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The Health Wrap: vaccination rollout, COVID and the brain, loneliness, health literacy, Indigenous workforce, 20-21 Budget, and more

The Health Wrap by Associate Professor Lesley Russell looks this fortnight at the vaccination rollout, COVID and the brain, pharmacists in primary health teams, loneliness, health literacy, Indigenous workforce strengths, 2021-22 Budget asks, and an Obama and Springsteen duet.

It comes amid breaking news that the Food and Drug Administration has authorised Johnson & Johnson’s single-shot COVID-19 vaccine for emergency use. This signals the beginning of a rollout of millions of doses of a third effective vaccine that could reach Americans by early next week, reports The New York Times.

STAT News reports that the vaccine, which has not yet been tested in children or adolescents and is for use in adults aged 18 and older, could offer a distinct advantage in the effort to vaccinate large swaths of the American public as quickly as possible.


Lesley Russell writes:

Australian news this past week has been all about coronavirus vaccinations rolling out. It’s so encouraging to see coronavirus infections under control (I had my first plane flight and my first escape from New South Wales in almost a year last week) and to imagine a time when we can get back to whatever the ‘new normal’ will be.

The early days of the vaccine roll-out have not been without their hiccups. To date these have been minor — if you call giving a 94 year-old four times the recommended dose minor, though this case has also, as Norman Swan and others have noted, revealed good practice in how the incorrect dose was revealed and followed up.

But frankly, after all the planning time they had, Australian governments can’t afford too many problems.

The data from Israel and the United Kingdom – both countries are making excellent progress in vaccination coverage – are rolling in and are very encouraging.

Israel is the exemplar here (perhaps it helps that there are elections due in March and Prime Minister Netanyahu’s government is under threat?).

As of February 17, more than 3.67 million Israelis (40 percent of the population) had received the first dose of the BioNTech-Pfizer mRNA vaccine and more than 28 percent had already received the second dose. Among those over 60, more than 80 percent  have already been vaccinated. Now anyone over the age of 16 can be vaccinated immediately.

The number of infections is falling significantly, especially among people older than 60, as preliminary analysis by the Weizmann Institute shows.

Astutely, Israel’s government has agreed to provide weekly data from the vaccination campaign to the manufacturers – something that is facilitated by the digitised health care system. In return, the manufacturers have committed to supplying Israel with vaccines until immunisation of 95 percent of the population is achieved.

A recent article asks the question “Who should be vaccinated first?” and compares the vaccine prioritisation strategies in Israel and European countries. The authors argue that following the Israeli approach of using broad criteria for prioritisation with fewer groups and a lower age threshold has several beneficial effects, including more manageable logistics and fewer roll-out delays, as well as potentially reducing pressure on hospitals.

A ready supply of vaccines would allow countries like Australia to implement broader criteria for vaccination going forward.

Total number of vaccination doses administered per 100 people in the total population. This is counted as a single dose, and may not equal the total number of people vaccinated, depending on the specific dose regime (e.g. people receive multiple doses): Our World in Data COVID vaccination data

COVID-19 brain drain

In the previous edition of The Health Wrap I wrote about the links between coronavirus and dementia. Quite early on neurological manifestations were reported for SARS-CoV-2 infections. Most common are headache, smell and taste disorders, delirium and cognitive dysfunction but other complications include ischemic stroke, haemorrhages and neuropsychiatric complications such as psychosis and mood disorders.

While coronaviruses primarily target the human respiratory system, they can also enter the central nervous system and may cause chronic disability. Scientists are increasingly looking at this in the estimated 10 percent of people who are Covid-19 “long-haulers.”

Many patients who recover from COVID-19, especially those who were in ICU and on ventilators, have symptoms like those associated with a brain injury. Some of these may relate to oxygen deficiency, but others appear to be linked to the infection.

Late last year the National Institutes of Health published a study of brain tissue from New Yorkers who died of COVID-19 and found areas of the brain where blood vessels were leaking and inflamed – the sort of damage that is usually associated with strokes and neuroinflammatory diseases. Many of these patients (mostly older) had died suddenly and with minimal respiratory symptoms. Interestingly, no virus was detected in the brain samples, but there is evidence, based on studies in mice, that the SARS-CoV-2 spike protein might cross the blood-brain barrier and thus wreak damage.

Now it is speculated that the increased risk for people with dementia of infection and death from coronavirus is because of dysfunction in the blood-brain barrier – this would explain the very high risk for patients with vascular dementias.  There is also a possibility that severe COVID-19 may increase the risk of developing Alzheimer’s disease.

Such findings highlight the urgent need for research to better understand “long COVID” and to find treatments, and to  expand healthcare services to cope with this new form of chronic illness.

Recently researchers from more than 30 countries have formed a consortium to study the long-term effects of COVID-19 on the brain.


Integrating pharmacists into primary care teams

Major drivers for healthcare reform are the huge burden of chronic disease, the lack of integration of care across the system and professions, and the growing number of preventable acute care services. Much has been written but little has been trialled and consequently, little progress made in addressing these problems.

A paper just published in the Medical Journal of Australia reports the results of the Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME) trial and offers a promising reform initiative.

The study, conducted in Brisbane, looked at the effect of a comprehensive, face-to-face medicine management consultation with a pharmacist integrated into general practice for patients with chronic conditions and multiple medications in the week immediately following their discharge from hospital. This is followed by a consultation with their GP and further pharmacist consultations as needed. The protocol has been previously published.

It’s a good place to start reform efforts. Patients with chronic conditions and those with five or more medications recently discharged from hospital after an acute illness are at high risk of being readmitted. A major contributory factor is that as many as 44 percent of patients do not follow medication changes initiated in hospital.

The research showed this care model was associated with a 31 percent lower combined incidence of hospital re‐admissions and ED presentations. The authors attributed this to:

  1. Timely and coordinated care provided by the pharmacist and GP.
  2. Clinical rapport and trust between the co‐located practitioners.
  3. The ability of the pharmacists to reconcile accessible general practice records with the hospital discharge medicine list.
  4. GPs having additional clinical information and tacit knowledge about their patients.

Significantly, there was a substantial net benefit to the healthcare system, with a return over 12 months of $31 per $1 invested.

Previous findings regarding medication review and reconciliation involving collaboration between pharmacists and GPs have been mixed (see for example this systematic review).

Large sums have been allocated to medication management reviews (admittedly not collaborative models) as part of every Community Pharmacy Agreement, with little to show for the value delivered. All the evaluations to date make the same observation: that the data “do not allow a conclusive determination to be made with regard to the clinical and cost-effectiveness.” (See for example this evaluation from 6thCPA). I could not determine the source of funding for this research.

This project was started in 2017 and is now complete. I do not know if it is continuing in the GP practices that were part of the research or if it has been expanded. Are there efforts to promulgate these findings? If not, it is a real waste of resources and a failure to implement research that could make a real difference to health outcomes and healthcare costs.

It’s a shame we do not see more co-operative efforts between general practice and pharmacy. In 2020 only 13 percent of GPs reported they worked in practices employing pharmacists.


On loneliness – again

The topic of loneliness and its impact on health and wellbeing is one I return to often – see, for example, here and here and here.

It’s an international problem, made worse by the exigencies of the coronavirus pandemic.

The United Kingdom has — sort of — been a leader here, with some excellent reports and initiatives starting with the 2017 report from the Jo Cox Commission on Loneliness, but a lack of consistent government policy has meant three Ministers for Loneliness in two years.

More recently the Campaign to End Loneliness has picked up the action. Their report “Promising Approaches Revisited”, released in October 2020, calls for urgent action by governments across the UK, health bodies, funders and service providers to better address the critical issue of loneliness in light of a national survey highlighting  the devastating impact of the pandemic.

This past week the Japanese Government, confronted with a rise in suicides in 2020, announced the appointment of a Minister for Loneliness.

Prime Minister Suga tapped minister Tetsushi Sakamoto, who is simultaneously in charge of combating the nation’s falling birth rate and revitalizing regional economies, for the new portfolio. Suga expressed concerns that “more women are feeling lonely and prone to suicide” and instructed Sakamoto to deliver “comprehensive” policies against loneliness.

With isolation tied to an array of social woes such as suicide, poverty and hikikomori (social recluses), the Japanese Cabinet Office has also established a task force to address the problem of loneliness across various ministries.

An article in the Sydney Morning Herald makes the case that Australia should consider taking similar action. In 2018, The Australian Loneliness Report found more than one in four Australians were lonely. That figure is surely higher now.


Equity and health literacy – and where is the National Preventive Health Strategy?

The February issue of the Health Promotion Journal of Australia, produced in partnership with the Northern Territory Primary Health Network, has 21 papers with a special focus on equity and health literacy.

These papers provide insights into the ways health literacy is understood, experienced and addressed among different communities, including Aboriginal and Torres Strait Islander people, immigrants, and people from low socio‐economic backgrounds.

As the editorial states, health literacy is increasingly viewed as a social determinant of health, and health literacy scholarship is now synonymous with discussions about health equity. But the emerging evidence is often inaccessible to policymakers, poorly utilised by health practitioners in clinical settings, and not available to inform public health advocacy efforts.

The authors use this quote, below, from the recent report from the Consumer Commission led by the Consumer Health Forum of Australia “Making Better Health Together: Optimising consumer‐centred health and social care for now and the future”:

The Commission calls for greater investment in health promotion, prevention and health literacy to make up a minimum of 5% of overall health expenditure … in order to address the social determinants of health and reduce inequities in health outcomes.”

In particular, they reference the fact that the consultation paper associated with the development of a National Preventive Health Strategy (the development of which seems to have completely slipped off the Morrison Government’s radar although it’s supposed to be finalised by March 2021) indicates that action to address health literacy is central to mobilising a robust preventative health approach and a reduction in health inequities throughout Australia.

There is also a need to help Australians acquire practical transferable skills to understand which information to trust and improve their health literacy.”

Nothing could be more important in these pandemic times and we look to protect and vaccinate the nation.


Culture of respect  transforms Indigenous healthcare

A recent paper in PLOS ONE demonstrates how positive patient outcomes and a strong Indigenous health workforce can be achieved when a health service has strong leadership, commits to an inclusive and enabling culture, facilitates two-way learning and develops specific support structures appropriate for Indigenous staff.

The study was undertaken as a component of the Centre of Research Excellence in Discovering Indigenous Strategies to improve Cancer Outcomes Via Engagement, Research Translation and Training (DISCOVER-TT CRE), based in Western Australia, and looks at the operations of two high-performing cancer services.

In-depth interviews of Indigenous and non-Indigenous hospital staff, Indigenous cancer patients and their family members revealed eight core themes successfully supporting the Indigenous workforce:

  1. Strong executive leadership.
  2. A proactive employment strategy.
  3. The existence of an Indigenous Health Unit.
  4. The role of the Indigenous Liaison Office (ILO).
  5. Multidisciplinary team inclusion, including ILO participation.
  6. Availability of professional development.
  7. A supportive work environment.
  8. A culture of respect.

Both these health services have an Indigenous-led Indigenous Health Unit, which is responsible for managing the ILOs, supporting Indigenous staff, designing and delivering cultural awareness training and quality improvement. Significantly, both of the units feel that they are afforded enough autonomy and independence to ensure that what they do is Indigenous led.

The ILO role is a valued and respected role within the multidisciplinary team where it is seen as important in care coordination, family and community involvement and patient advocacy.  Indigenous staff increased the cultural safety within the facilities through their presence and interactions with patients, but also through advising non-Indigenous staff.

This paper is well summarised here.


The best of Croakey

My Croakey colleague Jennifer Doggett has done a sterling job of reporting on the health budget submissions to the federal Treasury. So much hard work, some good policy recommendations (and often a fair slice of self-interest!) goes into these submissions which rarely get the attention from Government they deserve (by that I mean the best are too often ignored, the most self-serving are too often addressed).

My wish (along with some sustainable funding and resources for needed policy changes) is for more Budget transparency so policy wonks and budget tragics like me can track spending (and outcomes?) over time, a task that has become increasingly difficult.


The good news story

Okay, so this is not a health story but it will improve your mental wellbeing. Two of my favourite men – Barack Obama and Bruce Springsteen – shoot the breeze. They first met in 2008 and although they have very different backgrounds and careers, they formed a deep friendship. They plan eight podcasts “Renegades: Born in the USA”.

You can access the first of them (free) here.


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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