Jovi Stuart
Welcome everyone to tonight's webinar, New South Wales Covid update. We are joined tonight by panellists, Dr Amanda Stephens, Dr Jeremy McAnulty, Dr Martina Gleeson, Dr Shannon Saad and our facilitator speaker, Professor Charlotte Hespe. My name is Jovi and I am your RACGP host for this webinar.
Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea in which we live and work, and we pay our respects to elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. I am dialling in from the traditional lands of the Cammeraygal people on Sydney's north shore.
I would like to formally introduce you to our speakers for this evening, Dr Amanda Stephens has had a diverse background with degrees in arts and medicine and a PhD in law. In her clinical practice, she was previously an ED Registrar and is currently working for the RPA Virtual Hospital. Amanda continues her academic interests and has also been recently appointed as a senior member of New South Wales Civil and Administrative Tribunal. Dr Shannon Saad is a community general practitioner and staff specialist in virtual healthcare in Sydney. Shannon has extensive experience in teaching and research in medical education, including the fields of healthcare, communication, clinical skills and clinical assessment. Dr Jeremy McAnulty is a public health physician and executive director of Health Protection, New South Wales and New South Wales Health, overseeing the state-wide public health aspects of communicable disease control and environmental health. Jeremy has previously headed New South Wales Health Covid Public Health Response Branch and has led and published on a range of public health investigations and responses. Jeremy holds a Master of Public Health and is trained with NSW Health Public Health Training Scheme and also the CDC's Epidemic Intelligence Service. Dr Martina Gleeson is a GP in the Sutherland Shire of Sydney. Martina is also the regional clinical advisor at the New South Wales Health Pathways. Last but certainly not the least, Professor Charlotte Hespe, who works part time in clinical general practice in Inner City Glebe as principal of a 16 GP group practice. Charlotte also works as head of General Practice and a primary care research for University of Notre Dame, Australia, School of Medicine in Sydney. Charlotte has held numerous positions at the college including Vice President, National OSCE Facilitator, expert committee member and examiner and is also former chair of NSW&ACT State faculty. I would like to hand over now to Charlotte who will go over the learning objectives for this evening. Over to you, Charlotte.
Professor Charlotte Hespe
Thank you so much, Jovi. Before I start, I would also like to acknowledge the traditional owners of the land that I am speaking from, which is the Gadigal people of the Eora Nation. On with the show nice and quickly, but it is really important to know that what we are aiming to be able to cover in this short hour is summarise current epidemiology on Covid and other viruses that are coming out to get us at this time of year, to explain how to appropriately use the referral pathways for GPs, look after our patients particularly with Covid and other illnesses using health pathways, outline treatments of patients for Covid-19 under the current recommendations given the recent changes and the vaccination guidelines, and basically have a good opportunity to think through how we are going to face winter coming up.
Next slide please, Jovi. At that point, I am going to rapidly hand over to Jeremy who is going to take us through all the current stats, the epidemiology and maybe talk about what we are about to face this coming winter. Thank you so much, Jeremy.
Dr Jeremy McAnulty
Thanks very much, Charlotte, and I too would to like to acknowledge the traditional custodians of the lands in which we are meeting here. I am going to talk about Covid and other winter respiratory infections that we see every winter and no doubt we will see in great numbers this winter and next. Let us just as a spoiler alert, the current situation is we are seeing relatively low levels of Covid-19 at the moment having seen a peak around Christmas and New Year. Influenza is relatively low at the moment and RSV activity is are pretty high and has been for the last little while. I am going to look at some how we know that and some of the indicators we follow. First for Covid.
Next slide. For each of these infections, we have a range of surveillance systems. One of our most useful for the respiratory group of infections is looking at number of people coming to emergency departments and whether they are admitted from the emergency departments. We have got around 88 emergency departments that we track in pretty much real time to look at the type of reasons people are coming into the to the ED and from that we can pull out certain conditions like the ones I am about to talk about. It gives a pretty good indication of the trends. This is first looking at Covid. The red line is admissions. The blue line is all presentations to EDs. The grey line is the proportion of presentations who get admitted to hospital. You can see that bounces up and down but it is pretty a stable proportion. It gives us a sense of whether the particular infection is getting more severe or not, which might be important for looking at different strains. For Covid, as I said earlier we saw a peak around Christmas, New Year and subsequently a decline. We tend to see with Covid a winter increase and then a summer increase. We do not know, of course, what is going to happen this winter, but there is a good bet that we will see an increase in Covid at some point, but we are always hopeful.
Next slide. This again shows us the same colours mean the same things, but a peak of presentations to EDs in winter around July last year and subsequently a steady decline. We are not seeing much flu at the moment but for all of these infections, we are continuing to see relatively low levels in the community, no doubt, because of international travel and some limited transmission.
Next slide. RSV.
Next slide. Some people talk about the big three winter infections and that is flu, Covid and RSV. RSV traditionally occurs in peaks before influenza but with the Covid lockdowns and lack of international travel some of those patterns got disrupted. We saw a lot more RSV than we had prepandemic, we are seeing a lot more in the post-pandemic years. You can see from this graph that cases peaked last year around April, then kind of very slowly declined. I should say these are presentations for bronchiolitis in children under 4. Bronchiolitis can be caused by a range of things but is largely caused by RSV in children and the pattern of presentations reflects very well the patterns of laboratory tests we see. You can see steady decline since about a year ago and then bottomed out around Christmas time but then we have seen a sharp increase since February.
Next slide. That was hospital ED presentations. We can also look at the number of tests that are done by laboratories and the proportion that tests positive. The proportion of tests that tests positive for each condition is a pretty good indicator of the activity. The higher proportion, the more cases we can see. This set of graphs looks at on the left hand side Covid, then influenza, then RSV and you can see just really to show you that the pattern the lab test reflects very well the pattern that we saw in those ED presentations. At the moment, we are seeing a relatively low but not zero positivity rate of around 5% for Covid. For influenza, it is low at around 4% and for RSV it is about 8%.
Next slide. Another way we track activities of these respiratory infections is by looking at what is happening in outbreaks in residential aged care facilities. These are pretty well reported to public health units and we can track what is happening over time. This graph shows a number of outbreaks across New South Wales. The red ones being Covid, the Navy ones being flu and the light blue ones being RSV. You can see overwhelmingly the number of outbreaks have been due to Covid. Aged care facilities are pretty good indicators because they have got relatively high rates of testing because they are looking out for symptomatic people. You can see the pattern for Covid at least reflects what is happening in the broader community as you would expect, similarly with RSV. Perhaps a bit surprisingly, influenza has not featured hugely in recent times, but in previous years was much more common cause.
Next slide. Now I wanted to touch on a couple of non-viral infections that we are just starting to see increasing in a rather concerning way. With Covid, of course, and the lack of travel and lockdowns, we saw very little of these infections, in fact, no cases of measles and very few cases of pertussis just because they were not spread. Prior to the pandemic lockdowns, for pertussis, we would see outbreaks every 3 to 5 years but now as you can see in this graph, we have seen a resurgence from the beginning of the end of last year. If you look at the colours there, school aged children 5 to 14 have the highest rates of infection followed by little kids. That is probably to do with waning immunity after vaccination when you are in the high school years. This is concerning. Of course, the problem is that pertussis can be spread to younger family members who are more vulnerable.
Next slide. Measles, similarly, we saw no cases during the Covid period, but beginning in 2022, we saw the occasional sporadic case. With the international Covid situation, we saw a decline in vaccination programs internationally. Sadly, now we have got raging epidemics of measles in many parts of the world, particularly parts of Asia, such as India, Pakistan, parts of the Middle East. We have seen increasing cases this year and a couple of incidents of transmission locally to close contacts. This is something we are really concerned about because epidemics of measles can easily take hold in under-vaccinated communities.
Next slide. Pneumonia in children. We know that this has increased significantly since just before Christmas, around November, December and has continued to increase with similar patterns having been seen internationally and like internationally, it appears that the cases in New South Wales of pneumonia are probably a mixed bag of things. One of the things that is unusual is mycoplasma has increased. We are seeing mycoplasma diagnoses increase in the laboratories and reflected here in these graphs with kids under 5 and 5 to 16 year olds both seeing an increase in presentations from pneumonia. Mycoplasma outbreaks tend to occur every three to seven years and so that is what we are likely seeing at the moment.
Next slide. Health practitioners, GPs have a particularly important role in some of these infections, particularly pertussis and measles. I just wanted to plug for a moment. For both conditions, it is about being aware of the diagnosis, doing the appropriate tests to confirm the diagnosis. For pertussis, early treatment with appropriate antibiotics reduces the infectiousness of the case, which is really important when there are vulnerable smaller children or pregnant women around and vaccination is important to promote. For measles, it is really a disease at the moment and hopefully stays the disease of travellers. Being aware when somebody presents with rash and fever to check their international travel history or whether they have been in contact with any cases. Please let the public health unit know right away if you suspect a measles case, take the appropriate testing and encouraging vaccination is really important.
Next slide. Now, I just want to touch on some of the what is happening with immunisation coverage and also a bit on treatment uptake for Covid. Influenza vaccine coverage. Historically, it has never been up there with measles vaccination rates but historically, we have probably got for people over 65, 70% plus vaccinated in some years. However, it has dropped off particularly last year. There appears to be a range of reasons for that, perhaps a bit of vaccine fatigue but last year we saw some pretty disappointing rates of vaccination for influenza. For people over 65, it was down to the mid 60s, and for children who have free recommended vaccine if they are under 5 down to just over a quarter of kids being vaccinated. We have been really disappointed at those low uptake rates given the severity that influenza has in those age groups and people may not appreciate just little kids have quite high rates of hospitalisation. We occasionally see deaths from influenza in little kids, but certainly quite frequently in older adults and adults with underlying medical conditions. Flu vaccine program is just being rolled out now, so really the message is try and while imperfect it is the best thing we have to prevent influenza, so really encouraging vaccination is important.
Next slide. Similarly, Covid vaccine while during the first part, when it first became available during the pandemic was very encouraging with very high rates, but again that has dropped off. These are vaccination rates in aged care facility residents who are now recommended to be vaccinated if they are over 75 every six months. We are seeing rates of vaccination in the last six months down to about just under 40% in New South Wales aged care facilities. We have got a big way to improve vaccination rates there.
Next. Just a single slide on antiviral uptake for Covid. This has been quite encouraging. We have seen quite high rates of vaccination use in people who are vulnerable and are eligible for antivirals. If you look at the number of scripts in this graph, it follows quite well the incidence of Covid in the community. There is some disappointing evidence that the uptake of scripts is much better in wealthier suburbs such as Northern Sydney compared to Southwestern Sydney, the poorer areas of the city. We will talk about soon the importance of making a plan with your patients, so they know what to do and when to get antivirals.
Next slide. Just briefly about some of the recommendations from a public health point of view. Influenza recommendations have been fairly stable for the last few years. ATAGI recommends anyone wanting to avoid flu get vaccinated if they are over 6 months of age, and you can see they are the usual people who we recommend have free vaccine through the National Immunisation Program in New South Wales. We also fund this year for the first time mental health service patients who in studies we have identified as having increased rates of hospitalisations from flu and other vaccine preventable diseases.
Next slide. The vaccine program is still run by the federal government but thankfully the recommendations from ATAGI for what doses should be given to who have been simplified in February, which is a great relief because they were quite complex until then. This table really summarises that if you are over 75 a vaccine every six months, if you are over 65 every 12 months, younger people can consider every 12 months and younger people not generally recommended but stronger recommendations if you have got severe immunocompromise.
Next slide. Some exciting news is about RSV. New vaccines have been developed. There is a new vaccine for adults that is available on the private market but it is not available through the National Immunisation Program at the moment. However, the thing that is available through New South Wales Health through the public system is the new monoclonal antibodies called Beyfortus which is a passive immunisation. It is a monoclonal antibody, provides protection for up to five months. There is an international difficulty with supply but New South Wales, Western Australia and Queensland have been managed to be able to secure a small volume. For New South Wales where rolling went out through private and public hospitals to those most vulnerable, children who are at risk of more severe disease.
Next slide. Here is a list. I will not go through it, but essentially premature babies, all Aboriginal and Torres Strait Islander babies and other children who are susceptible due to chronic lung disease, hemodynamic abnormalities and other conditions. That is an exciting program. RSV causes lots of nasty hospitalisations. This has good evidence that it will prevent those.
Next slide. In general, the public health advice for the community for winter is in aged care facilities trying to keep people safe through vaccination, infection control but getting the balance right, so people in aged care facilities continue to live healthy lives with good social connections, care and support. Encouraging that to get that balance right. In the general community, we have got a campaign coming up. It should be launched this week, I believe, targeting particularly pregnant women, carers of young children, elderly people and Aboriginal people about vaccination and things they can do to avoid serious disease.
My final slide. It is the key messages which are about staying up-to-date with all your vaccinations, staying at home if you are symptomatic. If you do need to go out, wear a mask. When Covid is common in the community, which is not now, but when it is moderate or high in the community, consider taking a RAT test before visiting vulnerable sites and when you have gatherings, do them in well-ventilated areas, reminding parents and patients that flu can be a very serious disease and vaccination is our best protection against it. Vaccine against Covid is still free and easy to get through your GP or pharmacist. Making sure you keep up-to-date with those recommended time slots for vaccination. Importantly, as we alluded to earlier, if you are vulnerable to severe disease, make sure you have a plan with your GP about what you do when you get symptoms of a respiratory infection, what tests you need to do, and are you eligible for antiviral, so we can minimise the delay in people getting treated because antivirals work very well. I will leave it there. Thank you very much and we will take questions later.
Professor Charlotte Hespe
Thank you so much, Jeremy. I would like to introduce Shannon to take over and talk to us about the RPA virtual hospital. Thank you Shannon.
Dr Shannon Saad
Thanks, Charlotte, and thanks everyone joining here from Gadigal Lands. I am a community GP and I also have the privilege part-time to work as a Staff Specialist in a virtual hospital. We were at RPA virtual. We are part of the Sydney Local Health District, and we come under New South Wales Health where the first virtual hospital that was established in Australia and the strategic objectives were to deliver more hospital level care in the community, and as such our medical staff consists both of general practice and general practice trainees and ED and other specialist groups. We have that nice interface between general practice as community specialists and our hospitalists. We are set up so that our care is delivered in the virtual environment so as you can see in the diagram there, we have got care pods set up. We have nursing staff who perform assessments and then refer on to our medical staff as appropriate. We deliver wearables to our community members so that we can monitor some of their vital signs and obs, and we also have an extended group of allied health within the virtual hospital, so physiotherapists, psychologists, social work dietitians. We wanted to enhance the patient experience by offering flexible and tailored care, and also we have a research imperative because what we are doing is new, it is cutting edge, it is innovation, and so in medicine we need a research base and an evidence base to build on what we do.
Next slide. Then you could see that we were established in February 2020, and with that in mind, we then rapidly were transformed, so our service then became a part of the care for people in the community with Covid-19. We cared for all the patients who were in the special health accommodation, all the people who had come back from overseas or were transiting boarders who had particular health needs and to be cared for during their quarantine period. We looked after thousands of people in the special health accommodation. We then became the Covid service for the state where we looked after over 28,000 Covid positive patients, a lot of them isolating at home, pregnant women in the special health accommodation and Aboriginal and Torres Strait Islander patients as well received support through our service through those Covid years and that burning platform, we were forced to make rapid, innovative changes without really understanding the consequences, we have evolved out of that that knowledge. We have we have examined our outcomes. We have looked at how our models of care performed under those circumstances, and out of that, we have now developed an acute respiratory model of care. The acute respiratory model of care that we now have in the virtual hospital, we do not just look after Covid, we look after Covid, flu, COPD exacerbations, all kinds of things, and these are patients who are referred into us either from emergency departments where the decision has been made. This is a patient who is borderline for needing admission. Is there a virtual service that can provide additional care and monitoring at home to make sure they are progressing and escalate them back to hospital as needed. We also receive community general practice referrals through the health pathways which Martina will take us through later, and there are probably other virtual health services like RPA virtual in your area that that may or may not be available, but they will be evolving because as I said, we were the first and I am sure there are many other virtual health services that are coming through spread throughout the state and throughout the country. Under the acute respiratory model of care, we have two levels. We have what we call level one who receive three times a day virtual nursing assessments and a virtual daily medical officer review, and then we have level two patients or patients who are less acute, who will have virtual nursing assessments twice a day and medical officer review are escalated as needed. The clinical reviews ideally occur via video, though we acknowledge that some of our patients have less access to the virtual environment. It does come along with a bit of social privilege to have the ability to have the device to connect the internet, access to connect that kind of thing, so ideally we do it by a video because then we can make virtual clinical assessments of patients. We can see their environments and GPs and myself as a GP too, a lot of us are doing these video assessments of our patients too. We are comfortable with that. We can see the respiratory rate of the patients, hydration status and get a general observation for themselves and their environment and how they are moving around in it. We use devices. We send out pulse oximeters to our patients which then of course can read the oxygen saturation and the heart rate and also their temperature. We send a thermometer in our packs out to our patients, and we check their clinical progress and review whether they need in-person care or face-to-face review. We are very lucky that patients can also in-reach into us. We have a 24x7 virtual care centre staffed by nursing staff 24 hours a day. Our medical cover is 8:30 a.m. to 11:00 p.m. I myself am on call this evening for the hospital, so if the junior medical officer who is on, if they have any concerns they will be calling me. Medications that we prescribe through the acute respiratory model of care, most of these medications, if they are not provided from the emergency department as people are discharged or if they have not been provided already by the community general practice, we will access medications through dispensing through the community pharmacies, and I think this is where we get into things that we have noticed about changes to oral antiviral prescribing.
Next page please. There have been changes to antiviral prescribing, and in particular the one that has impacted our health service is the changes that are available through public hospital services through the National Medical Stockpile. Previously, hospital emergency departments with people presenting with Covid who were able to be discharged could be discharged with supply provided from the national medical stockpile that is no longer going to be available from the 30th of April. If there are medications there, they can still be used, but they will no longer be being replenished. We have had to adjust our health service to make sure that we have alternative PBS supply available for our patients, and that would be include things like us ensuring that they have made appropriate telephone or video virtual consultation with their own GP to ensure they get the antiviral prescribing. Nurse practitioners are also able to access antivirals on prescription, and of course other alternatives are the emergency doctor's bag, the antiviral still are available to prescribers through the emergency doctor's bag for circumstances where usual and timely supply cannot be achieved in the community in urgent cases, so it is not merely a convenience, but it is a where there is an urgent imperative there, and then there are also health direct services. If patients cannot identify a PBS supply, the Health Direct Service Finder may direct patients to, for example, private telehealth providers, instant scripts for example, has a Covid assessment pathway. That is the first change to oral antiviral prescribing that to be aware of, and I think that will impact community general practice in that health services will be looking for GPS to have that facility available. The other changes to antiviral prescribing, the National Clinical Evidence Taskforce, which I have put there, the graphic that I have put there, this is a great resource still very clearly written some excellent diagrams and frameworks there for you to give you some risk stratification tools, but their advice is Paxlovid first line because of the greater efficacy that we have seen in the panoramic trials and they outline all that evidence in their website if you are interested in that sort of thing, but very well spelt out about why those recommendations are being made in the Omicron era post vaccinations. Backup of Lagevrio, of course, is still there if there is no other option and high risk of severe disease and no other option for any other sort of supply. If you do have the option of or knowing about your local health service, whether it will offer remdesivir, which is an IV in-patient, for example, in Sydney local health district where we have had patients who have called up our service and we have realised that they are not eligible or they cannot stop their medications to take Paxlovid and they are too high risk just to go with Lagevrio, we have organised inpatient admission for remdesivir infusions. Just a reminder to check that particular website for that that evidence, and of course there are the new PBS eligibility criteria. These seem to change fairly frequently in response to availability of medications and clinical evidence. There are new PBS eligibility criteria now in effect from March 2024, and we will outline those on the next page please. These are the new March 2024 eligible populations. A lot of this will be familiar to you, so the familiarity within five days of symptoms not of testing positive can be positive either RAT or PCR, but five days of symptom onset, mild-to-moderate disease, so disease not requiring hospitalisation is the sort of things to think about. The usual sorts of eligible populations outlined here on the left greater than 70 years, 50 to 69 has now reverted to the plus two risk factors, whereas for I think it was three or four months, maybe even six months, I cannot remember how long, but there was only one risk factor necessitated for people over 50. It is gone back to two risk factors. First Nations patients over 30 years need one risk factor and greater than 18 years with moderate-to-severe immunocompromise are an eligible population or greater than 18+ years with a previously hospitalised with Covid-19. There your general eligible populations and risk factors as you can imagine are very similar residential aged care, significant amounts of disability or frailty or geographic remoteness are also risk factors to take into mind when you are calculating those things, and of course there are other example risk factors, and I would always recommend you go and see the PBS fact sheet, or there is actually just to give it a little plug, there is actually an excellent CPD on oral treatments for Covid-19 prescribing information for GPs, which goes over every all of this in great detail, only an hour's worth, but if you feel the need to go and brush up again, that is an excellent CPD activity available on the RACGP website.
Dr Shannon Saad
Next slide to Dr Martina Gleeson.
Dr Martina Gleeson
Thanks very much, Shannon. My role is really to reinforce what everybody else is teaching and give you a suggestion for where you are going to find the information we are presenting tonight to reinforce your learning and jog your memory. There are a couple of health pathways that are available across New South Wales. One of them is the Covid Vaccination Pathway, which was updated yesterday, and it has a link to the ATAGI updated recommendations for the frequency of boosters depending on age groups and comorbidities and also under each of the individual vaccines, it is updated the information on the number of doses recommended for each vaccine for a primary course because that was recently changed by ATAGI, so if you have got someone coming in, they have never had a Covid vaccine before and you are not sure how many shots they have, you can go to Health Pathways to find out that information.
Next slide please Jovi. This is just a screenshot of the Covid vaccination pathway on the south eastern Sydney, but they all look the same, and that my hand drawn arrow is showing you where to find that ATAGI statement on the frequency of vaccines, and I have also circled the send feedback button because if you cannot find what you are looking for or if you find something that is inaccurate, we really value people sending feedback so that we can make sure that we keep the pathway updated, and if you click that send feedback button, it will get back to our clinical editors who are writing the pathways.
Next slide please. There is also the Covid-19 requests pathway, which should host the link to the virtual care teams if your region has them. Sydney has it, southeast Sydney has it, and I checked out the Covid pathways across New South Wales over the weekend and about half of our regions have documented a virtual care team like RPA virtual that can help you with your high risk patients that might need a little bit more monitoring than what you can provide.
Next slide please. This is what a Covid-19 request pathway looks like on Sydney and under respiratory assessment, other teams have called it virtual care teams, but you can find a link to the IPA Virtual Acute Respiratory Infection Service, and that will take you to where you need. That will show you the criteria and the contact details and how to refer your patient into that service.
Next slide. I just wanted to give you an example of how you can use health pathways for your winter respiratory illness planning. We have talked about the Covid-19 vaccination pathway. There is also an influenza immunisation pathway available across New South Wales, which includes the 2024 National Immunisation Program eligibility. We talked about people with comorbidities. I do not know if you remember, but last year obesity was one of the comorbidities you could use for a National Immunisation Program, influenza vaccine that has been taken off the list this year. There is also an immunisation in adults health pathway that has up-to-date information on other illnesses like RSV, Boostrix and Prevnar eligibility for people who are under the age of 70 but have comorbidities. Some of them are eligible for a funded Prevnar, and this change to Prevnar funding came through when we are all battling Covid and went under the radar a bit, so it is worth having a look at as well as information on the shingles vaccine.
Next slide please. When you are planning with your patients who are particularly at risk, so your elderly people or your patients who do have two comorbidities, we suggest you use the Covid-19 medications page to help you discuss that Covid-19 plan using the Pre-assessment action plan, and also in the oral antiviral section, there are some autofills that you can use for your clinical software to take you through the assessment process with your patient to determine which is the best antiviral for them. We also suggest you discuss the treatment of or post-exposure prophylaxis for household contacts of influenza who are at risk of severe disease or RACF residents because you can actually use oseltamivir at a half dose for grandma who is at home when mom has got the flu and grandma is at high risk to help prevent grandma getting the flu. Also suggest that you advise your patients to get some RATs for at home and if they can afford it, the combined influenza and Covid ones are good, and also consider giving some of your patients a pre-filled pathology form and a swab so that they can self-collect a PCR if you think they have likely to have Covid, but the RATs are turning up negative and you really want to give them antiviral medication if you can. Have a discussion about home equipment, if people have can access an oximeter or thermometer or even a BP monitor, they are often quite affordable and they help when they are monitoring themselves at home, and there is also a health pathway on COPD that has got a link to the COPD action plan, and it is always worthwhile making sure the patients who need those have got them current. Remind the patient even if you did it with them last year, remind them that they have it and they can refer to it should they get some kind of respiratory illness this winter?
Next slide. This is where you find the New South Wales Pre-Assessment Action plan for respiratory infections. That is going to be demonstrated on my next slide. It is going to be talked about again, but in the Covid-19 medications under our antivirals that is where you are going to find that form, and just underneath you can see when completing clinical software consider using auto fills, and there is links to those auto fills that we have designed for you.
Next slide. That is what the Pre-assessment action plan looks like and that is going to be discussed in the next talk. Thanks very much.
Professor Charlotte Hespe
Thank you. I would invite Amanda.
Dr Amanda Stephens
Thanks, Charlotte. Good evening everyone. Thank you so much. I know it is a mixed audience, so I apologise in advance if anything I say is a little bit simplistic, but Shannon and I just thought it would be a good way to talk about some of the cases that we have seen primarily Covid, but as she explained, we have now expanded our respiratory model as well. Some of those things have obviously helped us learn in other ways, and it is a rapidly evolving field. I am going to start telling you about Alice. Alice is a 38-year-old woman and she has been unwell for two days, and because you are her excellent GP and you have taught her the importance of testing, she swabbed her throat and her nose and it is come up positive. I want you to very quickly and we are not going to have long to do it, but if you could just throw in the chat if you would like to some ideas of the background information that you think it is important to know about for Alice. Otherwise you are just going to have to think about it while I keep talking, because we are going to want to get to some questions later as well. I am going to tell you that Alice is indigenous. She has got asthma. It has never been terribly well controlled. Her BMI is 38. She has got some mild chronic renal impairment. She has not, to her knowledge, had a previous Covid infection and her last vaccine was quite a long time ago now, it was over a year and a half at the stage. She is actually currently on some prednisone because she has had an exacerbation of her asthma. It has been a bit difficult to wean and she is on her inhalers as well. Obviously as part of background and we can never say this enough, particularly to our med students, this is such an important part of what we do and how we end up doing things. I am going to tell you that she lives with her three children and one of them has rheumatic heart disease. She has a boyfriend, is sexually active. She has got lots of extended family nearby, very supportive family. She works part time. She does smoke, but she does not drink or use any recreational drugs. Right now, what is happening for her, as I said, she has this two days of symptoms. She is a little bit lightheaded. She is really not eating much at all. However, she is drinking quite well and her urine output is good. She has lost her taste and her smell, and now hopefully that is just a short-term thing with some inflammation affecting the sensory epithelium, but as we know, long-term anosmia has been quite common as a post-Covid sequelae, and as we also know, damage to the olfactory bulb can be associated with the sort of degeneration that we see in things like early Alzheimer's or Parkinson's, so that is going to be something you are going to want to keep an eye on long-term for her, and thankfully, she has got no other respiratory or gastro symptoms at this point in time, and because you are her excellent GP, you have made sure that she has a few things at home to monitor her so you can tell that her obs are pretty good. Okay. Opening it up again, if you do not mind throwing a few things in that I want you to just think about, what are some of the things that we need to consider in treating Alice. One word answers is fine too.
Jovi Stuart
If you would like to write a response in the Q&A, you are welcome to.
Dr Amanda Stephens
If you are too shy, that is okay too. I just want you to have a think about what are you going to be thinking of?
The first thing we always think of is, does this patient need an acute face-to-face assessment, and we have got to think about well what are the parameters for that. When would we be telling her to go into emergency or to call an ambulance or to see or to be seen in person and so forth, and I showed you her obs, I showed you her history. Obviously she is very high risk, but to me there was nothing that suggested that she needs to be seen acutely right now, but it is really important that you have those parameters in place that we very clearly safety net these people so that they know exactly when and that is what Martina was talking about, of being prepared in advance so that patients are not scrambling to do this when they are unwell, but they have very clear parameters and they know when they need to be seeking help. If she is at home, then she needs some form of at home monitoring, and again Martina talked about there are some places you can get that sort of virtual care and we have been lucky enough to be able to offer that in our local health district, but if you do not have that, it is worth thinking about some other creative ways of doing it. Maybe there is somebody who she can call daily and let them know her obs and she gets trained to do them twice a day, that sort of thing, just something so that there is some ongoing progress for her, and obviously antivirals. Now the thing that is a little bit unique that we need to think about with her is, is she pregnant because of her age? And obviously we need to think about all the usual things as well, so we need to think about drug interactions. We need to think about renal function because as we said she has some mild renal impairment. Now, she does fit the criteria obviously because she is over 30, indigenous and high risk from both her BMI and from her moderate-to-severe asthma. This is actually quite a complex consent discussion, and again, if you can have aspects of that in advance rather than trying to do it on the hop when she is acutely unwell, that sort of thing is extremely helpful. We need to make sure her asthma is well controlled because we know she has already had an exacerbation, and this respiratory infection can definitely make it worse. One of the things that we can talk about that is very low cost, low toxicity, well tolerated treatment that may have some benefit not just symptomatically but may also play a role some evidence of decreased morbidity as well as increased viral clearance is just a very bog standard old fashioned saline rinse, and that can be something really useful for patients as well, and in the same vein, mouth or throat gargles with either saline or perhaps with cetylpyridinium chloride, which has got some antiviral properties and again has been shown to possibly speed up some viral clearance, so some very easy low toxicity things that you can talk about with her. Antihistamines possibly could play a role, again something just to think about as they can also potentially help symptomatically, and there is some early lab and possibly clinical data that there may also be some help in terms of suppressing inflammation and speeding up viral clearance there as well, and obviously really importantly for this woman is how are we going to care for these children given she has particularly a very vulnerable child and her extended family are likely to be vulnerable as well. I am sure you have all seen this, but just in case you have not. This is obviously a really quick, easy way that we can plug in our medications to check for interactions, and when we do that with prednisolone, we can see that, yes, there is a possible interaction because of the metabolism of CYP3A4, and you could get increased concentration of the prednisolone, but it is unlikely to be clinically significant with this short duration of treatment, so it is not really a problem, although with some patients, if they are on very large doses, you might want to have a chat with them about how it might increase those prednisolone side effects. Okay, Tina, she is 75. She is Greek speaking and she is confused and febrile and her daughter is down a RAT. Again, I think I might just speed through it, but just have a think about, what do you want to know for these people? What is important to know. Tina has your classic history of high cholesterol, high blood pressure. There is some possible dementia. Her daughter said that at the beginning of 2022, she started to forget a few things, and then she had an infection of Covid in July 2022, and even though she had quite a good acute illness progression that afterwards she just seemed to be not quite herself and had a lot more forgetfulness, more apathy and not dealing so well, so quite a common story, as you would well know. She is currently on atorvastatin and lisinopril and metoprolol. She is widowed. She lives alone, but she is lucky she has got her son and daughter who drop by every day. She is independent with showering and toileting. She needs help with cleaning. She can walk around, so really functionally, she is pretty good despite this dementia, but right now she is confused. She is oriented to person, but not to place or time, and it is unusual for her not to know where she is in particular. The patient says she thinks she has a sore throat. She says she does not have a cough, but she is actively coughing in front of you. She says she has not got any chest pain and no one has noticed any vomiting or diarrhoea. You cannot tell how much she is eating because she really cannot tell you, but her daughter says she left her meal from last night untouched. You are really quite worried. She is probably not eating or drinking very well at all, and again, you have set her up well. She is well prepared. She has got these obs at home and you can tell that you are a little bit worried because her blood pressure in particular a little bit on the low side. Heart rate is a little bit up. What are we going to do for her? Again, the first question is, are we going to do face-to-face assessment, and I would argue that here, you know, really you would want to have a think about it because she is delirious. She is very high risk, and you are worried about her oral and fluid intake in particular, and she is a little bit tacky and a little bit hypertensive. However, if she is discharged from emergency, when she has gone in and had her ECG, chest x ray and bloods and she goes home, or if the daughter really does not want her to go in, then she is still going to need some really good at home monitoring, and again, it is thinking about a creative way to do that if you do not have that sort of virtual support. She is eligible for antivirals very easily as Shannon talked about, and you would want to just make sure in terms of making sure her renal function is okay. She might not be able to comply with the rinses because if she is that delirious, then there may be a risk of aspiration. It may not actually benefit her, but that is really very much a judgement call, and of course she is going to require more care than usual. She does have also have a drug interaction and you all know about the statin one, but with atorvastatin, even though one of the recommendations is that you could consider stopping it and start again three days later, there is also a suggestion in the drug checker that you could just drop to the lowest dose possible, and that is because we know that the increased risk of cardiovascular events with Covid is really quite significant, and so there have been some guidelines that have suggested around the world that you might want to continue at the lowest dose possible, but it is either way that drug checker can give you that information and making that decision, but of course there is that risk of continuing it of myelitis and so forth.
Okay, so very quickly, what are some of the things that the pandemic has taught us? And of course, I am not saying the pandemic is over because as Jeremy has quite clearly demonstrated it is not and will continue to learn more and more each day, but we have learnt a lot from treating an enormous number of Covid patients and now lots of other respiratory patients as well, and so we just wanted to share some of those with you, and I think one of the biggest ones is that as doctors, we are actually in a really privileged position where we can actually be that face of public health messaging and talk to our patients and have those chats about prevention, so talk to them about getting their vaccinations, talk to them about really simple ways of having clean air, gathering outside or opening windows. Some patients you can talk even about HEPA filtration which have multiple benefits in terms of mould and dust and bushfire smoke as well, talking to them about how well fitted masks protect them better in indoor spaces, talking to them about how to test, making sure that patients know the high false negative rate with a RAT, especially if you only swab your nose and when to seek PCR as well, and that is what Martina was showing you with that pathway of how to talk to patients about this in advance and as well as obviously preventing infections, you want tertiary prevention as well, so you want to make sure that you are trying to reduce the sequelae from this, and that is where those important things such as vaccination or really simple things like saline rinses etc come into play. Taught us about the importance of preparation, and I know we have all talked about this a little bit, but this is just really important of making sure that you know what the plan is going to be in advance so that if those preventions fail and they are infected, well, what do we do about it to there to reduce the morbidity and mortality for them, and one of the things that we often think about is making sure that patients have a bit of a viral pack for them at home, so not only their regular medications, but is there a way they can have something set aside if they can afford to do so where they have got things like paracetamol and hydralyte and so forth ready for if they do become unwell, and this is again just briefly, that is the link to the thing that Martina was talking about the Pre-assessment action plan, and finally we have learnt that because of the increased morbidity, particularly in terms of cardiovascular disease and cerebrovascular disease with Covid, that it is just really important to discuss that with patients to have those screening where you can to make sure that you are maximising control of all those other risk factors like diabetes and high blood pressure, and to make sure that patients are aware and educated so that they take their symptoms seriously, and we all know those patients who battle on and think it is heartburn when in fact it could be an ischaemic event, so just making sure that patients are aware and so know when they should be seeking help with that increased risk after that. I think that is very whirlwind trip, but hopefully that is just giving you an idea of some of the things that we have gone through. Thank you.
Professor Charlotte Hespe
Thank you so much, Amanda. Thank you everybody. We have had an amazing journey of some learnings. We have got a very short amount of time before the end in terms of being able to do questions. I might just very quickly say that the summary is I think that we need to be mindful that Covid, flu and RSV are on the rise, that we need to therefore be have a plan in place for making sure that we maximise the vaccination rates for everybody, babies included. That vulnerable babies are qualified and that there are changes to the guidelines and the vaccination rates. If you have forgotten what they are, go to health pathways. Health pathways will also give us all a plan and in particular if you have got aged care facility patients, it is really, really useful to have that plan in place. I am just going to quickly ask Jeremy, do you want to have a little bit of a quick comment around the vaccine rates in terms of reducing infection, and also, is there a new Covid vaccine coming out?
Dr Jeremy McAnulty
The second question, I do not know the answer to that, I am ashamed to say. Manufacturers are continually looking at improving them and matching the strains, but I cannot answer that. I am sorry. The first question is about what I think the vaccine does to your severity.
Professor Charlotte Hespe
Does it actually decrease your transmission rate? So I do not think it was rather than saying does it decrease your ability to getting infected, but do you also have a less likelihood of spreading it?
Dr Jeremy McAnulty
I cannot answer that specifically. My understanding is that it certainly does reduce the severity of the disease, and that is the main benefit. That is why we are seeing less deaths and hospitalisations, particularly in people with underlying disease in the elderly. In terms of whether it reduces transmission, my understanding is that it does so, but only for a short period, and that is why we see ongoing epidemics every six months or so. The benefit is the protection against severe disease.
Professor Charlotte Hespe
Absolutely, and good reminder to all of our vulnerable patients, and certainly I think people have got vaccine fatigue, so we need to continue to remind them about the benefits that vaccine has been provided, and we have also got the RSV vaccine for adults, which is now privately available and is really worthwhile talking to patients who you think are likely to be affected knowing that although we talk a lot in general practice about children, in actual fact it causes as many hospitalisations and reasons for admission to ICU in the over 75 who are very vulnerable, so please, it is a worthwhile conversation having, do not prejudge patients on what sources they want to do.
Dr Martina Gleeson
I just wanted to add on the RSV. Hospitalisation with RSV is associated with cognitive decline, and decline in ECoG status, so it is really worthwhile trying to prevent if we can.
Professor Charlotte Hespe
Thanks, Martina, and it is actually not just cognitive decline, it is actually decline across the whole spectrum that we know that frailty goes up considerably after RSV in the vulnerable. They are more likely not to be able to return home and it increases cardiovascular deaths. It is not an insignificant illness I think just because we have not had treatment nor a vaccine, I think we have sort of ignored it, but now we do not need to ignore it, we have vaccine, which is very effective and more effective than the vaccine for worth looking at. I am going to hand over to Jovi who is going to tell you about what next?
Jovi Stuart
Thank you Charlotte. I would like to extend my thanks to, of course, Charlotte, Jeremy, Shannon, Martin and Amanda and also everyone that has joined us online tonight. We hope you enjoyed tonight's presentation, and the rest of your evening. Just a reminder that as this is a CPD accredited activity and to be allocated your CPD hour, you must complete the survey. Following this webinar, a copy of the presentation will be emailed to your email address tomorrow morning, and of course, if you have missed any parts of this webinar, recording will be available on the website within the next week. This is a two-part series of a Covid update, and the next webinar will be on post-acute and antivirals in two weeks, 29th of April and a Monday at the same time 7:30. You can register via the RACGP website and also on the resources that we will be sending out tomorrow. Thank you everyone and good night.