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The Health Wrap: latest news in infectious diseases, pain management, health costs and snakebite

In this latest edition of The Health Wrap, Associate Professor Lesley Russell reports on the continuing scourge of infectious diseases, the need to improve chronic pain management, and some under-recognised costs of obesity.

Russell also details a new report comparing Australia’s health expenditure with that of other OECD countries, and efforts to put snakebite on the global public health agenda. And don’t miss the happy landing.


Lesley Russell writes:

I started out as a lab bench scientist with expertise in infectious diseases, so I’m always paying attention to what is happening in that space.

If you share my interest, I recommend you follow Dr Ian Mackay (@MackayIM) who always has interesting data cleverly presented on Twitter.

Ebola

In January I reported on the growing outbreak of Ebola in the Democratic Republic of the Congo. Unfortunately, things since then have got much worse. The number of cases continues to grow (this is now the second largest outbreak in history), the disease has spread and there are growing attacks against healthcare workers.

The World Health Organization (WHO) reports that as of 28 May 2019, there have been 1,945 Ebola cases and 1,302 deaths (a fatality ratio 67 percent). Fifty-eight percent of victims were female and 29 percent were children (aged less than 18 years). The number of healthcare workers affected has risen to 108 (six percent of total cases).

The DR Congo outbreak, which began last August, affects primarily the country’s north-eastern provinces of North Kivu and Ituri; these two provinces are among the most populous in the country and border Uganda, Rwanda and South Sudan.

The disease has proved difficult to bring under control because of remote locations, sporadic violence by armed militias, community mistrust and violent attacks on healthcare workers. Last month, the WHO said this outbreak was taking place in one of the “most challenging circumstances ever confronted by WHO.”

There have been more than 170 attacks on treatment centres and healthcare workers since January. A recent National Public Radio program highlighted the threats that responders in the Ebola zone constantly face and a second NPR program looked at what and who is generating these attacks.

Doctors Without Borders (Medecins Sans Frontieres) staff have been badly attacked, prompting the group to suspend work in some Ebola-hit areas. You can read MSF reports on the crisis here.

Attempts to contain the Ebola outbreak hinge on the successful deployment of an experimental vaccine. To date, some 130,000 people have been vaccinated.

Still unlicensed, the vaccine, V920 –  made by Merck, has been deployed on “compassionate use” grounds, beginning soon after the current outbreak was officially declared last year. It has  proved highly effective, delivering close to 100 percent protection for the more than 129,000 people vaccinated.

There is a “ring vaccination” strategy: by forming a “ring” of immunity around a confirmed case, the disease is less likely to spread. But to be effective, this strategy requires investigating every single case of Ebola to identify each person who might have been in contact with them – a time-consuming system known as “contact tracing”. This also requires community cooperation.

The targeted vaccination has caused some confusion in certain communities where people see some members getting vaccinated but not others, so there has recently been some modifications of the original strategy.

In addition, in the face of concerns about vaccine shortage, doses have been cut – from the current 1ml to 0.5 ml for first- and second-level contacts, and down to 0.2 ml for the third-level contacts.

Measles

This week the Centers for Disease Control and Prevention (CDC) announced that the number of measles cases in the United States this year had surpassed 1,000. This is the highest number of cases since 1992 and puts the nation at further risk of losing its status of having “eliminated” the disease.

The majority of Americans cases involve unvaccinated children and most cases can be traced to unvaccinated travellers who have brought measles back from overseas.

That same threat now faces Australia. This week there were two reports of measles cases in people flying into Australia: one case was a child flying in from the Philippines and the other case a man who had visited Bangladesh.

These alerts bring the total number of measles cases in NSW to 36, including eight children under the age of five. Nationally, as of the beginning of June, there have been 127 confirmed cases of measles, compared to 103 for the whole of 2018 and 81 for the whole of 2017.  Just five years ago, Australia was declared measles-free.

Data from WHO show why Australian travellers must be careful and ensure their vaccinations are up-to-date. To date in 2019, there have been 21,905 suspected cases in the Western Pacific Region and 28,037 in the South-East Asian Region. Some of the most affected countries include India (19,544), the Philippines (7,518) and Thailand (5,784).

Measles is so contagious that if one person has it, up to 90 percent of the people close to that person who are not immune will also become infected.

There is a sobering long read in the The Sydney Morning Herald on the reluctance of many families in the area around Byron Bay (“the anti-vaxxer capital of Australia”) to have their children vaccinated and the social antipathies that result.

Influenza

Hopefully by now everyone reading this has had their annual flu vaccination, because it seems we are headed for a nasty flu-ridden winter.

Flu cases have surged, with 40,000 laboratory-confirmed cases of influenza in 2019 so far, almost three times the number recorded at the same time in recent years.

In NSW alone the flu has killed 49 people so far this year, with six deaths and 2,345 newly confirmed flu cases recorded in just the week ending June 2.  And this could be just the tip of the iceberg as many cases go un-reported.

So far in 2019, 119 influenza-associated deaths have been notified nationally, but this does not represent the true mortality associated with this disease. Experts are predicting about two million people would get the flu this year and there will be some 4,000 deaths as a result.

This year there is a mix of two subtypes of flu Type A and one of flu Type B circulating.


The often unrecognised costs of obesity

The growing cost of obesity to the healthcare system is well recognised; without needed action, the economic burden of treating obesity-related diseases in Australia is estimated to be $21 billion by 2025.

But there are some costs that are not so obvious. Hospitals must increasingly supersize if they are to meet the challenge of caring for obese patients – everything from beds, trollies and wheelchairs to toilets and syringe sizes.

A newspaper article I came across about the new Bendigo Health hospital (opened in 2016), highlighted this and provides a striking snapshot into the future (although some might counter that the future is now).

It has 27 custom-designed “bariatric” rooms, exclusively to be used by obese patients. These rooms, each costing $266,000, are four square metres larger than standard and equipped with a bigger, reinforced bed, a larger toilet, shower, wheelchair and trolley, and an electronically operated ceiling track hoist capable of moving patients weighing up to 300 kilograms. The equipment costs for such rooms ($30,000) are more than three times that of a standard room.

Special equipment is also needed for the surgical and medical treatment of obese patients. This includes scanners with wider holes and stronger tables, longer needles to deliver injections into thicker arms, equipment to locate veins in patients whose fat obscures their vascular access, and special surgical tools to gain access to abdominal cavities.

There is growing recognition of the special attention that must be paid to the treatment of obese patients. For example, there are limitations on the effectiveness of abdominal ultrasounds and diagnostic quality X-rays require technical adjustments.

Sadly, despite all of this investment in equipment costs, there is evidence that obese patients often get poorer treatment and have poorer outcomes.

Some of this relates to discrimination – doctors who don’t see past the obese person to their clinical need – and some relates to a failure of clinical guidelines.

For example, patients who are obese are more likely to die from cancer than those who are not. This may be partially due to how chemotherapy doses are determined and the failure to recognise that larger patients will need larger doses of chemotherapy. It is also difficult to effectively target radiation therapy in obese patients.

Recent data from an Australian public hospital found that 90 percent of patients having knee or hip replacements were obese or overweight (62 percent were obese, 28 percent were overweight). These patients were more resource intensive at every stage of their admission.

But although the (unidentified) hospital in question complained that rising rates of surgery for obese patients created “a very big bottleneck” and limited their ability to perform more elective surgeries, little is done to manage this situation.

The risk of osteoarthritis of the knee in overweight people is double that in people of normal weight; in obese people, it is four times as high. An estimated 43 percent of knee osteoarthritis and 53 percent of total knee replacements in Australia are due to obesity.

A paper published this year by Australian researchers estimated that, based on recent growth, the incidence of total hip and total knee replacements for osteoarthritis is estimated to rise by 276 percent and 208 percent, respectively, by 2030.

The total cost to the healthcare system would be $5.32 billion, the majority ($3.54 billion) to the private sector. Projected growth in obesity rates will result in 24,707 additional total knee replacements totalling $521 million.

The long waiting times for joint replacement surgery (especially in the public sector) are not effectively utilised to help patients – even at this stage it is not too late to intervene to prevent the need for surgery.

Arthritis Australia cites that up to 68 percent of those on elective surgery waiting lists have undertaken no prior conservative management except medication.

Their report Time to move: Osteoarthritis makes the case that better and wider implementation of a number of current multidisciplinary, conservative management strategies would result in substantial improvements in the care of people with osteoarthritis, including reduced waiting times for patients, improved clinical outcomes, increased uptake of conservative management, and more appropriate prioritisation of surgery in line with clinical need.

Moreover, results indicate that effective conservative management could remove around 13 percent of people from waiting lists because they no longer require surgery.


Australia’s heath expenditure

A report just out from the Australian Institute of Health and Welfare compares key measures of Australia’s health expenditure with that of other OECD countries during the period 2000–2016.

The AIHW’s publicity about this report make much of the facts that Australia’s health expenditure to GDP ratio has constantly been higher than the OECD median (9.2 percent vs 8.2 percent) and Australia’s health expenditure per person was higher than the OECD median ($6,661 vs $5,107).

In my nervous cynicism, and with memories of the 2014-15 Budget still fresh, I can just see how the Morrison Government might respond to this. Let’s hope the Cabinet reads the AIHW explanations!

The health expenditure to GDP ratio provides a measure of the contribution of a country’s health system to the overall economy. As such, it provides an indication of the size of the health system relative to the overall economic wealth of the country.

The faster increase of Australian’s health expenditure to GDP ratio compared with other OECD countries does not necessarily imply that the healthcare system is becoming less sustainable.

It is perhaps most useful to look at where the health spend goes. In 2016, Australia spent:

  • one percent of health expenditure on hospitals (15th highest, just slightly above the OECD median of 43.6 percent)
  • nine percent on ambulatory services (13th highest, OECD median 27 percent)
  • three percent on medical goods (23th highest, OECD median 18.9 percent)

Unfortunately, preventive health services are lumped into the “other” category with administrative costs, ancillary services etc and, interestingly, no commentary is provided on the section of the report that looks at the total health expenditure contributed by government and other financing mechanisms.

In 2016, the government and compulsory health insurance agreements contributed about 68 percent of the total health expenditure in Australia (OECD average was 75 percent).

A note for those who pay attention to the numbers: the figures in this report are generated according to the System of Health Accounts (SHA) 2011 framework used by the OECD.

This results in differences between Australian figures in this report and those derived from the Australian National Health Accounts, which are produced annually by the AIHW.


Behind the growing opioid crisis

We’ve heard a lot about opioid abuse in the United States – even President Trump has noticed – but there are very real reasons for Australia to be concerned too.

I wrote about America’s opioid crisis for Inside Story last year. The article is not too dated largely because, despite lots of talk, the Trump Administration has done little to address the crisis and indeed, their efforts to pull Obamacare apart have worsened the situation.

A report recently released by Pain Australia highlights the awful costs of a growing opioid crisis among people who suffer chronic pain. More than 3.2 million Australians are crippled by headache, back ache, arthritis and other chronic pain and the wait to see a pain specialist can be as long as four years.

There are only 316 pain specialists across the country and only one in every 100 people with chronic pain ever receives the multidisciplinary care they need.

For many people, pain killers are the only treatment they get, and there are heavy consequences: there were 823 deaths and 3011 hospitalisations for prescription opioid misuse in 2017-18, costing the health system $13.4 million. A further 10,756 Australians used medicines to treat opioid misuse the report found at a cost of $60 million.

The Australian Institute of Health and Welfare states that in 2016–17, 15.4 million prescriptions for 3.1 million people were dispensed for opioids (most commonly for oxycodone). All forms of opioids (including codeine and heroin) are addictive.

About 40,000 Australians used heroin in 2016-17 and about 715,000 people used pain-killers/analgesics and pharmaceutical opioids for illicit or non-medical purposes.

In a series published in The Lancet in April, which included work from Australian researchers,  inappropriate opioid prescribing after surgery is put forward as a major cause of the opioid epidemic (This issue was also discussed at a recent Choosing Wisely Australia conference, as reported by Marie McInerney).

Chronic pain occurs in 10 percent of surgical cases. It typically begins as acute postoperative pain that is difficult to control and develops into a persistent pain condition with features that are unresponsive to opioids.

To address the increased risk of opioid misuse for surgery patients The Lancet authors identified several strategies:

  • Specialised clinics for tapering patients off opioids after surgery
  • Drug monitoring policies
  • Improved medical training in opioid prescribing
  • New pain management methods including the use of alternative pain relief medication.

Following on from the American example, there is now discussion as to whether pharmaceutical companies should be sued for selling addictive products.

But more important than law-suits is ensuring that Australians get help to manage their chronic pain and their opioid addictions.

Health Minister Greg Hunt has indicated support and funding for a national action plan on chronic pain management and there was an election campaign commitment of $6.8 million to “improve understanding and management of pain by consumers and health professionals”.

It is also clear that more health professionals must be trained in pain management – yet another in the endless line of examples that highlight how much Health Workforce Australia is missed and needed (you might note that this is a recurrent theme of mine!).


Putting snakebite on the global agenda

In June 2018, shortly before his death, Kofi Annan wrote that snakebite is “the biggest public health crisis you have likely never heard of”.

Now, after decades of relative neglect, snakebite is on the global health agenda, as outlined in a recent issue of The Lancet.

Snakebites kill between 81,000 and 138,000 people annually and cause lasting disabilities in another 400,000 people. This is likely to be an underestimate as many bites and deaths go unrecorded.

The burden of snakebite death and disability is equal to that of prostate or cervical cancer and is greater than any other neglected tropical disease.

Yet investment into snakebite has been just £30 million ($54.6 million) between 2008 and 2017, with limited research, stagnating development of treatments, and declining access to antivenoms in many countries.

On May 23, WHO launched its global strategy, which aims to halve death and disability from snakebite by 2030 (you can access the WHO resources on snakebite here).

And on May 16, Wellcome launched a new £80 million program for snakebite, aiming to transform research to produce effective, safe, and accessible treatments for all.

In Australia there are around 3,000 snakebites each year, with recent figures showing around 550 hospitalisations and an average of two deaths per annum. Make sure you are aware of the best way to manage snakebite – advice from the Royal Flying Doctor Service here.


The good news story

It has to be the story about the 97-year old veteran who parachuted out of a plane 75 years after he took part in the D-Day invasion. His story is here.

There is a video of his perfect jump and his joy afterwards here, and a slightly longer version below.

Sadly, I couldn’t find a video of the take I saw on TV where he laughed with childish delight as he landed – you will have to use your imagination for that.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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