In this edition of The Health Wrap, Associate Professor Lesley Russell looks at shocking death rates from COVID-19 among children in Brazil, early thinking on the need for COVID-19 vaccine booster shots and how the pandemic has brought out the best and worst in Australia.
Away from COVID-19, Russell urges more focus on patient safety in primary care and on public health funding, in the US and here, plus much more.
Why are children in Brazil dying from COVID-19?
The perceived wisdom has been that children do not suffer severely from infection with coronavirus. But that is not the case in Brazil, Indonesia and India.
Brazil has been especially hard hit by the pandemic (it is among the three worst affected countries) and now data show COVID-19 is causing severe illness in young Brazilian children at levels not seen in other parts of the world.
As of late April, more than 67,000 children under the age of ten had been hospitalised and 2,200 of these children died from COVID-19; more than 900 of the fatalities occurred in children under the age of five.
In the United States, a country hit just as hard by the pandemic, only 113 children the age of five have died.
The higher mortality rates in young children in Brazil are thought to be related to the Gamma variant (previously called P.1); this variant is thought to be more infectious and lethal than the original strain.
It is also postulated that the high mortality may be due to poverty, crowded housing and poor access to healthcare services in these countries – plus the bias that COVID-19 is not a disease of young children and so it is not diagnosed and treated early.
There is also evidence that the Gamma variant in Brazil is leading to higher death rates among pregnant women and causing women with the virus to give birth to stillborn or premature babies.
By the beginning of May, 803 pregnant and postpartum deaths had been reported and authorities have warned women to delay pregnancy as alarm rises.
US experts Dr Peter J. Hotez and Dr Albert I. Ko wrote last week in The New York Times that in the modern history of catastrophic infectious diseases in Brazil, children often suffer the most in terms of deaths and disability.
When dengue epidemics emerged in 2007 and 2008, children accounted for more than half of the fatalities, they say. When pregnant women became infected with the Zika virus during an epidemic that began in 2015, more than 1,600 newborn Brazilian infants were born with devastating microcephaly birth defects, far more than in any other nation.
Respiratory viruses continue to disproportionately affect Brazil’s children, while hookworms and other intestinal parasites stunt childhood growth and development, especially in poor rural areas.
Vaccination efforts using a number of vaccines, including those from China and Russia, are proceeding apace; to date some 30 percent of the adult population has received at least one dose and 11 percent are fully vaccinated.
Coronavirus vaccine booster shots
Even as the Australia vaccination rollout lags so dreadfully, elsewhere public health and infectious disease experts are starting to discuss the need for booster shots to provide continued protection against coronavirus.
A recent article in The New York Times characterised these discussions as a lot of questions without any answers. At this stage it is not clear how long the protective effects of current vaccines (and coronavirus infection) will last and whether and how emerging variants of the coronavirus will change vaccination needs.
The US National Institutes of Health recently announced that it has begun a new clinical trial of people fully vaccinated — with any authorized vaccine — to see whether a booster of the Moderna (mRNA) vaccine will increase their antibodies and prolong protection against getting infected.
The trial will test whether people can mix and match shots when the need arises and whether there is an advantage — or a risk — in switching from one brand or vaccine technology to another. You can read more here (paywalled).
It’s possible that the protection from the less effective coronavirus vaccines will fade more quickly. The Chinese Sinopharm vaccine, which has an efficacy of 78 percent, may already be showing some signs of this decline. The United Arab Emirates and Bahrain are now offering boosters to people who received the Sinopharm vaccine to bolster their waning immunity.
The failure to quickly and fully vaccinate populations where the virus is still circulating is believed to put more pressure on the coronavirus to mutate. Current thinking is that until there is a significant reduction in SARS-CoV-2 circulation and COVID-19 disease it is likely that booster doses will be needed to provide full protection.
The pandemic highlights the best and the worst of Australia
These days I spend a lot of time explaining the magnificent work done by state public health departments in Victoria and New South Wales in tracking and containing coronavirus to public health colleagues in the United States – they are in awe of the capabilities.
And then I have to explain the vaccination chaos – and they are gobsmacked.
In many ways it’s the reverse in the United States, where President Biden has set a goal of 70 percent vaccinated by Independence Day, July 4. Already some 13 states have achieved this goal. The contrast between Trump and Biden highlights just how important political leadership and community efforts are in tackling the pandemic.
A recent article in The Conversation by Frank Bongiorno, Professor of History at the Australian National University, explored these issues. It looks at a series of polls that show trust in Australian governments increasing since January 2020.
Bongiorno sees Australians as broadly understanding, even agreeing with, many of the tough decisions Australian governments have made. But he also makes the point that: “If governments have pursued the utilitarian ethic of the greatest good for the greatest number, they might – indeed have – at times have been negligent and even callous concerning some minorities.”
Minorities here could include Australians stuck overseas and unable to return, international students without any supports, people with disabilities and in aged care and their carers, and casual workers.
Their treatment has been in stark contrast to that available to the rich and famous and politically well-connected who fly in and out of the country without restrictions.
Still, even as the Aussie egalitarian ideal is undermined, and in the face of continuing failures by the federal government on quarantine, vaccine purchases and the vaccination rollout, the majority of Australians have acted and continue to act for the public good.
Bongiorno concludes: “Despite the inevitable grumbles, government excesses, opportunistic posturing of this and that politician, a likely increase in racist bullying, and the odd protest from sovereign citizens and others – the existence of this surprisingly wide and deep well of social discipline is by far the most important thing that we’ve learned about Australians in the age of COVID.”
It’s what he has elsewhere called “an obedient nation of larrikins”. Now if we can just persuade all the larrikins to get vaccinated!
On that score, Professor David Isaacs, in an article in The Conversation, offers an encouraging take based on the history of vaccinations: “From smallpox to polio, vaccine rollouts have always had doubters. But they work in the end.”
Social experiments during the pandemic
Somewhat related to the previous topic is an interesting London School of Economics blog post which posits that the pandemic has been as intense a period of not just scientific research, but also socio-political experimentation.
Such policy experiments have been critically important in shaping advice on public behaviour on issues such as wearing a mask, practicing frequent hand washing, and maintaining social distance.
The author cites examples from the governments of Canada, the United States and the United Kingdom of experiments to test the impact of behaviourally-informed communication materials in encouraging adherence to key COVID-19 prevention behaviours.
There’s also evidence of governments using the results of past experiments seeking to increase the uptake of other recommended vaccinations to inform COVID-19 vaccination policy.
The blog post refers to policy experiments that have contributed to a vision of a post-pandemic world and cites the rise of urban cycling networks by municipalities looking to provide alternatives to public transport.
The rapid implementation of new cycling infrastructure offers a glimpse into how to rethink city planning to embrace cycling as a core component of urban transportation systems.
The pandemic has also provided an impetus to reconsider the working day and the working week. Spain will test the idea of a four-day work week as a means of improving work-life balance and reducing greenhouse gas emissions using a randomised control trial.
The article does not refer to what the pandemic has taught us about how readily seemingly intractable problems like homelessness and poverty can be addressed when there is the political will to do so. We have certainly seen this in Australia: I wrote about this in the February 14 edition of The Health Wrap.
The BMJ has just published an editorial on how the pandemic has forced governments to implement economic initiatives, such as basic income programmes, that previously would have been politically untenable. Once introduced, the data from these programs can highlight how universal basic oncome, or a variant, can help economic and health outcomes during the pandemic and beyond.
I should point out that there is considerable debate around some of these social experiments, particularly around those that involve children. An article in Wired discusses this in the context of the huge “natural experiment” around children returning to classrooms. In particular, the use of self-testing in some British schools has been quite controversial.
Quality and safety in primary care
A recent paper in BMJ Quality and Safety reports on a retrospective study of avoidable significant harm in primary care in England.
It found that there is likely to be a substantial burden of avoidable significant harm attributable to primary care. Three types of incidents accounted for more than 90 percent of the problems found: problems with diagnosis (60.8 percent); medication-related problems (25.7 percent); and delayed referrals (10.8 percent). In 79.7 percent of cases, the significant harm could have been avoided if evidence-based guidelines had been followed.
The authors suggest that improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.
Most research on patient safety is focused on hospital-based care. That is certainly true in Australia where we know little about patient safety in other healthcare settings.
Back in 2015, Dr Paresh Dawda and I wrote an article (sorry that most of this is behind a paywall) published in the Medical Journal of Australia entitled “Patient safety in primary care: more data and more action needed”. Little or nothing has changed in the six years since.
Our paper was published just after the Australian Primary Health Care Research Institute, where we both then worked, had commissioned and published a “Patient Safety Collaborative Manual” – an important piece of work that went nowhere, likely because APHCRI was defunded at the end of 2015.
The World Health Organization’s Technical Series for Safer Primary Care (to which Dr Dawda and I contributed a section on clinical transfers of care) has highlighted that major evidence gaps exist and robust high-quality epidemiological studies are needed to definitively establish the burden of unsafe primary care.
Harm from hospital-based care may be more visible, but given the vast volume of patient consultations that occur in primary care, the potential aggregate burden of harm should not be ignored.
In 2017 the Australian Commission on Quality and Safety in Health Care produced a consultation paper on “Patient Safety and Quality Improvement in Primary Care” as the first phase of a program of work to develop a national approach to support improvements in patient safety and quality in primary care.
You can read the response from the Consumer Health Forum of Australia here. However, it seems that nothing more has happened in the public domain. Behind the scenes the ACQSHC is developing national standards which are due for publication in 2021.
The Australian Institute of Health and Welfare published a snapshot report on quality and safety in July 2020. This focused on hospitals but did provide a breakdown of the rate of potentially avoidable deaths by Primary Health Network.
Potentially avoidable deaths are defined as deaths below the age of 75 from conditions that are potentially preventable through primary or hospital care and include surgical complications as well as conditions that could have been addressed through screening, good nutrition and healthy habits such as exercise.
The AIHW report makes the point that “differences in the quality of care highlight the importance of nationally consistent standards and transparent performance reporting.”
The only reference to this important topic I can find on the Department on Health website is from 2012, during the time of the last Labor Government, in the archived pages.
Late last month the Australian Institute of Health and Welfare released an online report on palliative care services.
Here are some relevant statistics from the report:
- The number of Medicare-subsidised palliative care services received by Australians in their own home almost doubled between 2015–16 and 2019–20 (but note this is from a very low base).
- Home visits for palliative care specialist services increased by an average of 18 percent annually over the 5-year period 2015-16 to 2019-20, with a total of 2240 patients receiving home visits in 2019–20.
- However most palliative care services were received in hospital, with these services increasing by 12 percent over the same 5-year period. In 2018-19, 83,430 hospitalisations were palliative-care related.
- 4 percent of all hospitalisations where the patient died received palliative care and 18.6 percent received other end-of-life care.
- One in 77 (1.3 percent) of aged care residents were assessed as requiring palliative care. There is no data as to whether they received these services.
- Only one in six acute care public hospitals had a hospice care unit.
- I in 1,000 GP encounters were palliative care related.
- In 2018 there were 271 palliative care physicians, of whom 63 percent were female, 70 percent worked in a hospital setting, and 83 percent worked in major cities. There were 3,528 palliative care nurses, with slightly more than half (52 percent) working in hospital settings.
These data indicate how much more needs to be done to allow all Australians who need and want palliative care services to be able to access them in the setting they prefer.
At the same time I was reading the AIHW report, I came across an article in the most recent edition of the Australian Health Review that highlighted how late recognition of dying can expose patients to active interventions and minimises timely palliative care.
The point is made that only 12 percent of patients who die in hospital have existing advance care plans. Recognition of death is predominantly within the last 48 hours of life, and 60 percent of patients continue to receive investigations and interventions during this time which often means the delay of symptom relief.
There is a National Palliative Care Strategy, issued in 2018, to guide improvement of palliative care across Australia and to provide a shared direction.
However, it seems the individual frameworks and strategies of the states take precedence (probably because of the key role of public hospitals) and so there is a lot of variation in services and their availability.
The Implementation Plan for the National Palliative Care Strategy was released in October 2020, and there is to be a monitoring and evaluation plan to support reporting on the progress of the Strategy (I don’t think this has been developed yet).
The final report from the Royal Commission into Aged Care Quality and Safety recommended:
- compulsory palliative care training for aged care workers
- comprehensive sector funding specifically including palliative care and end-of-life care
- a review of the Aged Care Quality Standards to regulate high quality palliative care in residential aged care
- access to multidisciplinary outreach services, and
- a new Aged Care Act that includes the right to access palliative care and end-of-life care.
The Government’s response to the report’s recommendations is simply to expand the Greater Choice for Home Palliative Care measure that has been trialled in eleven Primary Health Networks. This pilot measure was announced in March 2018 as part of the launch of the fifth edition of the National Palliative Care Standards, with funding of $8.3 million through to June 2020.
The evaluation plan for this pilot is here but I have not been able to find any other evaluation documents. There is $37.3 million over four years in the 2021-22 federal Budget to expand the Greater Choice for Home Palliative Care initiative to all PHNs.
The importance of social relationships
This is a theme that I return to often. I recently came across a paper published back in 2010 in PLOS Medicine that looks at the impact of social relations on mortality and morbidity.
I think the findings are extremely important – and I’m surprised they have not had more public attention. Perhaps this is because clinical services do not hold the solution?
This is a meta-analysis of 148 studies to determine the extent to which social relationships influence risk for mortality, which aspects of social relationships are most highly predictive, and which factors may moderate the risk.
The findings indicate that the influence of social relationships on mortality is comparable to well-established risk factors such as smoking and alcohol consumption and greater than other risk factors such as obesity and physical inactivity. The editors’ summary notes that these effects might be an under-estimate as many of the studies analysed did not look at the complexities of social isolation.
This understanding of the links between social connectedness and health has come to the fore in these pandemic times. There is quite a deal of recent media commentary on the topic of social isolation linked to the paper.
A Health Policy Brief in Health Affairs last year proposed that it should be considered in with other social determinants of health and considered across all governmental sectors including health, transportation, education, housing, employment, food and nutrition, and environment.
US push for public health funding – lessons for Australia
The Yale Global Health Justice Partnership and the Yale School of Public Health this month released “Confronting a Legacy of Scarcity: a plan for America’s re-investment in public health”.
This follows on the heels of a report from Trust for America’s Health “The impact of chronic underfunding on America’s Public Health System : Trends, risks and recommendations, 2020.”
As I read these reports I was struck by how applicable they were in Australia.
The background of scarcity in public health funding in the US is that, since fiscal year 2010, funding for state and local health departments has fallen by approximately 17 percent and the Centers for Disease Control and Prevention’s program level budget has remained roughly constant.
A 2019 study found an annual gap of $4.5 billion, or $13 per person, in the funding needed to adequately carry out essential public health activities across the United States.
There was a major attempt to secure a mandatory, sustainable funding stream for public health with the inclusion of the Prevention and Public Health Fund as part of the Affordable Care Act (Obamacare) but was quickly raided as other priorities took precedence.
If the fund had remained intact an additional $12 billion would have eventually flowed to local and state health departments since 2010. (Forgive me for proudly noting here that I worked on rolling out the provisions of the Prevention and Public Health Fund during my time working in the office of the US Surgeon General.)
It’s difficult to determine how much Australia currently spends on public health and how much more is need, but the gap is almost certainly substantial. The Australian Institute of Health and Welfare stopped reporting on public health spending in 2012.
The best, most recent data come from a 2017 report from researchers at LaTrobe University. They found that preventive health spending in Australia, by Commonwealth, state and territory health departments combined, totalled $2.1 billion in 2013-14 (1.34 percent of all healthcare spending).
This compares to $2.3 billion for 2008-09, as reported in the last AIHW report, released in 2011. There is no reason to believe this has increased recently and federal contributions have almost certainly declined.
The key recommendations from the Yale report:
- There should be a new mandatory funding stream, made available to states and localities, and insulated from attempts to shift funding away from public health. Mandatory funding should be used to provide a core set of essential public health services on an ongoing basis.
- Support for this (perhaps made easier by the experience of the pandemic) requires effective communications regarding the benefits of public health investment and bringing communities into discussions about how to shape a healthier future for the nation.
- There is significant work to be done building coalitions and fostering coordination with public health authorities in order to improve the social determinants of health.
- There is a role for discretionary funding to address specific issues, but there are problems because this is time-limited and renewal is always uncertain.
The bottom line from the report is that the US cannot afford to continue with business as usual. The steady erosion of funding has meant the loss of huge numbers from the trained workforce and a public health crisis that means the nation is vulnerable.
All of these findings are applicable in Australia.
The focus of this report is very clinical. I found these three dot points on public health and prevention:
- A concerted push for public health and prevention activities aimed at preventing illness from occurring.
- Prevention becomes a foundation of healthcare planning and design.
- Emphasis is placed on key environmental, social and moral determinants of health.
The AMA calls for five percent of the total health budget to be dedicated to illness prevention, for the establishment of an Australian version of the US CDC and for Medicare items to cover GPs delivering preventive health services.
The best of Croakey
The good news story
This is in fact a 20-year-old story made new again by a musical written in 2013 that is just opening in Sydney; “Come From Away” is a story of community and caring set against the backdrop of the heinous acts of 9/11, about thousands of passengers suddenly stranded in the small town of Newfoundland in Canada that welcomed them all.
I loved it because it had some lovely subtle digs about Americans’ failures (at least sometimes) to get things in perspective (or at least understand the perspectives in a small Newfoundland town).
I also loved how it highlighted compassion and thoughtfulness for those who need help, regardless of who they are and where they come from. Imagine being a Muslim on one of those stranded flights!
Try to see the show if you can – we all need a feel-good musical about the value of kindness.
And if you can’t get to the show, here is some reading you might enjoy:
The timeline of events portrayed in the show (and photos) is here.
A recent article about the story behind it all is here.
The Guardian also has a recent article, here.
There’s some more reading here, on how 9/11 turned Gander, “The Capitol of Kindness”, into a tourist destination. Or you might like to read the book “The Day the World Came to Town” by Jim Defede.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
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