Infectious diseases

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Over the last century the burden of infectious, or communicable, diseases has dramatically reduced in the Australian population,1 and until the COVID-19 pandemic, infectious diseases constituted 2% of the total disease burden.2 The COVID-19 pandemic has had broad and long-lasting consequences on health and healthcare delivery in Australia, not only on those directly affected by the disease. Prior to COVID-19, influenza was the most common vaccine-preventable disease in Australia, accounting for the most notifications.1 Lower respiratory tract infections comprise the sixth leading cause of total disease burden for children aged under five, while influenza and pertussis had the highest notification rates among young people aged 15–29.1,2

The low incidence of vaccine-preventable diseases in Australia is testament to the successful public health intervention of the National Immunisation Program of which general practice is the major site of immunisation.3 Part of this program is to provide catch-up immunisation for all people aged less than 20 years and for adult refugees and humanitarian entrants.4,5 Haemophilus influenzae type b (Hib) was the most common serious bacterial infection in young children in Australia; however, since the introduction of the Hib vaccine, invasive Hib disease notification rates have decreased by more than 95% in Aboriginal and Torres Strait Islander children aged under 5 years.6

General practice is involved in the surveillance, diagnosis and reporting of infectious diseases, including blood-borne viruses (BBVs) and sexually transmissible infections (STIs).7,8 This is vital in the prevention and control of infection.9 The most prevalent BBVs include human immunodeficiency virus (HIV), hepatitis B, and hepatitis C.10 Human T-cell lymphotropic virus–1 is known to cause chronic kidney disease and is more prevalent in Aboriginal and Torres Strait Islander peoples in Central Australia.11

Priority population groups that require additional support to prevent, manage and treat BBVs include people living with chronic BBVs, people who inject drugs, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, people involved in the justice system, men who have sex with men and people engaged in sex work.10 Notifications of STIs including chlamydia, gonorrhoea and syphilis have increased in recent years, particularly among rural and remote Australians, Aboriginal and Torres Strait Islander peoples and non-Indigenous males in metropolitan settings.1

Part of a GP’s role is the control and management of infectious disease, including the prevention of acute rheumatic fever and rheumatic heart disease, where 89% of all cases are in Aboriginal and Torres Strait Islander peoples.12 There has been a continuing gradual decline in the prescription and use of antimicrobials, however, antimicrobial resistance continues to be a significant challenge.13 In 2019, more than 10 million people had at least one antimicrobial dispensed; this is significantly higher than other comparable countries.13 During the 2020 COVID-19 pandemic, there was a 22–49% decrease in dispensing of antimicrobials which suggests decreased seasonal respiratory infections because of increased public health infection control measures.13

Infection prevention and control is critical in general practice.14,15 Approximately 165,000 healthcare-associated infections occur every year in Australia.16 GPs and general practices have an important leadership role in preventing and managing infections like COVID-19, influenza and hepatitis in healthcare settings.15 The appropriate use of skin cleansers has been shown to have a role in reducing the incidence of healthcare-associated infections.8 Equally important is the safety of all clinical staff. Ensuring that all members of the practice team are safe, competently trained and aware of their role and responsibilities in relation to prevention and control of cross-infection and transmission of diseases is essential.16

References
  1. Australian Institute of Health and Welfare. Infectious and communicable diseases. Canberra, ACT: AIHW, 2020 [Accessed 13 September 2021].
  2. Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2015. Canberra, ACT: AIHW, 2019 [Accessed 14 October 2021].
  3. Australian Government Department of Health. Covid-19 vaccination – Australian COVID-19 Vaccination Policy, Sept 2021. Canberra, ACT: Department of Health, 2021 [Accessed 12 January 2021].
  4. Chow MYK, Danchin M, Willaby HW, Pemberton S, Leask J. Parental attitudes, beliefs, behaviours and concerns towards childhood vaccinations in Australia: A national online survey. Aust Fam Physician 2017;46(3):145–51.
  5. Mahimbo A, Seale H, Smith M, Heywood A. Challenges in immunisation service delivery for refugees in Australia: A health system perspective. Vaccine 2017;35(38):5148–55
  6. National Centre for Immunisation Research and Surveillance Australia. Vaccination for Our Mob. Summary report of vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2011-2015. Westmead, NSW: NCIRS, 2021 [Accessed 12 January 2021].
  7. Bradley C, Hengel B, Crawford K, et al. Establishment of a sentinel surveillance network for sexually transmissible infections and blood borne viruses in Aboriginal primary care services across Australia: The ATLAS project. BMC Health Serv Res 2020;20(1):769
  8. Van Gemert C, Guy R, Stoove M, et al. Pathology laboratory surveillance in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of sexually transmitted infections and blood-borne viruses: Protocol for a cohort study. JMIR Res Protoc 2019;8(8):e13625–e13625.
  9. Victorian Government Department of Health. Infectious diseases. Melbourne, Vic: Department of Health, 2021 [Accessed 13 January 2021].
  10. Australian Medical Association. Position Statement: Blood Borne Viruses (BBVs) 2017. Canberra, ACT: AMA, 2017 [Accessed 13 September 2021].
  11. Talukder MR, Clauss CS, Cherian S, Woodman R, Einsiedel, L. Risk factors for HTLV‐1, acute kidney injury and urinary tract infection amongst Aboriginal adults with end stage kidney disease in central Australia. J Med Virol 2021
  12. Australian Institute of Health and Welfare. Acute rheumatic fever and rheumatic heart disease in Australia, 2019. Canberra, ACT: AIHW, 2019 [Accessed 19 November 2021].
  13. Australian Commission on Safety and Quality in Health Care. AURA 2021: Fourth Australian report on antimicrobial use and resistance in human health. Sydney, NSW: ACSQHC, 2021. [Accessed 13 January 2021].
  14. National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra, ACT: NHMRC, 2019 [Accessed 14 October 2021].
  15. The Royal Australian College of General Practitioners. Infection Prevention and Control Standards. 5th edn. East Melbourne, Vic: RACGP, 2014 [Accessed 14 October 2021].
  16. The Royal Australian College of General Practitioners. Standards for general practice training. 3rd edn. East Melbourne, Vic: RACGP, 2021 [Accessed 14 October 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • take a sensitive, respectful, non-stigmatising and clear approach when communicating with patients at higher risk of, or diagnosed with, communicable infectious diseases
1.1.1, 1.1.2, 1.1.6, 1.2.1, 1.2.3, 1.3.1, AH1.3.1
  • support patients, their families and carers to understand the role of vaccines in preventing disease and address vaccine hesitancy
1.1.1, 1.1.6, 1.2.1, 1.4.4
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify and provide initial management to a significantly ill patient, including children, presenting with life-threatening infection
2.1.3
  • order rational investigations and interpret results in the context of a patient’s presentation
2.1.7, 2.1.8, 2.1.10
  • differentiate between a commensal and a pathogenic organism, taking clinical history and presentation into account
2.2.1, 2.2.2, 2.2.10, 2.1.2
  • determine management plans that appropriately treat the infection and prevent further spread of the disease
2.1.8, 2.1.3, AH2.1.2, 2.1.10, 2.3.1
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • provide targeted advice to patients who are at increased risk of infections due to their socio-cultural, occupational or environmental context
3.1.1, 3.1.3, RH3.1.1, 3.2.1, 3.2.2, 3.2.4
  • advocate for and administer vaccinations based on individual and community needs
3.1.2, 3.1.3, RH3.1.1, 3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • use regular self-reflective practice to identify the potential impact of personal biases, judgements, assumptions and attitudes when working with groups at high-risk for infectious diseases
4.2.1, 4.2.2, 4.2.4, AH4.2.2
  • seek opportunities to strengthen professional knowledge or skillset, including appropriate sampling and interpretation of pathology results and changes in recommendations for vaccine-preventable diseases
4.2.1, 4.2.5, RH4.2.3
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • report notifiable infectious diseases to respective state and territorial health authorities
5.1.1, 5.1.2, 5.2.1, 5.2.5
  • implement infection control and prevention policies and procedures
5.1.1, 5.1.2, 5.2.4, AH5.2.1

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Infectious diseases

Five-year-old John is brought in to see you by his father, Mar, with complaints of intense itching in between his fingers and toes which is worse at night. John’s family moved to Australia two months ago as refugees from Sudan; they are living in a public housing unit. John attends the local school and goes to after school care as his parents work long hours.

Questions for you to consider Clinical exam assessment area Domains

How would you communicate with the father if he has difficulty communicating in English?

How would you sensitively find out if anyone else in the family has similar symptoms?

How could you communicate the diagnosis to John’s school and after school care?

  1. Communication and consultation skills
1,2,5

What other information would you like to know about John’s skin?

What would your approach be if John had obvious patches of flexural eczema?

  1. Clinical information gathering and interpretation
2   

From the clinical history, how would you make a diagnosis of scabies?

What differential diagnoses would you consider for John?

What if John was 50 years old and not an immigrant?

What if the patient was a female and pregnant?

  1. Making a diagnosis, decision making and reasoning
2   

What would be your general management plan for John?

What medication options would you consider and why?

If John came from a remote Aboriginal or Torres Strait Islander community, what would be your management approach?

  1. Clinical management and therapeutic reasoning
2   

What treatment and prevention strategies would you recommend to the family?

Considering John attends school and after school care, how would you manage this situation?

What might you need to consider if John was 90 years old and living in an aged care facility?

If John was living in the same house with his extended family and a newborn cousin, how would you approach this situation?

  1. Preventive and population health   
1,2,3

If John’s father does not want to tell other family members about the diagnosis so that they can be treated, what would be your approach?

If John’s father is not willing to tell the school and after school care of the diagnosis, how would you manage this?

  1. Professionalism
4   

How would you follow up to ensure John’s symptoms resolve and he is no longer infectious?

What practice policies would you review for following up with John?

  1. General practice systems and regulatory requirement
5   

If you are not sure about the reason for John’s itching, how would you do skin scraping to confirm the diagnosis?

  1. Procedural skills
2   

If the symptoms were less clear-cut and you were uncertain of the diagnosis, how would you manage this situation?

  1. Managing uncertainty
2   

What would your management approach be if a patient presents with crusted scabies?

What if the patient lived in an aged care facility?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Scabies should be considered in any patient presenting with an intensely itchy papular rash, especially if multiple family members are involved. Make sure you treat the whole family for lice and worm infestations.
  2. Always make sure to check tetanus immunisation status when a patient presents with an injury – except for clean and minor cuts, all other wounds are tetanus prone.
  3. Don’t forget the possibility of reactivation of latent tuberculosis in immigrants presenting with a chronic cough.
  4. Remember to assess vaccination status of patients who may be immunocompromised, as they may be more at risk of infection and may need a modified vaccination schedule. Also remember in immunocompromised patients that typical infections can present in an atypical way, for example, herpes zoster involving multiple dermatomes.
  5. In a chronic non-healing ulcer, consider Mycobacterium ulcerans as the causative agent.
  6. Building trust with parents and patients, being honest about possible side-effects, providing factual data and your own personal experience, and addressing patients’ concerns are good ways of addressing vaccine hesitancy.
  7. Explain to patients that most upper respiratory tract infections, tonsillitis and sinusitis are caused by viral infections and are not helped by antibiotics, which have significant side effects. This will help educate the patient and avoid unnecessary prescribing.

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify notifiable conditions and diseases under surveillance in Australia.

  • Were there any that surprised you or that you didn’t expect?
  • When do you need to notify diseases and conditions in the state or territory where you work? How can you make sure you fulfill your responsibilities to report these?
  • Do a reflection of your practice. How could your practice’s processes be improved, and how do you plan to improve your own practice?

Do an audit of 10 randomly selected patients for whom you prescribed an antibiotic. Compare your practice against the recommended guidelines; for example, the Therapeutic Guidelines.

  • Were there any instances that didn’t align with the recommendations? If so, what will you change next time?

Review the Australian STI management guidelines on chlamydia, syphilis and gonorrhoea. Learn more about:

    1. how to gather sensitive information, such as a sexual history
    2. how to do contact tracing
    3. the notification procedures in your state or territory
    4. the management guidelines.
  • Reflect on what you have learnt. Did anything surprise you? What will you do differently in your practice?
With a supervisor

With your supervisor, do a case note review of a catch-up appointment you planned to review a patient’s vaccination schedule. Alternatively, create a fictional patient in your practice software and role-play the consultation with your supervisor.

  • How did you plan the catch-up session?
  • How did you explore the reasons for delayed vaccination? If vaccine hesitancy was a reason, what resources did you use to overcome this barrier? Does your supervisor have any suggestions to manage this situation?
  • Reflect on your areas of strength, where you could improve, and how you plan to do better next time.

With your supervisor, review your practice’s infection control protocols. Compare this with the RACGP infection prevention and control standards. Discuss your findings with your supervisor.

  • What is your practice doing well? What ideas do you have for improvements? Are there any barriers that need to be overcome to implement these changes?

Do the following role play with your supervisor: A parent is hesitant about giving the measles vaccination to their child because they’ve read that measles vaccination causes autism in children. Address their vaccine hesitancy and explain the benefits of measles vaccination. Consider resources that could help to reduce their fears.

  • How do you think you went? What feedback did your supervisor give you? How will you use this feedback to improve?
In a small group

Role-play the following scenario and then discuss as a group. Ranil, a 44-year-old man from Sri Lanka, has decided to buy farmland in a rural area. He plans to have some livestock on his farm. He is here to consult you about any medical issues he needs to be aware of before he moves to his farm. Consider:

    1. what, if any, infections he is more likely to get
    2. what preventive management advice you could give him in terms of infectious diseases
    3. any important vaccinations he should receive
    4. how you would manage the situation if he does not want to receive any vaccines.
  • What was done well? What could be improved? Think about how you would handle this type of case in your practice.

Hold a teaching session on hand hygiene for practice staff:

    1. Identify your target audience.
    2. identify resources you can use to deliver the session.
    3. Consider different methods to deliver the session.
    4. Ask for feedback after the session.
  • What did you learn? What feedback did you receive?
  • What resources could you use to give to patients?

Role-play the following scenario, swapping roles, and then discuss as a group. Seven-year-old Sonia’s parents come to see you. One of her classmates has been diagnosed with meningococcal meningitis and they would like to get some information. Explain meningococcal meningitis to Sonia’s parents, including the risk of Sonia picking up the infection, how it can be prevented, how to manage close contacts, and what vaccinations would be advised.

  • What was done well? What could be improved?
With a friend or family member

Do the following role play with a family member or friend. They are 26 years old and come to see you about an upper respiratory tract infection (URTI). They ask for antibiotics just in case the infection gets worse. Counsel the ‘patient’ and think about what resources and evidence you could use to assure them that antibiotics are not needed to treat an URTI.

  • What resources did you find?
  • If the patient were an Aboriginal or Torres Island Strait Islander, what different strategies might you use?
  • What if they were from a non-English speaking background? What resources would you use to convey the information?

Ask different friends and family about any vaccinations they have had in the past few years. Did they have any reactions? If so, did that change what they think about vaccination? Did they keep a record of their vaccinations? If they were to apply for a job where they have to list the vaccines they’ve had, do they know how/where to find out?

  • What did you learn? Will this information change anything you do in your practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Assess and manage a patient presenting with fever of unknown origin.
  • Assess and manage a patient presenting with fever with rash.
  • Formulate a differential diagnosis list in a patient presenting with lymphadenitis and painful lymph node swelling.
  • Assess and manage a patient with a suspected COVID-19 infection.
  • Take a focused history, clinically examine and manage a patient presenting with an infection affecting the following systems:
    • eye
    • upper respiratory tract
    • lower respiratory tract
    • urinary tract
    • intra-abdomen
    • central nervous system
    • gastrointestinal system
    • bones and joints
    • sexually transmitted and genital tract
    • liver
    • skin and soft tissues
    • heart
    • blood-borne infections such as hepatitis C.
  • Recognise and investigate a patient presenting with clinical features suggestive of sepsis-like fever, tachycardia and low blood pressure.
  • Describe common infections and their prevention in high-risk populations:
    • people in contact with the criminal justice system
    • refugees and migrants
    • Aboriginal and Torres Strait Islander peoples
    • individuals living in overcrowded housing
    • immunocompromised patients
    • pregnant women
    • LGBTIQ+ people
    • high-risk occupations, such as working with livestock.
  • Identify infections that a patient can acquire while visiting a general practice (eg influenza, COVID-19).
  • Identify and manage a patient presenting with a notifiable disease (eg pertussis).
  • Manage a patient presenting with a needle stick injury, including notification, investigation, review of infection control procedures and addressing medico-legal aspects.
  • Take a focused history, clinically examine and manage patients presenting with vaccine-preventable diseases:
    • measles
    • mumps
    • rubella
    • chicken pox
    • meningococcal infections
    • zoster and varicella
    • pertussis
    • pneumococcal disease
    • Q fever
    • rota virus
    • haemophilus
    • tuberculosis
    • monkeypox.
  •  Perform the following procedures:
    • blood culture
    • nasopharyngeal swab
    • high vaginal and cervical swabs
    • urethral swab
    • wound swab
    • urine dipstick and interpretation.
  •  Perform vaccinations:
    • Be familiar with current vaccination schedules.
    • Be familiar with routes of administering different vaccinations.
    • Counsel patients about vaccine reactions.
    • Manage vaccine reactions.
    • Document vaccinations in the electronic records.
    • Update vaccination records in the Australian childhood immunisation register.
    • Arrange recalls for further vaccination.
    • Understand (or be familiar with) cold chain requirements.
  • Be familiar with antimicrobial stewardship in a general practice setting.
  • Be familiar with infection control procedures and protocols in a general practice setting and any context in which a GP works, such as, residential aged care facility or hospital.
  • Be familiar with good hand-washing technique.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
An overview of the therapeutic approach to the common bacterial skin infections. This issue gives an overview of Q fever, leptospirosis, brucellosis and Australian bat lyssavirus infections. This issue has a number of useful articles related to vaccinations.
Textbooks
An overview of infections encountered in Aboriginal and Torres Strait Islander and refugee populations.
  • Murtagh J, Rosenblatt J, Coleman J, Murtagh C, editors. John Murtagh's General Practice, 7th edn. Sydney: McGraw Hill, 2018. (Available from the RACGP Library.)
    • Chapter 134: The health of Aboriginal and Torres Strait Islander peoples.
    • Chapter 135: Refugee health (infections in refugee populations).
Online resources
Clinical advice on the safest and most effective use of vaccines. Includes guidelines for management of different infectious diseases and choice of appropriate antibiotics. Resources for health professionals and patients, including education and training options, webinars on vaccination, patient resources and factsheets. Infection control standards in officed-based settlings, such as a general practice. A guide on supporting patients who have experienced COVID-19. Helpful websites with information about the benefits and risks of vaccination in childhood and pregnancy, set out in a very easy-to-read manner with infographics.
  • Murdoch Children's Research Institute. MumBubVax.
Learning activities
eLearning modules on the topic of infectious diseases.
  • The Royal Australian College of General Practitioners. gplearning:
    • Antibiotic use in children with acute otitis media.
    • check, unit 581, April 2021: Infectious disease
    • Identifying and managing Buruli ulcer.
    • Paediatrics and adult immunisation MCQs
A free online course about common respiratory tract infections and the use of antibiotics.
Other
This website aims to promote a national conversation about unnecessary tests, treatments and procedures. It has useful recommendations in relation to antibiotics.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/infectious-diseases 27/09/2022