In
this Issue March 2004
IPCRG 2nd World Conference Review
SARS war - defending the frontline
'Flu Season Looms
Virtual Roadshow - Children, asthma and the real
world!
The TSANZ 2004 Annual Scientific Meeting
Conference Diary 2004
IPCRG 2nd World Conference Review
Following a few weeks to reflect on the IPCRG 2nd World
Conference in Melbourne last month, for those of you who had the opportunity to
attend you would no doubt agree it was a stimulating meeting.
The calibre of presentation and excellent level of interest in
all presentations certainly seemed to fulfil Dr H John Fardy's expectation of
addressing the challenges of learning, sharing, experiencing and enjoying all
aspects of the conference.
Keynote 6
Associate Professor P Y Cheong, from Singapore, gave an
absorbing and comprehensive presentation about how SARS impacted on Singapore.
With SARS spreading at the speed of a plane, Dr Cheong explained how the SARS
virus came from a single hotel-room resident in Hong Kong and cost Singapore
some $8 billion.
Temperature was the only defence and with the knowledge that the
incubation period was 10 days, medical teams worked 10 days on and 10 days off.
Primary care doctors were really at the frontline of this
emergency with some novel challenges. Many primary care facilities are in high
rise buildings which poses unique problems when a suspected SARS patient was
identified. Getting the patient out of the building without exposure to other
building occupants required careful planning.
Four important lessons became apparent as the epidemic finally
was contained.
Firstly, that in the SARS situation there was more than one
frontline. Understanding how infectious disease can spread, who might be a
carrier and the incubation period are crucial. The flow of hospital workers
throughout the facility, whether or not they are medical personnel, was
significant. Understanding that infection can spread beyond the hospital well
before symptoms develop leaves all the community vulnerable.
Secondly, communication with the community had to be open and
direct. The difficulty of isolation for suspect cases was exceeded only by the
sadness of having to be nursed without human touch, particularly for those
patients who did not survive.
Thirdly, through the total defence measures instituted in
Singapore with Ministry of Health and Primary Care working in concert, no doctor
in Primary Care got SARS.
And, finally when there is something around like SARS, a case
anywhere in the world is a threat everywhere.
Associate Professor Cheong's abstract follows.
SARS war - defending the frontline
P
Y Cheong Community Occupational & Family Medicine Dept, National University of
Singapore
Purpose:
The Severe Acute Respiratory Syndrome (SARS) epidemic in
Singapore began on 1st March 2003 and ended three months later with 238 persons
infected, 42% of them healthcare workers (HCW) and 33 deaths. This paper
chronicles the experience of setting up the rings of defence as the epidemic
wore on.
Methods:
The strategy that evolved of detect, isolate and ring-fencing
(DIR) the virus using 4 rings of defence against this hitherto unknown disease
is described. The sources of this chronicle are from local and world-wide mass
media and medical literature
Results:
The Border Defence
All local cases in the epidemic can be traced to just one of the
8 imported cases. The border is thus a defence ring. Thermal scanning and health
declaration of passengers were implemented from April. A retrospective study
however revealed that of about 443 thousands persons screened, 136 were sent for
further screening but none was diagnosed as SARS. The enormous economic risk of
even one in-bound SARS patient causing community spread is nevertheless
justification enough.
The Hospital Defence.
The learning curve of defending the hospitals was steep. In Tan
Tock Seng Hospital (TTSH) where the first patients were warded, universal
Personal Protection Equipment (PPE) of N95 masks, gloves, gowns & goggles (M3G)
plus barrier nursing in single patient isolation rooms were instituted once it
was clear that SARS was very infectious to both HCW and patients and can be
lethal. These measures and strong clinical leadership to maintain staff
discipline and morale stopped all nocosomial transmission by 5th April. However,
it was not known then that signs of SARS may be masked in immuno-compromised
patients. A few such patients (with the virus but not considered SARS suspects)
discharged from ‘TSH were later admitted to other hospitals forming clusters of
cases. This lesson learnt led to swift global implementation of strict same
hospital re-admission policy, home quarantine orders (HQO) for 10 days for all
discharged patients, no visitor rule, and mandatory PPE, temperature monitoring
and restricted movements of every HCW. SARS suspect patients were immediately
transferred to the SARS hospital, TTSH by special ambulances.
The Community Defence.
Community defence initially emphasised knowledge of SARS and
personal hygiene. A watershed event was the closure of a large wholesale food
market on 20th April and deployment of the army to trace within 24 hours more
than 2000 people for HQO. Three days later, the Prime Minister invoked a total
defence doctrine involving personal responsibility encompassing every sector of
society to ensure that ‘there are no holes in our ring-fence against SARS’.
Community and civic organizations rallied.
Twice daily temperature taking was implemented at schools and
workplaces to detect fever as an early sign of SARS and also as a mass
psychological defence exercise. A Courage Fund for public donation and a mass
public campaign to appreciate (and not ostracise) HCW boosted morale. Intense
efforts were made to ensure that the SARS messages of DIR reached groups at risk
of being uninformed for example elderly illiterates.
The Primary Care Defence.
The primary care defence ring had the arduous tasks of detecting
suspect SARS from other common flu-like febrile illnesses for immediate
isolation in TTSH. A SARS workgroup set up by the College of Family Physicians
was crucial in translating Ministry of Health (MOH) directives into practical
measures. Such advisories were disseminated by print, e-mails and web-casting.
The community outbreak in the wholesale market created fear of wider community
spread. Contact with suspect SARS patients and travel history can no longer be
relied upon. Amongst other measures, a telephone hotline manned by doctors was
thus set up on 7 May to clarify diagnostic, PPE and HQO difficulties.
Conclusions
The SARS virus spread by jet from Hong Kong incognito to
Singapore and other affected countries. It spread to a few hospitals and into
the community. This epidemic showed that erecting the four rings of defence to
detect, isolate and ring-fence the virus, is crucial to rapidly contain
outbreaks caused by SARS.
For more on IPCRG Program Highlights go to
IPCRG
Melbourne 2004
(http://www.ipcrg-melbourne.org/news.htm#high)
'Flu Season Looms
Purposely, this article about influenza follows the Singapore
SARS story. Fortunately to date in Australia there has not been a death
involving SARS. However each year more people die from the 'flu and pneumonia
than perish in traffic accidents. And it is not just the elderly either.
People at particular risk of severe complications from influenza
include those with heart conditions, asthma and other lung conditions, diabetes,
kidney problems, those with weakened immune systems, residents of nursing homes
and other long-term care facilities, as well as anybody over the age of 65 years
regardless of their health status.
Beyond those in immediate danger from 'flu are the people who
care for, or are in close contact with, those at particular risk. Being in the
position to continue to care is vital, so avoiding infection and the potential
to pass it on is a necessity. If you are self-employed, a single parent, carer
or person who cannot afford to take 10 days out with the 'flu, it is time to
have your injection.
Useful Resources
Asthma
& Influenza - the Facts
Virtual Roadshow - Children, asthma and the
real world!
The National Asthma Council invites you to our second Virtual
Roadshow on Wednesday 21st April 2004, from 7.30 – 8.30 pm (AEST).
The Virtual Roadshow is an online presentation with an
interactive Q&A session, run directly from a computer via the Internet.
CPD/CME/CPE points will be available for participation.
Dr Ron Tomlins, Chairman, National Asthma Council will
facilitate presentations and discussions by three expert panellists:
-
Prof. Nicholas Glasgow
Director, Australian Primary Care
Health Research Institute,
the Australian National University, Canberra
-
Dr Dominic Fitzgerald
Paediatric respiratory and sleep
physician
Deputy Head of the Division of Academic and General Medicine at the
Children’s Hospital
Westmead, Sydney
-
Dr Amanda Barnard
General Practitioner,
Claremont,
Western Australia
Senior Lecturer, Department of General Practice,
University of
Western Australia
The panellists will discuss daily practice issues such as:
-
Types of medication pathways
-
The importance of lung function testing – case study
-
Adherence – the key driver for good asthma management
-
How it is done in general practice – case study
The panellists will answer your questions about paediatric
asthma live, during and immediately after the Virtual Roadshow. For the next
three days, the panellists will answer additional questions online, within 24
hours.
For more information go to
NAC Virtual
Roadshow
The
Thoracic Society of Australia and New Zealand
2004 Annual Scientific
Meeting
The 2004 TSANZ scientific meeting was recently held in Sydney.
A selection of presentations concerning asthma with particular relevance to
general practice were presented.
Brief Content |
|
Converting Evidence to Practice – MDI & Spacer V’s
Nebuliser
Vanessa McDonald1,
Peter G Gibson1,2, Michael J
Hensley1,2
and Jennifer Roberts2
1. Department of Respiratory and Sleep
Medicine, John Hunter Hospital, NSW 2310 2. School of Medical Practice &
Population Health, University of Newcastle, NSW 2308
Despite the the evidence to show that metered dose inhalers and spacers
are as good as nebulisers, in practice at three local hospital only 30%
of medical staff preferred them for acute asthma. This figure rose to
60% when MDI and inhaler was used for COPD.
Despite MDI and
inhaler being best practice for asthma, knowledge and traditional
practice are barriers to change.
|
|
Factors Associated With Asthma Practical knowledge.
Brett G Toelle BA1,
Stewart M Dunn PhD MPH2, Guy B
Marks PhD FRACP1.
1. Woolcock Institute of
Medical Research, University of Sydney & 2. Department of
Psychological Medicine, University of Sydney. Use of
hypothetical scenarios to test people 16 years or more, with doctor
diagnosed asthma and prescribed daily preventer medication about
practical knowledge of asthma. People were scored out of 25
responses to fast onset and slow onset exacerbation scenarios.
Potentially predictive factors measured included anxiety, depression,
personality, optimism, perceived involvement in care and specific
features of asthma.
Median scores for both scenarios were 12.
Having a written asthma management plan, being female and having had a
previous slow-onset attack were associated with adequate practical
knowledge about the slow onset scenario. |
|
Asthma Exacerbations And The Format Of Peak Flow
Charts
Helen K Reddel, Stephen D.Vincent1,
Jane Civitico2
1. Woolcock
Institute of Medical Research (RPAH and University of Sydney),
Camperdown NSW 2050,
2. Royal Prince Alfred Hospital Camperdown, NSW
2050
It seems that the format of peak flow charts, and
particularly the horizontal scale on which the data are
plotted, may have an important impact on the detection of
exacerbations by patients and health care professionals.
There were striking differences in the appearance of the exacerbation
when it was plotted in different formats. |
|
The Impact of Asthma on Quality of Life
Rosario D. Ampon1,2,
Margaret Williamson1,3, Leanne M.
Poulos1 and Guy B. Marks1
1.Australian Centre for Asthma Monitoring (ACAM) Woolcock Institute
of Medical Research,
2. Children’s Hospital at Westmead, 3School of
Health Information Management, University of Sydney. The aim of this
study was to measure the impact of having asthma on three aspects of
quality of life: psychological distress, self-perceived health and life
satisfaction.
The study concluded that the presence of asthma is
associated with poor quality of life and perceived health status and
higher than average levels of psychological distress. These represent
quantifiable impacts of asthma that can be monitored and, potentially,
modified with improved approaches to asthma prevention and control. |
|
Asthma Severity and the Impact on Quality of Life
(QoL)
Patricia K Correll1,
Margaret Williamson1,2
and Guy B Marks1
1. Australian Centre for Asthma Monitoring (ACAM) Woolcock Institute of
Medical Research, NSW 2050.
2. School of Health Information
Management, University of Sydney, NSW 2006 After adjusting for
demographic factors, comorbidities and smoking, having moderate to
severe asthma versus mild asthma was significantly associated with
poorer perceived health (odds ratio 2.25 95% confidence interval
1.88-2.68) poorer functioning (OR 1.78 95%CI 1.31-2.44), greater
psychological distress (OR 1.68 95%CI 1.40-2.01) and problems with
mobility (OR 1.57 95%CI 1.22-2.03), performing usual activities (OR 1.59
95%CI 1.24-2.04), pain and discomfort (OR 1.29 95%CI 1.05-1.58) and
anxiety and depression (OR 1.40 95%CI 1.22-1.74).
These results
demonstrate that among people with asthma the presence of moderate to
severe asthma is associated with a substantially increased risk of
having reduced QoL, including level of physical and psychological
functioning and perceived health status.
|
| Evidenced-Based Asthma Management
In The Emergency Department (ED).
Jason Bower1,
Susan A Welch1, Cassandra A
Slader1,2.
1. Pharmacy Department, Therapeutics Centre, St
Vincent's Hospital (SVH) Darlinghurst, 2010.
2. Faculty of Pharmacy,
University of Sydney, 2006. To date at St Vincent's Hospital Sydney,
standardised guidelines for acute asthma management in the ED have not
been developed. The National Asthma Council has recently updated its
guidelines for the emergency management of asthma. Additional
recommendations are suggested by analysis of the systematic reviews in
the Cochrane Database. The aim of this study was to compare the current
ED management of acute asthma with the evidenced-based guidelines, and
to identify practice inconsistent with these guidelines.
Fourteen
patients (23-77 years) were admitted during this period. Seven patients
were classified as moderate severity acute asthma, seven as severe.
Spirometry and peak expiratory flow were not measured in 79% (6/7
moderate, 5/7 severe) and 43% (5/7 moderate, 1/7 severe) of patients
respectively. Initial oxygen flow-rate was suboptimal in 57% (5/7
moderate, 3/7 severe). Prescribing of intravenous corticosteroids
deviated from guidelines (43%; over utilisation for moderate,
underutilisation for severe) and also for ipratropium bromide
(underutilised for 6/7 severe patients). Use of magnesium sulfate was in
accordance with the guidelines. Metered-dose inhalers with spacers are
currently not used in the SVH ED.
Several key areas have been
identified as inconsistent with the evidenced-based guidelines utilised.
These will be addressed in the subsequent guideline implementation and
education phase. |
|
Effect Of Fetal Gender On Maternal Asthma During
Pregnancy
Philippa Talbot1, Vanessa Murphy1,
Carolyn Kessell2, Warwick Giles1,
Roger Smith1, Peter Gibson2
& Vicki Clifton1
1. Mothers
and Babies Research Centre and
2. Respiratory and Sleep Medicine, Hunter Medical Research
Institute, Newcastle, NSW 2310 The study suggests that the female
fetus is associated with worsening maternal asthma during pregnancy
relative to the male fetus.
Furthermore it highlights that
asthma education and close monitoring of asthma during pregnancy are
important aspects of obstetric care. |
|
Enhancing Links Between Hospital And Community Based
Services to Facilitate And Coordinate a Paediatric Asthma Management
Program
Christine Burns1,
Melinda Gray2 and Professor
Richard Henry2
1. St George Hospital, Kogarah, NSW
2. Sydney Children’s Hospital
Randwick, NSW The “Aiming for Asthma Improvement in Children” program
commenced in July 2001 in the South East Health area in Sydney. Through
a service provision model that promotes evidence-based research, the
facilitation and coordination of a paediatric asthma management and
education program has been established. Implementation of standardised
emergency department clinical practice guidelines, strengthening of
links between the hospital and community, and delivery of asthma
education and training to key target groups form the basis of the model.
At local levels, liaising and coordinating with key stakeholders have
been integral components in ensuring the sustainability and delivery of
the service.
Paediatric asthma emergency department presentations
and inpatient separations have shown a decrease of 13%(263), and
15%(175) respectively, compared to figures from the financial year of
2000/2001. A minimum of 70% of schools and 40% of childcare services
have received asthma emergency training for their staff with asthma
management strategies implemented within their environments. Over 160
asthma education sessions have been delivered to key stakeholders. |
|
Asthma In Childhood and Lung Function Decline in
Adulthood
Xuan W, Toelle BG, Ng K, Belousova E, Marks
GB Woolcock Institute of Medical Research, University of Sydney, NSW
2050
Airway hyperresponsiveness (AHR) measured in childhood is
a significant predictor for lower FEV1/FVC ratio in
adulthood, independent of the ratio measured in childhood.
However, the decline in FEV1/FVC ratio between age 18 and 30
years is the same in people with and without AHR in
childhood. |
|
Relation Between Change In Asthma Prevalence And Use
Of Preventer Medications
De Meer G, Ng K, Toelle BG & Marks GB The
Woolcock Institute of Medical Research
Between 1992 and 2002 childhood asthma symptoms as well as symptom
severity decreased. This cannot be attributed to increased use of
preventer treatment, since there was a simultaneous negative trend in
preventer treatment, particularly among those with more frequent
symptoms. |
|
Risk Factors for Near Fatal Asthma In Children
PJ Lyell1,2,
E Villanueva3, D Burton2,
NJ Freezer1,4
and PG Bardin1,4
1. Department of Respiratory and Sleep Medicine; Monash Medical Centre.
2. Charles Sturt University.
3. Monash Institute of Health Services
Research.
4. Monash University.
The asthmatics with near fatal asthma (NFA) were more
likely to be male (p=0.05), older (p=0.01), have younger
siblings (p=0.05) and a longer duration of asthma (p=0.02).
They were also more likely to have hayfever (p=0.002), use
inhaled corticosteroids (p=0.001), long acting β2 agonists
(p=0.02), have an asthma management plan (p=0.006), see a
respiratory specialist (p=0.001) and have poor adherence
with medication (p=0.003).
Parental smoking showed
no differences between the groups. Multivariate analysis
identified male sex (p=0.05) and inhaled corticosteroids
(p=0.07) as factors associated with NFA.
The study
identifies a number of factors associated with NFA, many are
similar to those found in adult patients. Asthma severity
may explain some of the findings but the data also suggest
that other independent risk factors may operate in children. |
|
Access To Spirometry In Less Accessible And Remote
Areas Of Australia Leanne M Poulos1,
Wei Xuan1, Rose D
Ampon1, Margaret
Williamson1,2, and Guy B Marks1
1. Australian Centre for Asthma Monitoring (ACAM)
2. School of Health Information Management, University of Sydney,
NSW 2006.
There was a significant downward trend in the claims for
spirometry with increasing remoteness among people of all
ages (p=0.0027).
In major cities of Australia there
were 9.0 claims per 100 population per year compared to 1.3
claims per 100 population per year in very remote areas.
There was a similar trend observed among people aged 5 to 34
years (p=0.02). In this age group, the rate of claims
decreased from 5.3 per 100 population per year in major
cities to 0.56 per 100 population per year in very remote
areas of Australia.
Strategies are needed to improve
access to spirometry among persons with respiratory disease
living in remote and less accessible areas of Australia. |
For full program abstracts go to
TSANZ
(http://www.thoracic.org.au)
Conference
Diary 2004
Submit brief conference/meeting details to the National Asthma
Council for possible posting in our Conference Diary by email to
nac@NationalAsthma.org.au.
International Pediatric Respiratory, Allergy and Immunology
Congress.
Hong Kong Convention and Exhibition Centre
10-13
July 2004.
IPRAIC Hong Kong
(http://www.ipriac.org) |
 |
National Medicines Symposium 2004
Quality Use of Medicines -
Time for total integration
Brisbane Convention and Exhibition
Centre
Brisbane, Australia
28-30 July, 2004
National
Medicines Symposium 2004
|
 |
Created March 26, 2004. Updated
January 29, 2008
