General medicine

To the Editor:We congratulate Cheney and colleagues1 for throwing light on the contributions of overweight and obesity on adverse birth outcomes by analysing data from a teaching hospital in central Sydney.1 Around 16% of the women presenting between 2010 and 2014 were overweight, while 7% were obese. Furthermore, despite obesity being an important risk factor for adverse pregnancy outcomes, their study showed a lack of recording of body mass index (BMI) in patients’ records. Adverse pregnancy outcomes are more common among Indigenous Australian women than non-Indigenous women;2 obesity levels are high in pre-conception and in pregnancy, and the subsequent adverse impact on increased metabolic health in offspring is likely contributing to early onset of diabetes and chronic disease in Indigenous Australians. Hence, we want to extend the debate to report on what is happening in primary health care (PHC) settings for Indigenous women. We have analysed continuous quality improvement data from audits of adherence to evidence-based guidelines for maternal care in 65 Indigenous PHC centres (1091 patient records) across Australia during 2012–2014.3 The majority of women at most PHC centres had the first trimester weight recorded (mean, 90%; range, 60–100%), but there was wide variation in recording of BMI (mean, ∼ 60%; range, 0–100%) (Box). This indicates that most barriers to BMI recording are more to do with clinicians’ understanding of the value of and ability to calculate BMI than around women’s willingness to be weighed. For women with an abnormal BMI (mean, ∼ 30%; range, 0–100%), there was wide variation in documented BMI management plans (mean, ∼ 40%; range, 0–100%). Dealing with these generally low levels of recording and wide variation in recording between PHC centres is a vital early step in limiting the contribution of obesity to adverse pregnancy outcomes and improving long term health outcomes for the mother and baby. Women attending PHCs that had participated in continuous quality improvement activities were more likely to receive recommended pregnancy care related to screening and brief interventions for modifiable lifestyle-related risk factors, such as obesity.4,5 These findings support the incorporation of continuous quality improvement activities into the delivery of maternal care. Box – Record of scheduled maternal care services received by Indigenous women at Indigenous primary health care centres, 2012–2014* BMI = body mass index. * More information on how to interpret box plots is available in Gibson-Helm et al,3 page 21.

Jodie Bailie · Jacqueline A Boyle · Ross S Bailie

To the Editor:In October 2016, we achieved the eradication and control of hepatitis C virus (HCV) in a New South Wales correctional centre, which we believe to be a first of its kind in NSW. HCV prevalence in NSW prisons is 30–40 times higher than in the community, where prevalence is about 1%.1,2 Elevated risk of HCV infection is associated with the high proportion of prisoners who have injected drugs, the rate of injecting in prison, and restricted or limited access to bleach and needle and syringe programs.3 The Justice Health and Forensic Mental Health Network (the Network) is responsible for health care in the NSW forensic mental health and criminal justice systems. The availability of direct-acting antivirals on the Pharmaceutical Benefits Scheme in March 20164 created an opportunity for the Network to cure all patients with HCV infection in one prison. The Compulsory Drug Treatment Program (CDTP) is run at the Compulsory Drug Treatment Correctional Centre — a stand-alone prison with a stable sentenced inmate population, where patients with repeat drug-related charges participate in comprehensive drug treatment and rehabilitation. Patients at this correctional centre have longer sentences than those in other centres, which allowed for the full course of treatment. The Network, Corrective Services NSW and Hepatitis NSW formed a partnership to ensure that patients were able to access health centres, have their medication scripted and administered, could undertake monitoring and were supported through the Network’s established nurse-led model of care.5 All 58 patients in the CDTP were offered screening, and 54 patients with risk factors were screened; of these, 18 patients had chronic HCV infection. After further work-up, including liver elastography to measure fibrosis, all patients were concurrently commenced on treatment. Of the remaining four patients who were not screened, all had recent negative HCV pathology results. Three months after the treatment, 15 patients achieved sustained virological response equating to cure of their chronic HCV infection, and three patients were released before final assessment.6 Concurrent treatment commencement with the direct-acting antivirals was recognised as an innovative measure in reducing re-infection, in conjunction with the more common practices of harm minimisation education and use of the hospital-grade disinfectant for general cleaning purposes offered by Corrective Services NSW to all incarcerated people. Throughout the course of the project, two new patients were admitted, screened, and returned negative HCV pathology results. A proactive screening approach with patient consent was adopted to ensure that new cases were able to be identified and treated to maintain elimination. Maintaining a prison HCV-free may mean that patients have to take some responsibility with regard to sharing needles with new inmates. A peer education approach is being developed to increase patients’ ownership of a prison’s HCV-free status. The CDTP treatment model, combined with ongoing screening of new admissions, is an innovative approach for eliminating HCV, and is considered suitable for adoption in similar-sized prisons across Australia. The Network is currently rolling out this approach within NSW.

James Blogg · James Wood · Colette McGrath · Camilla Lobo

To the Editor:Your publication of a review on global approaches to antimicrobial resistance is timely.1 We especially note that antibiotic-resistant pathogens are not limited by borders, have greater impact on disadvantaged communities, and will require coordinated, high level government commitment to minimise their threat.1 In Australia, Indigenous communities bear a disproportionate burden of infectious diseases. This burden arises on a background of overcrowding, poorly built and maintained water and sanitation infrastructure, and colonisation of companion animals by human pathogens. The delivery of biomedically oriented health services leads to frequent use of broad spectrum antibiotics, promoting the development of multiresistant pathogens.2 The prominent multiresistant pathogen methicillin-resistant Staphylococcus aureus first emerged in hospitals, but, in Australia, it was soon identified in remote Indigenous communities.2 Health services have been unable to control its development and spread. As a consequence, community-acquired methicillin-resistant S. aureus is now the dominant strain of this bacterium in Central Australia, where Indigenous people are one-quarter of the population, but bear three-quarters of the S. aureus disease burden in Alice Springs Hospital.3 Primary health care is founded on full community participation and an intersectoral approach, incorporating education, housing and other sectors to complement health services.4 Housing for Indigenous communities remains inadequate, and government responses deficient, particularly in remote regions.5 As a result, even high quality health services have limited impact on Indigenous people’s health and wellbeing. Safe, secure, functioning housing that is appropriate for its occupants is a building block to manage other areas of Indigenous disadvantage.5 The deficit in appropriate housing contributes to bacterial colonisation, infection and development of antimicrobial resistance among Indigenous Australians.2 “Illness is a weapon” was intended as a metaphor for the resistance of Indigenous people to their ongoing colonisation.6 However, the threat of antibiotic resistance evolving through the neglected conditions in which some communities find themselves could make this metaphor more real than was likely intended. The spread of antibiotic-resistant pathogens in Indigenous communities and elsewhere is a global threat, which highlights the need to transform services for Indigenous people using approaches driven by communities and focused on their strengths.

Rosalie Schultz

To the Editor: After reading the recent article by van Driel and colleagues,1 we want to report on hepatitis C treatment outcomes in a Sydney general practice. New direct-acting antiviral (DAA) therapy for the treatment of chronic hepatitis C became widely available in Australia on 1 March 2016 via the Pharmaceutical Benefits Scheme, and general practitioners are able to prescribe it in consultation with a specialist. We describe here the treatment outcomes from the first 60 days of DAA prescribing in a single general practice clinic. We searched the clinic database to extract demographic and clinical data for all patients prescribed DAA from 1 March to 30 April 2016. We found that 47 patients had been prescribed DAA agents by a GP, five had received DAA therapy via an early access program, 41 had genotype 1 hepatitis C virus (HCV), six patients had genotype 3 HCV, and 11 patients had co-infection with HIV. All treated patients had an assessment of liver fibrosis performed with a FibroScan. Most patients had early liver disease, with three having cirrhosis. On 1 May 2017, we assessed the outcome data: 33 patients were treated with ledipasvir and sofosbuvir (all had genotype 1 HCV), nine were treated with daclatasvir and sofosbuvir (three had genotype 1 HCV, and six had genotype 3 HCV), and five patients were treated with paritaprevir + ritonavir + ombitasvir + dasabuvir (all had genotype 1 HCV). Forty-six patients had started treatment, with sustained virological response (SVR16; ie, undetectable virus 16 weeks after the end of treatment) results available for 45 patients. One patient had treatment failure, one had not started treatment and one patient was waiting on SVR results. On-treatment SVR (cure) rate was 96%. A steadily increasing percentage of patients in Australia are receiving hepatitis C treatment prescribed by their GPs, with 19% of prescriptions provided in this setting in September 2016.2 GPs are well placed to provide care for patients living with chronic hepatitis C, with reassuringly high cure rates.

David Baker · Marilyn McMurchie · Vanessa Farr