Issues
Volume 221 Issue 4
Editor's choice
Effective management of infectious diseases requires ongoing engagement across the health system
This issue of the MJA has a focus on infectious diseases, a topic that has been top of mind globally in relation to public health, recently driven by the coronavirus disease 2019 (COVID‐19) pandemic. But of course, infectious diseases and diverse pathogens cause a very wide spectrum of illness beyond COVID‐19 and although new pathogens emerge, old ones continue to have clinical importance and require continued attention across the health system. A research article and an editorial on congenital syphilis underline the importance of not forgetting about older diseases. In their research article, Hengel and colleagues (https://doi.org/10.5694/mja2.52388) describe the notification rates for infectious syphilis in women of reproductive age (15–44 years) and congenital syphilis in Australia. To many readers, the numbers will seem alarmingly high: during 2011–2021, there were 5011 notified cases of infectious syphilis in women aged 15–44 years, and the notifications rose year on year. In the same years, 74 cases of congenital syphilis were notified, increasing from six in 2011 to a peak of 17 in 2020. Crucially, mothers of 32 of the infants with congenital syphilis had not received antenatal care. In their editorial on this article (https://doi.org/10.5694/mja2.52393), Bond and Chen note that the research shows a changing picture of syphilis over the past decade, from previously, where the disease was more prevalent in men who have sex with men and in remote Aboriginal and Torres Strait Islander communities, to now where there are increasing notifications among women living in urban areas. This rise is not unique to Australia — other high income countries such as the United States are seeing cases rise. Bond and Chen note how important these numbers are, especially of cases of congenital syphilis: “The resurgence of congenital syphilis indicates a breakdown in syphilis control, and should be seen as an urgent call to action”. They conclude that multiple approaches are needed, including efforts to reduce stigma for sexual health testing and treatment and “coordinated policies in both antenatal and sexual health care, clear guidelines, and broad education programs”. Other countries have eliminated congenital syphilis: Australia must commit to doing the same. Another area of critical health policy in infectious diseases lies in how seasonal influenza vaccines are managed in Australia. Each year, the rollout of these vaccines is a vital component of the response to influenza. Key to its success is public confidence in the vaccines, and that includes early detection of adverse events following immunisation. In a perspective, O'Moore and colleagues (https://doi.org/10.5694/mja2.52381) describe the process for vaccine pharmacovigilance and the bodies involved, including the Therapeutic Goods Administration, the nationally funded surveillance initiative AusVaxSafety, and state and territory health departments. These processes are not static; as O'Moore and colleagues note, influenza vaccine safety surveillance was updated in 2022, and now, importantly, aligns with the methodology for COVID‐19 vaccine safety surveillance that commenced in March 2021. These and other updates, they conclude, “support the health and safety of Australians through close monitoring of seasonal influenza vaccines and rapid communication of any emerging safety signals”. Outside of COVID‐19 and influenza, vaccination for adults is often not discussed extensively; yet the familiar childhood vaccine combination of tetanus, pertussis and diphtheria has an important role in the prevention of disease in later life. In a lessons from practice article, Torres and colleagues (https://doi.org/10.5694/mja2.52380) describe two women aged in their 80s with tetanus from New South Wales, one of whom, who had no record of tetanus vaccination, died. This is not an aberrant finding — as they say, “Notably, no patients with a confirmed tetanus diagnosis in NSW over the past decade had complete age‐appropriate tetanus vaccinations”. In a research letter, Hendry and colleagues (https://doi.org/10.5694/mja2.52389) confirmed that vaccination status for older adults in Australia is not optimal, by assessing tetanus, pertussis and diphtheria vaccination coverage among Medicare‐registered older adults in Australia. The Australian immunisation handbook recommends that adults receive diphtheria–tetanus–pertussis (dTpa) combination vaccine at 50 years of age if not given during the preceding ten years and a second dTpa booster dose at 65 years of age or older if not given during the preceding ten years. They found that tetanus, pertussis, and diphtheria‐containing vaccine coverage among older Australians was suboptimal, and especially so for vaccines containing pertussis. This lack of coverage is problematic because of the potential for severe disease from pertussis in older adults — and also, as the article by Torres and colleagues shows, the chance of severe disease from tetanus. What might be the reason for low uptake? Hendry and colleagues note that tetanus, pertussis and diphtheria‐containing vaccines are not funded by the National Immunisation Program for older adults and the vaccination recommendations in adults can be complex and misinterpreted. Finally, in their perspective, Fowkes and colleagues (https://doi.org/10.5694/mja2.52398) look beyond just Australia to discuss the challenges of malaria elimination in the Asia–Pacific. This is an important time to raise awareness of continuing work on malaria elimination, given that as they note, “progress in reducing the malaria burden in the Asia–Pacific region has been highly variable within and across countries and Plasmodium spp, and recently it has stalled, and even reversed, in many countries”. As the authors discuss, the reasons for the stalling of progress are multifactorial, including a lack of sensitive tools to detect malaria, malaria prevention tools that are not fit‐for‐purpose, and that treatment of malaria is affected by drug resistance and toxicity. The solutions unsurprisingly are not simple and as the authors conclude, it is required to have “political commitment … national and regional collaboration, evidence generation from researchers, and effective community engagement”. Fowkes and colleagues’ conclusions could be applicable to much of the current status of infectious diseases and have lessons for the Australian health system. Where there are less than optimal outcomes, there undoubtedly will have been a failure of one or more of political commitment, collaboration, robust evidence generation or effective community engagement. It's up to everyone engaged in the health system to understand where the failures lie and work to address them.
Virginia Barbour
Perspective
National pharmacovigilance of seasonal influenza vaccines in Australia
Australia’s national pharmacovigilance systems work collaboratively to monitor the safety of seasonal influenza vaccines, with improvements to these systems ensuring the continued safety of medicines and vaccines available on the Australian market
Megan O'Moore · Belinda Jones · Megan Hickie · Catherine Glover · Lucy Deng · Yuanfei Huang · Michael Dymock · Evelyn Tay · Julie A Marsh · Nicholas Wood
The challenges of malaria elimination in the Asia–Pacific region
The Asia–Pacific region is progressing towards malaria elimination, but there are significant roadblocks to overcome
Freya JI Fowkes · Leanne J Robinson · Julie A Simpson · Kamala Thriemer · Moses Laman · Win Han Oo
Medical education
Group A streptococcal colitis: an under‐recognised entity?
In August 2023, an otherwise healthy 54-year-old woman presented to hospital with acute onset fevers and sweats, followed by four days of nausea, vomiting, generalised severe abdominal pain and diarrhoea.
Samuel WL‐W Baumgart · Suzanne English · Tony Sebastian · Sarika Suresh · Timothy J Gray
Severe tetanus infections across New South Wales in 2023
An 85-year-old woman presented with three days of dysphagia, headache, lower abdominal discomfort, and trismus
Romeo Torres · Ernest Tee · Sophie Harper · Leemin Chan · John Ng · Andie Lee
Treatment‐resistant tinea caused by Trichophyton indotineae in Australia
An otherwise well 25-year-old man presented with an itchy rash of 15 months duration on his groin and thighs, with no systemic symptoms
Kyra YL Chua · Catriona L Halliday · Sharon C‐A Chen · Sonia Koning · Jedrzej Pawlikowski · Philipp du Cros · Tony M Korman
Editorial
The resurgence of congenital syphilis in Australia: novel approaches and sustained, effective public health efforts are required
Coordinated antenatal and sexual health care policies, clear guidelines, and broad education programs could reduce the rate
Stephanie Bond · Marcus Y Chen
Ensuring a fit‐for‐purpose resource for consumers, clinicians and health services: the updated Osteoarthritis of the Knee Clinical Care Standard
The updated Clinical Care Standard is an important tool that can support best practice care for people with knee osteoarthritis
Ilana N Ackerman · Fiona Doukas · Rachelle Buchbinder · Sally Dooley · Wendy Favorito · Phoebe Holdenson Kimura · David J Hunter · James Linklater · John B North · Louise Elvin‐Walsh · Christopher Vertullo · Alice L Bhasale · Samantha Bunzli
Research
Notification rates for syphilis in women of reproductive age and congenital syphilis in Australia, 2011–2021: a retrospective cohort analysis of national notifications data
To avert congenital syphilis, equitable access to antenatal care must be secured for all women
Belinda Hengel · Hamish McManus · Robert Monaghan · Donna B Mak · Amy Bright · Ximena Tolosa · Kellie Mitchell · Lorraine Anderson · Jackie R Thomas · Nathan Ryder · Louise Causer · Rebecca J Guy · Skye McGregor
Outcomes for people admitted to Australian and New Zealand intensive care units with primary, exacerbating, or incidental SARS‐CoV‐2 infections, 2022–23: a retrospective analysis of ANZICS data
SARS-CoV-2 infections are still associated with poorer clinical outcomes for people admitted to ICUs
Alastair Brown · Andrew Udy · Martyn Kirk · Sonya Bennett · Shaila Chavan · Sue Huckson · David Pilcher
The public health and economic burden of long COVID in Australia, 2022–24: a modelling study
The health and economic burdens of long COVID are substantial, especially for working adults
Valentina Costantino · Quentin Grafton · Tom Kompas · Long Chu · Damian Honeyman · Adriana Notaras · C Raina MacIntyre
Research letter
Tetanus, pertussis, and diphtheria vaccination coverage in older adults, Australia, 2023: analysis of Australian Immunisation Register data
Tetanus, pertussis, and diphtheria-containing vaccine coverage among older Australians is suboptimal, particularly with respect to dTpa uptake
Alexandra J Hendry · Helen E Quinn · Kristine Macartney · Frank H Beard
Letter to the editor
The Alfred Health post‐COVID‐19 service, Melbourne, 2020–2022: an observational cohort study
To the Editor: Holland and colleagues reported on the Alfred Health post‐COVID‐19 service experience with the health of patients who had previously been hospitalised, or managed in a hospital‐in‐the‐home setting, with COVID‐19.1 Participants responded to an invitation to register for follow‐up, and then completed a questionnaire. The study also included a separate group (13% of the cohort) who were not necessarily admitted to Alfred Health but lived in the Alfred Health catchment — and might have been managed as outpatients or inpatients in another service but were referred by their local doctors to a specialist clinic targeted for patients with symptoms after initial COVID‐19, and subsequently completed the questionnaire. Sixty per cent of respondents had at least one persistent symptom at eight weeks. The study reported apparently high prevalences of other symptoms, such as post‐traumatic stress disorder in 23%. These results are derived from their cohort and may not be generally applicable. The authors caution: “We could not distinguish between new symptoms and those attributable to other health conditions. Our study did not include a contemporary control group”.1 More importantly, there was no control group of patients hospitalised from non‐COVID‐19 viral illness (with sufficient severe illness to lead to almost 5% spending time in an intensive care unit), who were then concentrated by an invitation, and then sufficiently motivated to fill out a questionnaire. Plausibly in such a group, at eight weeks, 60% would report at least one persistent symptom. Interpretation of their results is also obscured by the patients referred from the community, who came from a bigger population of patients with COVID‐19 concentrated to include only those who sought or agreed to a referral to a specialist follow‐up clinic. The authors wisely identified weaknesses and they should be applauded for their review of their experience. More definitive conclusions about higher rates of persisting ill health caused by COVID‐19 (in comparison to similarly severe infectious illness) might be achieved if they can follow this up — as they perhaps recognise — with a prospective analytic design in a cohort of patients presenting with similar severity of viral illness comparing those with and without COVID‐19 over the long term.
Jeremy L Millar
The Alfred Health post‐COVID‐19 service, Melbourne, 2020–2022: an observational cohort study
In reply: We thank Millar1 for taking the time to respond to our article,2 which details an evaluation of the Alfred Health post‐COVID‐19 clinical service established in June 2020. At that time we, like many health services around the world, faced the challenge of providing ongoing clinical management for patients with persistent and debilitating symptoms following SARS‐CoV‐2 infection, with little evidence to guide service provision or model of care. As there were no data to guide patient selection, we invited all patients with a diagnosis of COVID‐19 who had been managed by our health service (in hospital or in the community) to opt in if they perceived a need for ongoing care. This allowed us to quantify demand, as identified by patients who were affected. Our data confirm that a small proportion (6%) of individuals had persistent symptoms of long COVID that required medical and allied health specialist management. We consider this opt in approach a strength of our report; estimates of ongoing care needs following COVID‐19 vary enormously,3 and our data suggest that demand may be at the lower end of those estimates. As the pandemic progressed and more people with COVID‐19 were managed in the community, we adapted to the clinical needs of our patients by accepting referrals from general practice. We agree that there are limitations to our report, which are inherent in its nature as a service evaluation. We did not aim to provide epidemiological data on the prevalence or characteristics of long COVID; rather, we aimed to document the proportion of our patients following COVID‐19 who identified ongoing care needs, and to describe their characteristics. The recent federal parliamentary inquiry into long COVID4 states that “The role of specific long COVID clinics as a resource for primary health providers is very important to allow adequate services for major complications” and calls for the establishment of multidisciplinary long COVID clinics in selected public hospitals. We hope that our experience might be informative for other health services who are seeking to provide care for this small but important group of patients.
Anne Holland · Simone Dal Corso
Building and acting on the evidence for primary prevention of cancer
Elizabeth Zuccala
Overcoming disparities in hepatocellular carcinoma outcomes in First Nations Australians: a strategic plan for action
Jessica Howell · Troy Combo · Paula Binks · Kylie Bragg · Sarah Bukulatjpi · Kirsty Campbell · Paul J Clark · Melissa Carroll · Jane Davies · Teresa de Santis · Kate R Muller · Bella Nguyen · John K Olynyk · Nicholas Shackel · Patricia C Valery · Alan J Wigg · Jacob George · Stuart K Roberts
Priorities for planetary health equity in Australia
Sharon Friel · Katherine Trebeck · Nicholas Frank · Sandro Demaio · Megan Arthur · Chelsea Hunnisett · Francis Nona
Using conversant artificial intelligence to improve diagnostic reasoning: ready for prime time?
Ian A Scott · Tim Miller · Carmel Crock
Living evidence syntheses: the emerging opportunity to increase evidence‐informed health policy in Australia
Samantha P Chakraborty · Alex Collie · Rebecca Hodder · Suman S Majumdar · Kim Sutherland · Bernie Towler · Joshua Vogel · Andrew Wilson · Luke Wolfenden · Sally Green · Tari Turner
National Hypertension Taskforce of Australia: a roadmap to achieve 70% blood pressure control in Australia by 2030
Aletta E Schutte · Belinda Bennett · Clara K Chow · Geoffrey C Cloud · Kerry Doyle · Zoe Girdis · Jonathan Golledge · Andrew Goodman · Charlotte M Hespe · Meng P Hsu · Sharon James · Garry Jennings · Taskeen Khan · Audrey Lee · Lisa Murphy · Mark R Nelson · Stephen J Nicholls · Natalie Raffoul · Breonny Robson · Anthony Rodgers · Andrea Sanders · Catherine Shang · James E Sharman · Nigel P Stocks · Tim Usherwood · Ruth Webster · Jun Yang · Markus Schlaich
Mimics of inflammatory bowel disease: commonly encountered differentials of an uncommon condition
Kathryn Demase · Mark G Ward