Implementation of Non Invasive Prenatal Test (NIPT) as a contingency test in Wales Presented by: Sharon Hillier/ Director of Screening Division, Public Health Wales November 2018

Implementation of Non Invasive Prenatal Test (NIPT) as a contingency test in Wales June 2014 - UK National Screening Committee (NSC) recommended screening for Edwards’ syndrome and Patau’s syndrome in the first trimester UK NSC also recommended screening in twin pregnancies January 2016 UK NSC recommended evaluative roll out of NIPT as a contingency test for Down’s Syndrome, Edwards’ syndrome and Patau’s syndrome

Combined Screening in Wales In Wales offer of combined screening for Down’s syndrome was fully implemented from September 2015 Offer of screening in twin pregnancies and screening for Edward’s and Patau’s syndromes was not possible to implement until combined screening was implemented for all eligible women in the first trimester The decision taken in Wales was to include these changes to the pathway at the same time as NIPT so that managing one change process

Implementation Plan Project initiation Project initiation document Project Board Scope Issues and finances Obtain recommendation of how to implement from Welsh Government Devise education and information strategy to promote women making personalised informed decisions

Stakeholder engagement Colleagues from Wales (screening, Welsh Government and services) are represented in the UK level groups for NIPT implementation. Groups have wide representation Project board in Wales had wide representation including charities representing parents with children with the syndromes. Information produced underwent focus group discussions for feedback and review. Effective working with the genetic laboratory in Cardiff UHW who procured and validated test (a lot of work).

Implementation Decisions (Welsh Government) Initial Screening Test Combined screening: Offered for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome To women at 11+2- 14 +1 weeks with a singleton or twin pregnancy. Quadruple screening: Offered for Down’s syndrome where NT measurements not obtained and when too late for the combined test in singleton pregnancies.

Implementation Decisions (Welsh Government ) NIPT Following a higher chance screening result from the combined or quad test: Non-invasive prenatal testing (NIPT) or an invasive test offered to women with a singleton pregnancy An invasive test offered to women with a twin pregnancy

Important points Personal informed choice: Women to be offered choice at each stage of the pathway and their choice supported. Women can opt out of the pathway at any point. The NIPT test result is not a diagnostic test for the condition. An invasive test is a diagnostic test If the NIPT test is low chance then the woman is not offered an invasive test. The cut off of higher chance remains 1 in 150 It is expected that the number of unnecessary invasive tests is reduced in Wales due to the offer of NIPT as a contingency test

Health Board Implementation All Health Boards agreed to education and implementation date (it was ambitious!) Health Boards had regular implementation meetings with relevant stakeholders Project team supplied action list to be used if required Project team member attended health board implementation meetings

Project resources Project supplied: Cascade training session and resources for roll out to promote choices (FASP and voluntary organisations supplied resources and undertook the face to face training) Mandatory E-Learning package for professional information and education Information resources for women: pretest written information and film clip post test information written information and scan pads Information for professionals on screening in twin pregnancies Mandatory E-Learning package for professional information and education Information resources for women, including pretest written information and a flim clip, and post test information

Implementation Date The date of 30th April 2018 was set for implementation - any woman having her scan on or after this date was on the new pathway for screening No major issues with implementation across Wales Health Boards reported being prepared for the implementation

Evaluation Supply data to UK NSC evaluation Pre implementation agreement to evaluate in Wales using data and questionnaires Evaluation board to be developed from members of project board Six monthly reporting to the board Delay in England

Data to be evaluated UK NSC evaluation to look at: how many women choose NIPT when it’s offered how well NIPT detects Edwards’ and Patau’s syndromes how often NIPT fails to produce a result and why this is

Data collection in Wales Questions to be answered What decisions do women make? What is the laboratory turnaround time for NIPT tests in Wales? How does the NIPT test perform for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome? How often is the laboratory unable to give a result and the reason? What are the sample collection to laboratory turn around times? How often are there sampling or request card errors?

Evaluation of Information for Women Pre test written information: Reviewed as part of the implementation process – subject to routine annual review by Antenatal Screening Wales. Pre test film clip: New resource for implementation, reviewed by focus groups and project board prior to implementation. Post implementation evaluation with women completed Post test written information: Three former booklets were reviewed and amalgamated into new, more comprehensive book and reviewed by project board prior to implementation Post test evaluation with midwives and women just completed

Ongoing Evaluation of Information Focus groups planned Input from Nuffield Council on Bioethics and other voluntary organisations

Data Publication Data will be published to stakeholders when the pathway is completed for the first cohort of women.