

me

phar

mac

eutic

al c

ompa

nies

have

web

site

s w

ith in

form

atio

n an

dad

vice

line

s.

Slova

kia

Tuber

culo

sis

Ther

e is

a n

atio

nal p

olic

y of

scr

eeni

ng fo

r TB

. Vac

cina

tion

of in

fant

sha

s no

w b

een

abol

ishe

d af

ter

a co

ntin

uing

dec

line

in in

cide

nce

over

the

past

few

yea

rs. V

acci

natio

n w

ill o

nly

be d

one

in th

e ca

ses

of c

onta

cts

or h

igh

risk

of e

xpos

ure.

Scr

eeni

ng w

ill c

ontin

ue fo

r ch

ildre

n of

sch

ool a

ge a

t ent

ry a

nd a

t the

end

of p

rimar

y ed

ucat

ion.

Ther

e is

a r

egis

ter,

and

targ

etin

g an

d re

calli

ng p

atie

nts

is p

ossi

ble.

A

ll pr

even

tive,

dia

gnos

tic, t

reat

men

t and

reh

abili

tatio

n se

rvic

esre

late

d to

infe

ctio

us d

isea

ses

are

fully

rei

mbu

rsed

by

the

natio

nal

heal

th in

sura

nce

and

incl

uded

in th

e ba

sic

serv

ices

pac

kage

.

HIV

Ther

e is

a n

atio

nal p

olic

y of

scr

eeni

ng fo

r H

IV. H

IVis

scr

eene

d fo

r ro

utin

ely

in a

ll pr

egna

nt w

omen

, in

all p

atie

nts

with

a n

ewly

esta

blis

hed

diag

nosi

s of

syph

ilis

and

in a

ll th

ose

dona

ting

bloo

d an

d ot

her

tissu

es (b

oth

sinc

e 19

86).

It is

pos

sibl

e to

test

for

HIV

anon

ymou

sly o

r op

enly

at s

ever

al p

oint

s an

d th

ere

is v

olun

tary

incl

usio

n te

sting

for

high

-risk

gro

ups.

Furth

erm

ore,

HIV

testi

ng is

offe

red

upon

info

rmed

cons

ent t

o dr

ug a

ddic

ts in

cen

tres

acro

ss th

e co

untry

.

Chla

mydia

A n

atio

nal p

olic

y of

sc

reen

ing

for

Chl

amyd

iais

unde

r de

velo

pmen

t at t

hem

omen

t. Se

vera

l cro

ss-

sect

iona

l stu

dies

wer

e pe

rform

ed fo

r C

hlam

ydia

inw

omen

and

gui

delin

es fo

rro

utin

e sc

reen

ing

are

bein

gde

velo

ped.

Slove

nia

60

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Tuber

culo

sis

Ther

e is

a na

tiona

l pol

icy

for s

cree

ning

, mon

itorin

g an

d tre

atin

gTB

. The

figh

t aga

inst

TB is

car

ried

out b

y th

e TB

dis

pens

arie

san

d Fi

ght A

gain

st TB

ass

ocia

tions

. The

nat

iona

l pol

icy

is b

ased

on a

def

ined

pop

ulat

ion

whi

ch in

clud

es p

rimar

y sc

hool

chi

ldre

n(b

etw

een

7 an

d 11

yea

rs o

f age

), re

giste

red

sex

wor

kers

(onc

ea

year

), an

d m

en c

ondu

ctin

g th

eir

com

pulso

ry m

ilita

ry s

ervi

ce(2

0–41

yea

rs).

TB s

cree

ning

is a

lso a

pro

cedu

ral r

equi

rem

ent

for

all j

ob a

pplic

atio

ns a

ssoc

iate

d w

ith jo

inin

g an

y of

the

exis

ting

insu

ranc

e sc

hem

es. T

B sc

reen

ings

of p

rimar

y sc

hool

child

ren

and

sex

wor

kers

are

fina

nced

from

the

gove

rnm

ent

budg

et. A

lthou

gh a

ll ot

her

bene

ficia

ries

have

to p

ay fo

r th

ete

st, th

e am

ount

pai

d fo

r th

is s

ervi

ce a

t tub

ercu

losi

sdi

spen

sarie

s is

sym

bolic

.

HIV

In T

urke

y, H

IV te

sts a

re ta

ken

on a

vol

unta

ry b

asis

, and

stri

ct m

easu

res

of c

onfid

entia

lity

are

in p

lace

rega

rdin

g th

e na

mes

of t

he p

erso

ns te

sted,

with

the

exce

ptio

n of

the

follo

win

g gr

oups

, for

who

m th

e H

IV s

cree

ning

is c

ompu

lsory

: blo

od d

onor

s, r

egis

tere

d se

x w

orke

rs (o

nce

in th

ree

mon

ths)

, ille

gal i

mm

igra

nts

sex

wor

kers

, men

con

duct

ing

shor

t-ter

m

mili

tary

ser

vice

, any

pat

ient

s un

derg

oing

a b

lood

test

at p

ublic

hea

lthun

its, p

regn

ant w

omen

und

er p

rena

tal c

are,

pat

ient

s un

derg

oing

su

rger

y.

Som

ewha

t con

trove

rsia

lly, c

oupl

es a

pply

ing

to g

et m

arrie

d ar

e al

sore

quire

d to

take

the

HIV

test;

but

ther

e ar

e no

pro

visi

ons

bann

ing

anH

IV-p

ositi

ve p

erso

n fro

m g

ettin

g m

arrie

d. H

IV s

cree

ning

s of

blo

oddo

nors

and

sex

wor

kers

are

fina

nced

from

the

gove

rnm

ent b

udge

t; al

l oth

er b

enef

icia

ries

have

to p

ay fo

r th

e te

st th

emse

lves

.

Chla

mydia

Onl

y re

giste

red

sex

wor

kers

are

subj

ect t

osc

reen

ing

for

Chl

amyd

ia(ro

utin

e ch

ecks

are

twic

e a

wee

k), a

nd it

isfin

ance

d fro

mth

e go

vern

men

tbu

dget

.

Turk

ey

Tabl

e A

2.1

con

t.

61

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aTh

ere

is a

Nat

iona

l Stra

tegy

for

prop

hyla

xis

of h

ered

itary

dis

ease

s, d

iath

eses

and

cong

enita

l mal

form

atio

ns (2

000–

2005

). Th

e 20

04 b

udge

t for

this

pr

ogra

mm

e w

as 6

86 3

30 le

va (€

350

974)

. The

exi

sting

nat

iona

l neo

nata

l sc

reen

ing

prog

ram

me

is a

mon

g th

e m

ost e

ffici

ent a

nd c

ost-e

ffect

ive

of s

imila

rpr

ogra

mm

es e

xisti

ng w

orld

wid

e. T

he b

asic

def

icie

ncie

s of

the

prog

ram

me

are

of a

n or

gani

zatio

nal n

atur

e an

d ar

e re

late

d to

the

sign

ifica

nt n

umbe

r of

babi

es n

ot e

xam

ined

whi

le s

till i

n m

ater

nity

hos

pita

l. PK

U: a

nat

iona

l neo

nata

l scr

eeni

ng p

rogr

amm

e fo

r con

geni

tal m

alfo

rmat

ions

has

been

in p

lace

sin

ce 1

979.

All

new

born

bab

ies

are

exam

ined

bet

wee

nth

e se

cond

day

and

fifth

day

afte

r bi

rth w

hile

stil

l in

hosp

ital.

If th

e PK

U te

stis

pos

itive

, the

chi

ld is

reg

iste

red,

rec

eive

s sp

ecia

l foo

d an

d co

ntin

uous

med

ical

follo

w-u

p. B

ulga

ria h

as th

e se

cond

low

est i

ncid

ence

rat

e of

PKU

(afte

r Fi

nlan

d): 1

in 3

500

0 ne

onat

es. A

t the

sam

e tim

e, th

e in

cide

nce

rate

of

PKU

in th

e Tu

rkis

h m

inor

ity is

am

ong

the

high

est i

n Eu

rope

: 1 in

700

0ne

onat

es (t

he r

egis

tere

d PK

U in

cide

nce

rate

in T

urke

y is

1:2

000)

. The

PKU

inci

denc

e ra

te a

mon

g th

e Bu

lgar

ian

gyps

ies

is le

ss th

an 1

:100

000,

muc

hlo

wer

than

for

the

Slov

ak g

ypsi

es, f

or e

xam

ple,

whe

re th

e in

cide

nce

is1:

1000

. D

own

synd

rom

e an

d sp

ina

bifid

a: a

nat

iona

l sel

ectiv

e an

tena

tal s

cree

ning

prog

ram

me

is in

pla

ce. A

mni

ocen

tesi

s is

not

obl

igat

ory,

but

is o

ffere

d fre

e of

char

ge to

all

preg

nant

wom

en o

ver

35, t

o w

omen

who

alre

ady

have

a c

hild

suffe

ring

from

con

geni

tal m

alfo

rmat

ion,

or

to th

ose

refe

rred

by

a ge

neal

ogis

t (a

fter

perfo

rmin

g bi

oche

mic

al s

cree

ning

and

det

ectin

g a

high

er r

isk

of fe

tal

mal

form

atio

n). F

or fi

nanc

ial r

easo

ns o

nly

abou

t 5%

of a

ll pr

egna

nt w

omen

inth

e hi

gher

ris

k gr

oup

unde

rgo

amni

ocen

tesi

s.

Bulg

ari

aCer

vica

l ca

nce

rA

Nat

iona

l Stra

tegy

for

prop

hyla

ctic

onc

olog

ical

scre

enin

g (2

001–

2006

)w

as a

ppro

ved

in 2

000.

It

was

initi

ally

fund

ed b

yfo

reig

n N

GO

s. F

orei

gnin

vestm

ent h

elpe

d to

bui

ldup

the

basi

s an

d th

e in

tent

ion

was

that

the

Bulg

aria

n go

vern

men

tw

ould

find

mon

ey to

finan

ce th

e pr

ogra

mm

eits

elf f

rom

200

5.

Giv

en th

e sc

arce

reso

urce

s de

vote

d to

this

strat

egy,

pre

vent

ive

exam

inat

ions

for

cerv

ical

canc

er a

re r

ecom

men

ded

only

as

part

of r

outin

egy

naec

olog

ical

ex

amin

atio

ns.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSy

stem

atic

bre

ast c

ance

r sc

reen

ing

has

not

been

intro

duce

d ye

t. Th

e ex

amin

atio

ns a

ndan

alys

es to

det

ect c

olon

and

rec

tal c

ance

r ar

epr

ovid

ed to

pat

ient

s at

hig

her

risk

(e.g

. tho

sew

ith r

elat

ives

suf

ferin

g fro

m c

ance

r) an

d ar

efin

ance

d th

roug

h pu

blic

hea

lth in

sura

nce.

Patie

nts,

how

ever

, pay

a fe

e to

vis

it th

e do

ctor

.Th

ere

is a

proj

ect t

o in

trodu

ce m

ore

co-p

aym

ents

in th

e fu

ture

. Th

ere

is a

n A

ssoc

iatio

n fo

r En

dosc

opic

Prev

entio

n fo

r al

l the

pat

ient

s w

ith c

ompl

aint

s,an

d th

eir

rela

tives

. In

spor

adic

cas

es g

enet

icsc

reen

ing

is c

arrie

d ou

t. Bl

ood

sam

ples

are

colle

cted

and

DN

A a

naly

sis

is p

erfo

rmed

on

all p

atie

nts

unde

rgoi

ng s

urge

ry fo

r co

lore

ctal

carc

inom

a. U

sing

this

pro

gram

me,

a n

atio

nal

regi

stry

for

inhe

rited

mut

atio

ns le

adin

g to

co

lore

ctal

car

cino

ma

has

been

cre

ated

.C

linic

ians

follo

w u

p al

l the

pat

ient

s. B

etw

een

2001

and

200

5 a

Swis

s N

GO

cov

ered

all

the

nece

ssar

y ex

pens

es (l

abor

ator

yeq

uipm

ent,

sala

ries

and

all s

ampl

es).

Sinc

eJa

nuar

y 20

05 th

e pa

tient

s pa

y fo

r vi

sits

to th

edo

ctor

, lab

orat

ory

sam

ples

, etc

. The

Ass

ocia

tion

is tr

ying

to r

aise

fund

s fo

r th

e pr

ogra

mm

e.

Tabl

e A

2.2

Cer

vica

l can

cer,

brea

st c

ance

r, co

lore

ctal

can

cer,

PKU

, Dow

n sy

ndro

me

and

spin

a bi

fida

62

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aM

ater

nal a

nd c

hild

hea

lth s

ervi

ces

are

offe

red

free

of c

harg

e to

all

Cyp

riots

thro

ugh

a ne

twor

k of

mat

erna

l and

chi

ld h

ealth

cen

tres.

Am

ong

the

serv

ices

offe

red

are

diag

nosti

c te

sts fo

r in

fant

s an

d ch

ildre

n up

to th

e ag

e of

6, a

s w

ell a

s co

unse

lling

and

con

sulta

tion

serv

ices

to p

regn

ant w

omen

and

new

mot

hers

. Pre

gnan

t wom

enar

e str

ongl

y en

cour

aged

to te

st fo

r th

ese

dise

ases

to m

inim

ize

the

poss

ibili

ty th

at th

eir

child

will

be

born

with

an

abno

rmal

ity. P

KUan

d sp

ina

bifid

a ar

e ra

re in

Cyp

rus.

Dow

n sy

ndro

me

has

decr

ease

d dr

amat

ical

ly to

the

poin

t of e

xtin

ctio

n am

ong

neon

ates

,du

e to

ear

ly d

iagn

osis

and

term

inat

ion

of p

regn

ancy

.

Cypru

sCer

vica

l ca

nce

rTh

ere

is a

nat

iona

l pol

icy

on s

cree

ning

for

cerv

ical

and

bre

ast c

ance

rs b

ased

on

the

popu

latio

n re

giste

r. Th

ere

is a

n in

crea

sed

effo

rt to

info

rm w

omen

of a

ll ag

es o

f the

risks

of s

uch

dise

ases

and

the

role

of

inhe

ritan

ce in

thes

e m

atte

rs. T

he n

atio

nal

polic

y on

scr

eeni

ng fo

r cer

vica

l can

cer c

over

sal

l wom

en a

ged

25–6

5. T

he p

rogr

amm

e is

offe

red

free

of c

harg

e an

d w

ith a

rig

ht o

ffre

e ch

oice

of d

octo

r.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rA

free

-of-c

harg

e sc

reen

ing

prog

ram

me

for

brea

st ca

ncer

has

beg

un o

n a

trial

basis

and

cov

ers

wom

en a

ged

50–6

9.W

omen

are

invi

ted

to p

artic

ipat

e in

the

prog

ram

me

via

a pe

rson

al le

tter

sent

by

the

Min

istry

of H

ealth

. The

parti

cipa

tion

rate

is 4

8% a

nd r

isin

g.Te

sting

for

colo

n an

d re

ctal

can

cer

isth

e re

spon

sibi

lity

of in

divi

dual

s.

PK

U,

Dow

nsy

ndro

me,

spin

a b

ifid

aTe

sts to

iden

tify

PKU

, Dow

n sy

ndro

me

and

spin

a bi

fida

are

avai

labl

e. T

estin

gfo

r spi

na b

ifida

and

Dow

n sy

ndro

me

ispa

rt of

bas

icsc

reen

ing

durin

gth

e pr

enat

al p

erio

d.Th

e te

sts a

re p

aid

for

from

pub

liche

alth

insu

ranc

e.

Cze

ch R

epublic

Cer

vica

l ca

nce

rSc

reen

ing

for

cerv

ical

canc

er (c

ytol

ogic

alan

d m

icro

biol

ogic

alex

amin

atio

n) is

prov

ided

ann

ually

as

a pa

rt of

pre

vent

ive

gyna

ecol

ogic

alex

amin

atio

nfo

r ad

ult

wom

en a

re th

e ta

rget

grou

p. W

omen

are

calle

d or

rec

alle

d by

thei

r gy

naec

olog

ists,

who

are

rei

mbu

rsed

by h

ealth

insu

ranc

efu

nds.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rA

pro

gram

me

of b

reas

t can

cer

scre

enin

g (m

amm

ogra

phy)

is r

ecom

men

ded

for

wom

en a

ged

45–6

9 at

two-

year

inte

rval

s. T

he e

xpen

ses

are

reim

burs

ed to

GPs

by

the

heal

th in

sura

nce

fund

s. W

omen

from

the

targ

etgr

oup

can

be c

alle

d or

rec

alle

d (d

epen

ding

on

thei

r G

P or

gyn

aeco

logi

st) a

nd th

ey c

an r

ecei

ve in

form

atio

nab

out t

his

exam

inat

ion

from

•

thei

r G

Ps

•

leaf

lets

and

mag

azin

es p

ublis

hed

by h

ealth

insu

ranc

e fu

nds

and

NG

Os

•

the

med

ia.

All

adul

t wom

en c

an b

e ex

amin

ed w

ithin

the

fram

ewor

k of

the

prog

ram

me,

but

if th

ey a

re n

ot in

the

targ

et a

ge g

roup

or

high

-risk

gro

up (i

ncid

ence

of b

reas

t can

cer

in th

eir

clos

e fa

mily

, dia

gnos

is o

f gen

etic

mut

atio

n BR

CA

1 an

d BR

CA

2 or

oth

er s

peci

fic r

ecom

men

datio

n), t

hey

have

to p

ay fo

r it.

The

cos

t of t

heex

amin

atio

n is

CZK

200

–300

(ultr

asou

nd) o

r C

ZK 4

00–6

00 (m

amm

ogra

phy)

. C

olon

and

rec

tal c

ance

rN

atio

nal C

olor

ecta

l Can

cer

scre

enin

g pr

ogra

mm

e is

indi

cate

d fo

r as

ympt

omat

ic in

divi

dual

s fro

m th

e ag

eof

50

at tw

o-ye

ar in

terv

als

by F

OBT

. It h

as b

een

incl

uded

as

part

of a

free

-of-c

harg

e pr

even

tive

chec

k-up

sinc

e 20

00. T

he c

osts

are

reim

burs

ed to

GPs

by

the

heal

th in

sura

nce

fund

s.Th

e M

inis

try o

f Hea

lth s

uppo

rted

the

prog

ram

me

with

8

mill

ion

to m

oder

nize

the

endo

scop

ic e

quip

men

tfo

r co

lono

scop

y an

d as

soci

ated

pro

cedu

res.

Indi

vidu

als

in th

e ta

rget

gro

up a

re n

ot c

alle

d (o

r re

calle

d) fo

rth

e ex

amin

atio

n bu

t hav

e to

pre

sent

them

selv

es. T

hey

can

obta

in in

form

atio

n ab

out t

his

test

from

•

thei

r G

Ps

•

leaf

lets

and

mag

azin

es p

ublis

hed

by h

ealth

insu

ranc

e fu

nds

and

NG

Os

•

the

med

ia.

Tabl

e A

2.2

con

t.

63

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aA

ll ne

onat

es in

Esto

nia

are

teste

d fo

r PK

U fr

om b

lood

sam

ples

take

n at

the

hosp

ital b

efor

e di

scha

rge.

G

enet

ic te

sting

is p

art o

f pre

nata

l car

e fo

r pr

egna

nt w

omen

ove

r 37

, and

youn

ger

preg

nant

wom

en w

here

indi

cate

d.Tw

o ul

traso

unds

are

par

t of t

he m

anag

emen

t of a

ll pr

egna

ncie

s.

All

are

paid

by

EHIF.

Esto

nia

Cer

vica

l ca

nce

r, b

reast

cance

r, c

olo

rect

al ca

nce

rSc

reen

ing

prog

ram

mes

for

cerv

ical

and

bre

ast c

ance

r ar

e fin

ance

d an

dad

min

iste

red

by th

e Es

toni

an H

ealth

Insu

ranc

e Fu

nd (E

HIF

). Bo

th a

re

targ

eted

pro

gram

mes

, with

wom

en in

the

appr

opria

te a

ge g

roup

rec

eivi

ngin

vita

tions

bas

ed o

n th

e EH

IF n

atio

nal d

atab

ase.

Th

e ta

rget

age

gro

up fo

r bre

ast c

ance

r scr

eeni

ng is

45–

59, a

t asc

reen

ing

inte

rval

of t

hree

yea

rs.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aN

ewbo

rn s

cree

ning

is m

anda

tory

for

PKU

.In

the

twel

fth w

eek

of p

regn

ancy

ultr

asou

ndex

amin

atio

n fo

r D

own

synd

rom

e is

car

ried

out.

Gen

etic

scr

eeni

ng fo

r D

own

synd

rom

ean

d sp

ina

bifid

a is

ava

ilabl

e.

Hungary

Cer

vica

l ca

nce

rIn

the

“Pub

lic h

ealth

scr

eeni

ngs”

sub

prog

ram

me

of th

eN

PHP

natio

nal p

olic

y on

scr

eeni

ng, b

reas

t, ce

rvic

alan

d co

lore

ctal

can

cers

is d

escr

ibed

in d

etai

l. G

ynae

colo

gica

l cer

vica

l scr

eeni

ng w

as la

unch

ed in

2004

and

is b

ased

on

Papa

nico

lau

cyto

logi

cal t

estin

gof

all

wom

en a

ged

25–6

5, w

hich

, if n

egat

ive,

isre

peat

ed e

very

thre

e ye

ars.

Expe

nses

are

cov

ered

from

the

NIF

bud

get.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rM

amm

ogra

phy

scre

enin

g w

as in

trodu

ced

in20

00 fo

r w

omen

bet

wee

n th

e ag

es o

f 45–

65 a

ndis

rep

eate

d bi

-ann

ually

. The

re is

a g

ood

rate

of

parti

cipa

tion.

Intro

duct

ion

of c

olor

ecta

l can

cer

scre

enin

g fo

rm

en a

nd w

omen

age

d 45

–65

usin

g th

e fa

ecal

occu

lt bl

ood

test

(FO

BT) i

s no

w in

a p

ilot p

hase

.Ex

pens

es a

re c

over

ed fr

om th

e N

IF b

udge

t.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aId

entif

icat

ion

of P

KU is

incl

uded

in th

e ch

ildre

ns’ p

roph

ylac

ticpr

ogra

mm

e: th

ere

is s

cree

ning

(blo

od te

sts) o

f all

neon

ates

in th

e fir

stfo

ur to

five

day

s of

life

, pai

d fo

r fro

m th

e he

alth

car

e bu

dget

.D

own

synd

rom

e te

sting

is p

rovi

ded

for

preg

nant

wom

en, w

ho a

rege

netic

ally

at h

igh

risk,

twic

e (u

p to

wee

ks 1

1 an

d 17

of p

regn

ancy

).H

igh-

risk

grou

ps in

clud

e: w

omen

ove

r 35

; fat

hers

ove

r 45

; whe

reon

e or

bot

h pa

rent

s ha

ve b

een

affe

cted

by

radi

atio

n; w

here

an

acut

e vi

ral i

nfec

tion

has

been

con

tract

ed d

urin

g th

e fir

st tri

mes

ter

ofpr

egna

ncy;

and

oth

er fa

ctor

s.

Latv

iaCer

vica

l ca

nce

rSc

reen

ing

for

canc

er is

incl

uded

in th

epr

ophy

lact

ic p

rogr

amm

e fo

r ad

ults

and

cove

red

in th

e he

alth

car

e bu

dget

.W

omen

age

d 20

–35:

one

onc

olog

ical

test

per

year

. If t

here

is a

neg

ativ

e re

sult,

the

test

is r

epea

ted

thre

e ye

ars

late

r.W

omen

age

d 35

–70s

: onc

olog

ical

test

annu

ally.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rFo

r br

east

canc

er, w

omen

age

d 50

–69

, one

mam

mog

raph

y ev

ery

two

year

s.

For

colo

rect

al c

ance

r, sc

reen

ing

for

men

and

wom

en a

ged

50 y

ears

and

abov

e an

nual

ly.

64

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aA

ll ne

onat

es a

re s

cree

ned

for

PKU

with

a b

lood

test

at 4

8 ho

urs,

paid

for

by th

e C

ompu

lsory

Hea

lth In

sura

nce

Fund

. Dat

a on

di

agno

sed

case

s of

PKU

are

sen

t to

the

Lithu

ania

n H

ealth

Info

rmat

ion

Cen

tre a

nd a

re in

clud

ed in

the

Birth

Reg

istry

. Sc

reen

ing

for

Dow

n sy

ndro

me

is p

erfo

rmed

onl

y if

the

cond

ition

is s

uspe

cted

. Pre

nata

l Dow

n sy

ndro

me

scre

enin

g (“

tripl

e” te

st) is

pe

rform

ed a

t the

Hum

an G

enet

ics

Cen

tre a

nd is

pai

d fo

r by

thos

ein

volv

ed. A

ll pr

egna

nt w

omen

age

d 35

and

ove

r, al

so th

ose

who

prev

ious

ly h

ad b

abie

s w

ith c

onge

nita

l abn

orm

aliti

es, a

nd th

ose

who

wis

h to

be

teste

d ar

e re

ferr

ed to

the

Hum

an G

enet

ics

Cen

tre.

The

“trip

le”

test

is pe

rform

ed d

urin

g w

eeks

14–

15 o

f pre

gnan

cy.

In th

e ca

se o

f abn

orm

al r

esul

ts, th

e di

agno

sis

shou

ld b

e co

nfirm

edby

the

amni

ocen

tesi

s an

d ex

amin

atio

n of

the

gene

tic k

aryo

type

.A

ccor

ding

to L

ithua

nian

law

, abo

rtion

can

onl

y be

car

ried

out

durin

g th

e fir

st 12

wee

ks o

f pre

gnan

cy a

nd D

own

synd

rom

e is

not

cons

ider

ed a

s ju

stify

ing

abor

tion.

Ultr

asou

nd e

xam

inat

ion

of th

ene

ck tr

anslu

cenc

e of

the

fetu

s in

the

11th

wee

k of

ges

tatio

n m

ayin

dica

te D

own

synd

rom

e bu

t thi

s ex

amin

atio

n is

not

per

form

ed o

n a

regu

lar

basi

s.

Ultr

asou

nd s

cree

ning

dur

ing

the

first

sem

este

r of

the

preg

nanc

y is

not

rou

tine.

Rou

tine

ultra

soun

d ex

amin

atio

n is

per

form

ed d

urin

gw

eeks

18–

20 a

nd 3

0–32

of p

regn

ancy

. Cho

rion

biop

sy is

not

use

dfo

r th

e di

agno

sis

of D

own

synd

rom

e –

this

pro

cedu

re is

per

form

edin

the

Hum

an G

enet

ics

Cen

tre d

urin

g th

e fir

st se

mes

ter

of p

regn

ancy

only

for

gene

tic n

ot c

hrom

osom

al a

bnor

mal

ities

. Dat

a on

con

firm

edca

ses

of D

own

synd

rom

e ar

e pa

ssed

to th

e Lit

huan

ian

Hea

lthIn

form

atio

n C

entre

and

are

incl

uded

on

the

Birth

Reg

istry

.Sp

ina

bifid

a ca

n be

iden

tifie

d du

ring

rout

ine

exam

inat

ion

but i

sno

t con

side

red

as a

n in

dica

tion

for

abor

tion

afte

r th

e 12

th w

eek

ofpr

egna

ncy.

Dat

a on

cas

es o

f spi

na b

ifida

are

pas

sed

to th

eLit

huan

ian

Hea

lth In

form

atio

n C

entre

and

are

incl

uded

in th

e Bi

rthRe

gistr

y.

Lith

uania

Cer

vica

l ca

nce

rN

atio

nal c

ance

r pr

even

tion

polic

y in

Lithu

ania

is b

ased

on

the

Nat

iona

l Can

cer

Prev

entio

n Pr

ogra

mm

e fo

r 20

03–2

010,

whi

ch w

as a

ppro

ved

by th

e Lit

huan

ian

Gov

ernm

ent o

n 10

Dec

embe

r 20

03.

Sinc

e Ju

ly 2

004

the

Cer

vica

l Can

cer

Prev

entio

n Pr

ogra

mm

e ha

s be

en fi

nanc

edfro

m th

e C

ompu

lsory

Hea

lth In

sura

nce

Fund

. For

pro

gram

me

adm

inis

tratio

n,im

plem

enta

tion

and

surv

eilla

nce,

the

com

pute

rized

dat

abas

e “S

veid

ra”

is u

sed.

The

data

base

con

tain

s lis

ts of

the

popu

latio

nco

vere

d by

com

pulso

ry h

ealth

insu

ranc

ean

d th

e he

alth

car

e se

rvic

es p

rovi

ded.

Th

e pr

ogra

mm

e ta

rget

s w

omen

age

d30

–60

and

scre

enin

g fo

r ce

rvic

al c

ance

r is

per

form

ed o

nce

ever

y th

ree

year

s.D

urin

g th

e se

cond

hal

f of 2

004,

12.7

–17.

1% o

f all

Lithu

ania

n w

omen

age

d30

–60

wer

e in

vite

d fo

r ce

rvic

al c

ance

rsc

reen

ing.

The

cer

vica

l can

cer

scre

enin

g(P

ap te

st) w

as p

erfo

rmed

on

7.2–

10.4

% o

fth

e to

tal t

arge

t pop

ulat

ion;

5.1

–7.5

% o

fth

e ta

rget

pop

ulat

ion

was

info

rmed

abo

utth

e te

st re

sults

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rIm

plem

enta

tion

of th

e Br

east

Can

cer

Prev

entio

n Pr

ogra

mm

e is

sch

edul

ed to

start

in th

e se

cond

hal

f of 2

005.

Th

e C

ompu

lsory

Hea

lth In

sura

nce

Fund

will

fina

nce

scre

enin

g fo

r br

east

canc

er.

Ther

e is

cur

rent

ly n

o sc

reen

ing

prog

ram

me

for

colo

rect

al c

ance

rfin

ance

d fro

m th

e C

ompu

lsory

Hea

lthIn

sura

nce

Fund

.

Tabl

e A

2.2

con

t.

65

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aM

alta

doe

s no

t hav

e a

scre

enin

g pr

ogra

mm

e fo

rPK

U. T

he te

st is

car

ried

out

if th

e co

nditi

on is

sus

pect

edcl

inic

ally

afte

r bi

rth.

How

ever

, a n

atio

nal r

epor

ton

PKU

cur

rent

ly b

eing

final

ized

is v

ery

likel

y to

reco

mm

end

rout

ine

scre

enin

g fo

r al

l neo

nate

s.

Mal

ta d

oes

not s

cree

nfo

r ch

rom

osom

al d

efec

tsin

clud

ing

Dow

n sy

ndro

me,

unle

ss th

e co

nditi

on is

cl

inic

ally

sus

pect

ed a

tbi

rth. I

t is

then

con

firm

edcy

tolo

gica

lly. D

own

synd

rom

e is

not

scr

eene

dfo

r as

this

is g

ener

ally

asso

ciat

ed w

ith a

te

rmin

atio

n pr

ogra

mm

ean

d te

rmin

atio

n of

pr

egna

ncy

is il

lega

l in

Mal

ta.

Spin

a bi

fida

is o

ften

diag

nose

d at

rou

tine

ante

nata

l ultr

asou

nd.

How

ever

, thi

s co

nditi

on is

som

etim

es o

nly

diag

nose

dcl

inic

ally

afte

r bi

rth.

Malta

Cer

vica

l ca

nce

rTh

ere

is n

o na

tiona

l pol

icy

on s

cree

ning

for

cerv

ical

can

cer,

brea

st ca

ncer

or

colo

rect

al c

ance

r.In

the

publ

ic s

ecto

r, sc

reen

ing

for c

ervi

cal

canc

er is

car

ried

out o

n an

opp

ortu

nisti

cba

sis.

Sm

ear

testi

ng is

also

ava

ilabl

e to

all

wom

en w

ho r

eque

st it

by m

akin

g an

appo

intm

ent w

ith th

e gy

naec

olog

y cl

inic

inth

e ar

ea h

ealth

cen

tre. T

he s

ervi

ce is

ver

ypo

pula

r as

dem

onstr

ated

by

the

high

dem

and

and

is p

aid

for

thro

ugh

the

publ

iche

alth

car

e sy

stem

. The

pro

blem

with

this

syste

m is

that

it te

nds

to a

ttrac

t the

“wor

ried

wel

l”. I

n fa

ct, s

ome

loca

l res

earc

hun

der

way

has

, as

expe

cted

, ind

icat

ed th

atm

any

wom

en w

ho d

evel

oped

cer

vica

l ca

ncer

had

not

had

a r

ecen

t sm

ear

test.

How

ever

the

num

bers

wer

e ve

ry s

mal

l. Th

e fa

ct th

at 4

1% o

f wom

en a

ged

20ye

ars

and

over

sta

ted

that

they

had

nev

erha

d a

smea

r te

st in

the

2002

nat

iona

lhe

alth

inte

rvie

w s

urve

y is

also

a c

ause

for

conc

ern.

In th

e pr

ivat

e se

ctor

, a la

rge

num

ber

ofw

omen

(no

statis

tics

avai

labl

e) u

nder

gosm

ear t

estin

g re

gula

rly. G

ener

al p

ract

ition

ers

or g

ynae

colo

gists

pro

vide

this

ser

vice

.So

me

of th

e be

tter

orga

nize

d cl

inic

s ha

vede

velo

ped

thei

r ow

n ca

ll an

d re

call

syste

mfo

r th

e pa

tient

s w

ho u

se th

eir

serv

ices

and

offe

r th

e se

rvic

e on

a y

early

bas

is. T

his

is

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBr

east

canc

er is

the

mos

t com

mon

cau

se o

f can

cer m

orta

lity

in w

omen

.Sc

reen

ing

for b

reas

t can

cer h

as b

een

a ho

tly d

ebat

ed to

pic

in re

cent

yea

rs.

A fe

w y

ears

ago

, the

Min

istry

of H

ealth

set

up

a co

mm

ittee

, the

Nat

iona

lA

dviso

ry C

omm

ittee

on

Brea

st Sc

reen

ing

to re

port

on th

e fe

asib

ility

of i

ntro

duci

ngbr

east

canc

er s

cree

ning

in th

e pu

blic

hea

lth s

ervi

ce. A

t the

tim

e th

e co

mm

ittee

had

conc

lude

d th

at it

was

not

feas

ible

but

it re

com

men

ded

thre

e im

med

iate

tom

ediu

m-te

rm m

easu

res

whi

ch w

ere:

•to

impr

ove

upon

the

then

cur

rent

dia

gnos

tic a

nd th

erap

eutic

ser

vice

s;•

to in

trodu

ce s

ervi

ces

for w

omen

at h

ighe

r risk

;•

to a

ddre

ss th

e ge

nera

l fem

ale

popu

latio

n.It

was

sub

mitt

ed in

Mar

ch 2

000.

With

in th

e pu

blic

hea

lth s

ecto

r, br

east

scre

enin

g, in

the

form

of c

linic

al a

ndm

amm

ogra

phic

exa

min

atio

n, is

cur

rent

ly o

ffere

d to

wom

en re

ferre

d fro

m p

rimar

yca

re w

ho a

re c

onsid

ered

as

bein

g at

a s

ubsta

ntia

lly in

crea

sed

risk.

Th

e fo

llow

ing

cate

gorie

s ar

e in

clud

ed u

nder

incr

ease

d ris

k: w

omen

who

hav

eal

read

y ha

d un

ilate

ral b

reas

t can

cer o

r ova

rian

canc

er; w

omen

who

hav

e ha

dpr

olife

rativ

e or

aty

pica

l hyp

erpl

asic

bre

ast d

iseas

e; w

omen

who

hav

e a

first-

degr

ee re

lativ

e w

ith b

reas

t can

cer a

t any

age

; wom

en re

ceiv

ing

horm

one

repl

acem

ent t

hera

py.

Ther

e is

no s

peci

fic p

olic

y an

d th

ere

may

be

som

e va

riabi

lity

amon

g di

ffere

ntsu

rgeo

ns. T

his

scre

enin

g is

offe

red

free

of c

harg

e si

nce

it fo

rms

part

of th

ena

tiona

lhea

lth s

ervi

ce.

In th

e pr

ivat

e se

ctor

, wom

en s

eek

mam

mog

raph

y sc

reen

ing

on th

eir o

wn

initi

ativ

e al

thou

gh o

ppor

tuni

stic

scre

enin

g is

wid

ely

prac

tised

. Sin

ce th

ere

is no

natio

nal p

olic

y, s

ome

clin

ics

have

set

up

thei

r ow

n ca

ll an

d re

call

syste

ms

with

mos

t clin

ics

reca

lling

wom

en o

n a

year

ly b

asis.

Thi

s is

norm

ally

pai

d fo

r out

of

pock

et b

y th

e se

rvic

e us

ers.

C

olor

ecta

l can

cer i

s th

e se

cond

mos

t com

mon

cau

se o

f can

cer-r

elat

ed d

eath

in

bot

h m

en a

nd w

omen

in M

alta

. In

the

publ

ic s

ecto

r, sc

reen

ing

for c

olor

ecta

lca

ncer

is o

ffere

d to

firs

t-deg

ree

rela

tives

of p

atie

nts

with

fam

ilial

pol

ypos

is.

In s

uch

insta

nces

pat

ient

s ar

e ad

vise

d to

info

rm th

eir r

elat

ives

of t

heir

incr

ease

d

66

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

Malta c

ont.

Cer

vica

l ca

nce

rno

rmal

ly p

aid

for

by th

e se

rvic

e us

ers.

Even

per

sons

cov

ered

by

a pr

ivat

e he

alth

insu

ranc

e m

ay h

ave

to p

ay o

ut o

f poc

ket

sinc

e m

ost s

chem

es a

vaila

ble

loca

llyex

clud

e pr

even

tive

care

and

scr

eeni

ng.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rris

k an

d to

adv

ise th

em to

pre

sent

for s

cree

ning

. Suc

h sc

reen

ing

is of

fere

d fre

e of

cha

rge

since

it fo

rms

part

of th

e na

tiona

l hea

lth s

ervi

ce. I

nfor

mat

ion

on th

e pr

ivat

e se

ctor

is n

ot a

vaila

ble

but a

necd

otal

evi

denc

e su

gges

ts th

at th

is ty

pe o

fsc

reen

ing

has

not r

eally

bee

n ta

ken

up in

Mal

ta to

the

sam

e ex

tent

as

mam

mog

raph

y or

sm

ear t

ests.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aIn

form

atio

n no

t ava

ilabl

e

Pola

nd

Cer

vica

l ca

nce

rIn

form

atio

n no

t ava

ilabl

eBre

ast

cance

r, c

olo

rect

al ca

nce

rIn

form

atio

n no

t ava

ilabl

e

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aSi

nce

2003

the

Min

istry

of H

ealth

has

def

ined

with

in it

s na

tiona

l hea

lth s

trate

gy a

spec

ial p

rogr

amm

e on

“pr

even

tion

of g

enet

ic s

yndr

omes

”. T

he p

rogr

amm

e is

aco

mpo

nent

(int

erve

ntio

n) o

f the

Nat

iona

l Pro

gram

me

for

Mot

her

and

Chi

ld H

ealth

that

aim

s to

red

uce

infa

nt a

nd m

ater

nal m

orta

lity.

It h

as tw

o m

ain

obje

ctiv

es: t

oor

gani

ze a

net

wor

k of

ant

e- a

nd p

ostn

atal

dia

gnos

is c

entre

s an

d to

pre

vent

gene

tic s

yndr

omes

. The

sys

tem

is d

esig

ned

on th

ree

leve

ls:1.

fam

ily d

octo

rs a

nd o

ther

firs

t-leve

l prim

ary

care

pro

fess

iona

ls w

here

risk

fact

ors

and

popu

latio

ns a

t risk

can

be

iden

tifie

d an

d co

unse

lling

can

be m

ade

avai

labl

e;2.

distr

ict h

ospi

tals

whe

re u

ltras

ound

and

gen

etic

tests

are

per

form

ed;

3.re

prod

uctiv

e he

alth

ref

eren

ce c

entre

s w

here

full

pack

ages

of i

nves

tigat

ions

are

avai

labl

e.Th

e pr

ojec

t des

crib

es d

etai

led

prot

ocol

s fo

r ea

ch le

vel a

s w

ell a

s th

e m

inim

umne

cess

ary

tech

nica

l equ

ipm

ent a

nd tr

aini

ng.

The

prog

ram

me

starte

d w

ith le

vel 3

– th

e “r

epro

duct

ive

heal

th r

efer

ence

cent

res”

– b

y ac

hiev

ing

the

nece

ssar

y eq

uipm

ent a

nd tr

aini

ng. F

utur

e ste

ps w

illfo

cus

on c

asca

de tr

aini

ng o

f lev

els

1 an

d 2.

The

who

le p

rogr

amm

e is

coo

rdin

ated

by th

e In

stitu

te o

f Mot

her

and

Chi

ld C

are.

PKU

scr

eeni

ng is

per

form

ed o

n ov

er60

% o

f neo

nate

s. T

he in

tent

ion

is to

ext

end

cove

rage

to 1

00%

.

Rom

ania

Cer

vica

l ca

nce

rTu

mou

rs a

re th

e se

cond

mos

tco

mm

on c

ause

of d

eath

inRo

man

ia. C

ervi

cal c

ance

rin

cide

nce

is th

e th

ird h

ighe

st in

Euro

pe a

nd to

p in

term

s of

mor

talit

y. T

he N

atio

nal P

ublic

Hea

lth S

trate

gy r

ecom

men

ds a

resh

apin

g of

the

natio

nal

canc

er r

egis

try b

y 20

06 a

ndth

e im

plem

enta

tion

of a

natio

nal p

rogr

amm

e on

scre

enin

g. A

t the

mom

ent,

scre

enin

g is

opp

ortu

nisti

c an

dpa

id fo

r fro

m th

e he

alth

insu

ranc

e fu

nd a

nd th

e M

inis

tryof

Hea

lth’s

budg

et th

roug

h th

ena

tiona

l pro

gram

me

onre

prod

uctiv

e he

alth

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBr

east

canc

er is

res

pons

ible

for

17%

of d

eath

s, a

s is

col

orec

tal c

ance

r.

Tabl

e A

2.2

con

t.

67

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aSl

ovak

ia h

as a

n an

tena

tal s

cree

ning

pro

gram

me

and

all p

regn

ant w

omen

und

ergo

ultr

asou

ndex

amin

atio

n to

iden

tify

Dow

n sy

ndro

me

and

spin

a bi

fida.

All

neon

ates

are

exa

min

ed to

id

entif

y PK

U b

y bi

oche

mic

al m

etho

ds.

Cos

ts ar

e co

vere

d by

hea

lth in

sura

nce.

Solv

ak

iaCer

vica

l ca

nce

rSl

ovak

ia h

as a

nat

iona

l pol

icy

on s

cree

ning

. Fo

r ce

rvic

al c

ance

r, sc

reen

ing

is o

ppor

tuni

stic

and

costs

are

cove

red

by h

ealth

insu

ranc

eco

mpa

nies

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rFo

r br

east

canc

er, w

omen

age

d 40

–60

are

targ

eted

for

perio

dic

mam

mog

raph

y, a

nd th

e co

sts a

re c

over

ed b

y he

alth

insu

ranc

e co

mpa

nies

. W

ith r

egar

d to

col

orec

tal c

ance

r, m

en a

nd w

omen

ove

r th

e ag

eof

50,

thos

e w

ith a

fam

ily h

isto

ry a

nd p

atie

nts

with

exi

sting

col

ondi

seas

e ar

e ta

rget

ed a

nd o

nce

agai

n co

sts a

re c

over

ed b

y he

alth

insu

ranc

e co

mpa

nies

.

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aPK

U is

scr

eene

d fo

r in

the

first

days

afte

rbi

rth a

nd it

is a

pplie

d un

iver

sally

– a

ll ne

onat

es a

re s

cree

ned.

D

own

synd

rom

e an

d sp

ina

bifid

a ar

eid

entif

ied

thro

ugh

asse

ssm

ent o

f risk

(bas

edon

nat

iona

l rec

omm

ende

d gu

idel

ines

) and

thro

ugh

ultra

soun

d te

sting

.

Slove

nia

Cer

vica

l ca

nce

rTh

ere

is a

nat

iona

l pol

icy

on s

cree

ning

for

cerv

ical

canc

er. T

he p

roje

ct ‘Z

ORA

’ inc

lude

s al

l wom

enbe

twee

n th

e ag

es o

f 25

and

64. T

hey

are

activ

ely

follo

wed

up

thro

ugh

a ce

ntra

l sur

veill

ance

sys

tem

,w

hich

iden

tifie

s th

e fre

quen

cies

of c

ervi

cal s

mea

rs.

Thes

e ar

e pe

rform

ed e

very

thre

e ye

ars

(afte

r th

efir

st tw

o, ta

ken

in th

e sp

an o

f six

mon

ths,

hav

e bo

thpr

oved

neg

ativ

e). N

on-re

spon

ders

can

be

trace

dby

two

syste

ms;

one

is th

roug

h th

e pr

ojec

t, w

hich

invi

tes

them

aga

in a

fter

six

mon

ths,

or

thro

ugh

the

prim

ary

care

gyn

aeco

logi

sts w

ho h

ave

a du

ty to

perfo

rm te

sts tr

ienn

ially

. In

both

sys

tem

s, th

e te

st is

eith

er c

ompl

etel

y fre

e of

cha

rge

or in

volv

es c

o-pa

ymen

ts. T

he o

nly

exce

ptio

n is

a te

st pe

rform

edon

req

uest

by a

pat

ient

, with

no

path

olog

y, s

oone

rth

an th

ree

year

s af

ter

the

prev

ious

one

.

Bre

ast

cance

r, c

olo

rect

al ca

nce

rBr

east

canc

er is

cur

rent

ly s

cree

ned

for

oppo

rtuni

stica

lly,

thro

ugh

the

netw

ork

of c

entre

s fo

r br

east

dise

ases

.Th

ere

is n

o na

tiona

l pol

icy

alth

ough

the

Nat

iona

lC

ance

r In

stitu

te is

tryi

ng to

hav

e th

e sta

ndar

d Eu

rope

angu

idel

ines

ado

pted

in S

love

nia.

How

ever

, nat

iona

lgu

idel

ines

hav

e be

en p

repa

red

and

are

awai

ting

appr

oval

by

the

natio

nal a

utho

ritie

s re

spon

sibl

e.

The

goal

is fo

r th

e en

tire

proc

ess

of s

cree

ning

to b

efin

ance

d by

nat

iona

l hea

lth in

sura

nce.

Col

on c

ance

r is

a r

apid

ly in

crea

sing

pro

blem

inSl

oven

ia. T

his

has

led

to th

e pr

epar

atio

n of

nat

iona

lgu

idel

ines

, whi

ch a

re r

eady

, and

an

asse

ssm

ent i

s to

be p

erfo

rmed

this

yea

r on

thei

r fe

asib

ility

in p

ract

ice.

Afte

r th

at, f

undi

ng fr

om n

atio

nal h

ealth

insu

ranc

e w

ill b

e so

ught

to fi

nanc

e th

is a

dditi

onal

scr

eeni

ng

prog

ram

me.

68

Scre

enin

g in E

uro

pe

– a p

olic

y s

um

mary

PK

U,

Dow

n s

yndro

me,

spin

a b

ifid

aA

mni

ocen

tesi

s is

use

d to

iden

tify

gene

ticbi

rth d

efec

ts. In

Tur

key

amni

ocen

tesi

s is

pe

rform

ed o

n th

e ba

sis

of a

phy

sici

an’s

reco

mm

enda

tion

and

ther

e is

cur

rent

ly n

ona

tiona

l pol

icy.

Turk

eyCer

vica

l ca

nce

rIn

rec

ent y

ears

, a n

atio

nal c

ance

r sc

reen

ing

polic

y ha

s be

en d

evel

oped

,an

d a

decr

ee h

as b

een

publ

ishe

d fo

r th

ees

tabl

ishm

ent o

f “ca

ncer

scr

eeni

ng

cent

res”

und

er th

e au

spic

es o

f pub

lic

hosp

itals.

The

se c

entre

s ar

e en

truste

dw

ith th

e ta

sk o

f adm

inis

terin

g at

leas

t one

scre

enin

g pr

ogra

mm

e ta

rget

ed a

t ris

kgr

oups

(for

bre

ast c

ance

r in

wom

en a

ged

40 a

nd o

lder

and

for l

ung

canc

er in

men

).

Bre

ast

cance

r, c

olo

rect

al ca

nce

rSo

me

pilo

t scr

eeni

ng p

rogr

amm

es a

re a

lread

y ru

nnin

g, o

ne o

fw

hich

is b

eing

con

duct

ed in

Izm

ir. In

the

fram

ewor

k of

this

parti

cula

r pi

lot,

the

heal

th c

are

pers

onne

l fro

m th

e sc

reen

ing

cent

res

visi

t dis

trict

s in

the

city

, and

scr

een

wom

en o

ver

the

age

of 4

0 fo

r bre

ast c

ance

r. Th

is sc

reen

ing

incl

udes

exa

min

atio

nby

the

phys

icia

n, u

ltras

ound

and

mam

mog

raph

y w

hene

ver

nece

ssar

y. B

esid

es th

ese

publ

icly

adm

inist

ered

scr

eeni

ng p

roje

cts,

som

e m

unic

ipal

ities

and

NG

Os

also

org

aniz

e sc

reen

ing

prog

ram

mes

on

thei

r ow

n, m

ainl

y ta

rget

ed a

t bre

ast c

ance

r. A

ll th

ese

scre

enin

gs a

re fr

ee o

f cha

rge.

Tabl

e A

2.2

con

t.

The European Observatory on HealthSystems and Policies supports and

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The

Euro

pea

n O

bse

rvat

ory

on H

ealt

h Sy

stem

s an

d P

olic

ies

is a

par

tner

ship

bet

wee

n th

e W

HO

Reg

iona

l Off

ice

for E

urop

e, th

eG

over

nmen

ts o

f Bel

gium

, Fin

land

, Gre

ece,

Nor

way

, Sp

ain

and

Sw

eden

, the

Ven

eto

Reg

ion

of It

aly,

the

Euro

pea

n In

vest

men

t Ban

k, th

eO

pen

Soc

iety

Inst

itut

e, th

e W

orld

Ban

k, C

RP-

Sant

é Lu

xem

bou

rg, t

he L

ond

on S

choo

l of E

cono

mic

s an

d P

olit

ical

Sci

ence

and

the

Lond

onSc

hool

of H

ygie

ne &

Tro

pic

al M

edic

ine.

This

pol

icy

bri

ef is

inte

nded

for p

olic

y-m

aker

s an

d th

ose

add

ress

ing

the

issu

e of

scr

eeni

ng in

hea

lth

care

.