Delivering a Healthy WA
Disease WAtch

October 2013, Volume 17, Issue 3

Full issue

Changes to the community-associated MRSA program and what they mean for GPs

Methicillin-resistant Staphylococcus aureus (MRSA) are characterised as community-associated (CA-MRSA) or healthcare-associated (HA-MRSA) strains based on molecular typing. The strains can be further classified according to whether the gene for Panton-Valentine leukocidin (PVL) is present. PVL is a toxin that can be present in any S. aureus isolate and is associated with the destruction of white blood cells.

Compared to HA-MRSA strains, CA-MRSA strains have distinct clinical, epidemiological and bacteriological characteristics. CA-MRSA strains have adapted to survive and spread successfully in the community environment, often causing skin and soft-tissue infections in otherwise healthy people.

In 2007, microbiologists and scientists raised their concern to the Communicable Disease Control Directorate (CDCD) about the increasing incidence of PVL-positive cases of CA-MRSA in Western Australia (WA). Scientific literature at the time indicated that PVL-positive strains posed a greater threat than PVL-negative CA-MRSA strains due to inherently greater virulence. To minimise the impact of PVL-positive CA-MRSA in WA, an intensive “search and destroy” CA-MRSA control program was undertaken, coordinated by the CDCD. This program required follow-up of all cases of PVL-positive CA-MRSA by the public health units (PHUs), including screening of household contacts, and decolonisation of cases and those household contacts who screened positive.

Since its inception in January 2008, the program has been reviewed annually by an Expert Advisory Group (EAG) consisting of clinical and public health specialists. The rising numbers of notifications of CA-MRSA and the resource-intensive nature of the search and destroy program meant that it was unsustainable. The recommendations of the EAG have varied according to the scientific body of knowledge at the time and availability of resources. In particular, the level of direct involvement by PHUs and the CDCD in case follow-up has declined, and the list of CA-MRSA strains that were the targets of enhanced follow-up has changed. Since 2009, GPs who ordered tests that resulted in PVL-positive CA-MRSA isolates received a letter from the Department of Health advising them to decolonise their patient.

Notifications of methicillin-resistant Staphylococcus aureus (MRSA)in Western Australia, 2004 - 2012, by strain grouping (HA=healthcare-associated strains; CA= community-associated strains; PVL=Panton-Valentine leukocidin)

Notifications of methicillin-resistant Staphylococcus aureus (MRSA)in Western Australia, 2004 - 2012

Data source: Typing Laboratory, PathWest Laboratory Medicine and Australian Collaborating Centre for Enterococcus and Staphylococcal Species (ACCESS) Typing and Research

Current situation

Following a review in 2012, and in light of new evidence on the role of PVL1 and the increasing incidence of all CA-MRSA notifications in WA, the EAG recommended that the focus of the program be on all people who acquire CA-MRSA, not just those with PVL-positive strains. In addition, recommendations were made for the management of individuals identified with CA-MRSA strains that were rare in WA but considered to be of particular significance owing to their increased virulence, transmissibility, or pattern of antibiotic resistance.

The key changes to the program are:

  • All CA-MRSA strains will be targeted, not just PVL-positive strains.
  • CDCD staff will cease to be directly involved in the management of individuals with CA-MRSA infections.
  • All individuals identified with a CA-MRSA infection (around 5000 per year) will be sent a letter advising them to attend their primary healthcare provider if they have an active or recurrent infection. It will include an information sheet and explanatory letter for them to take to their healthcare provider.
  • Letters from the Department of Health will no longer be sent directly to the requesting GPs.
  • Decolonisation will now be recommended only when individuals or their household contacts have recurrent CA-MRSA (or staphylococcal-like) infections, are carers or healthcare workers, or are at increased risk for acquiring staphylococcal infection, such as those with chronic skin disorders, diabetes, peripheral vascular disease or immunosupression.
  • The recommended length of decolonisation treatment has been reduced from 10 days to 5 days, and will now include an additional skin antiseptic option.  

Additional recommendations have been made for individuals identified as having rare strains of CA-MRSA that pose a particular risk to public health. Both the individual and the requesting GP will receive an advisory letter. Decolonisation will be required for each of these cases, and screening for clearance is required at week 1 and week 12 post-decolonisation.

These strategies are designed to increase knowledge and awareness of CA-MRSA among consumers and primary healthcare providers to ensure CA-MRSA cases receive the correct management and antibiotic treatment, when required, to minimise the risk of recurrent infections and severe disease.

What the changes mean for GPs

GPs are likely to experience an increase in the number of patients presenting to discuss CA-MRSA infections due to an increase in the number of individuals being sent advisory letters.

Individuals who present with recurrent infections should be decolonised. Complex cases can be referred to a clinical microbiologist or infectious diseases physician via the usual referral pathway for management.

GPs who suspect that skin or soft-tissue infections are occurring in a closely-associated local group, such as a day-care centre, sporting group or dormitory, should inform their local Public Health Unit of a possible CA-MRSA outbreak.

Resources

A range of resources for both consumers and healthcare providers has been developed. It includes information sheets for consumers, guidelines for the medical management of skin and soft-tissue infections, appropriate antibiotic therapy and indications for decolonisation treatment.

For consumer and healthcare provider information visit Western Australia’s Department of Health website and read the Department of Health’s Information Circular on the Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) program in Western Australia.

Reference

  1. Shallcross L, Fragaszy E, Johnson A, Hayward A. The role of the Panton-Valentine leukocidin toxin in staphylococcal disease: a systematic review and meta-analysis. The Lancet, 2013; 13:43–54.

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Influenza activity update - 2013 winter season

Western Australia has experienced a relatively mild and late influenza season in 2013. To date (23 September) there have been 1613 notifications of laboratory-confirmed influenza.

At the same time in 2012 there had been 4998 notifications. As shown in Figure 1, notifications in 2013 have tracked similarly to the moderate seasons experienced in 2010 and 2011, with peak activity considerably lower and later than in 2012 and the 2009 pandemic season. Based on trends in notifications and other indicators, such as percentage of positive laboratory tests and influenza-like illness syndromic surveillance undertaken in sentinel general practices and hospital emergency departments, it appears that activity for 2013 is currently around the peak.

Figure 1 - Influenza notifications in Western Australia by week, 2009 to 22 September 2013

Figure 1 - Influenza notifications in Western Australia by week, 2009 to 22 September 2013

2012 was an early and intense season, associated with the re-establishment of influenza A/H3N2 virus as the dominant subtype (estimated 62% of detections), a significant increase in influenza B circulation (37%) and the virtual disappearance of the 2009 A/H1N1 pandemic virus (1%). To date in 2013, A/H3N2 has continued to be the major influenza virus circulating in WA (60%), along with a diminished level of influenza B virus (13%) and a moderate resurgence in 2009 A/H1N1 circulation (27%), as demonstrated in Figure 2. Interestingly, in other states, A/H1N1 has been the most frequently reported influenza A subtype this year, and influenza B virus has also been more common than in WA, particularly in Victoria.

Figure 2 - Trends in influenza virus detections at PathWest laboratories, by type and subtype for the 12 months to 22 September 2013

Figure 2 - Trends in influenza virus detections at PathWest laboratories, by type and subtype for the 12 months to 22 September 2013

Syndromic surveillance for influenza-like illness in sentinel general practices has also indicated that 2013 has been a relatively mild and late-peaking influenza season in WA, as shown in Figure 3. Hospital emergency department surveillance has demonstrated a similar pattern. Non-influenza viruses including respiratory syncytial virus, human metapneumovirus and parainfluenza viruses have contributed significantly to the overall burden of respiratory illness during winter, but are now in decline.

Figure 3 - Rate of influenza-like illness presentations to Sentinel Practitioners Network of WA by year, 2009 to 22 September 2013

Figure 3 - Rate of influenza-like illness presentations to Sentinel Practitioners Network of WA by year, 2009 to 22 September 2013.

Consistent with the lower burden of influenza in the community, as indicated by notification and syndromic surveillance data, there have been numerically fewer adverse outcomes recorded in 2013 compared to 2012. Although the proportion of notified cases hospitalised this year (25.2%) is similar to that recorded in 2012 (27%), in absolute terms there have been around 1000 fewer admissions of influenza cases to public hospitals. Similarly, while 27 and 33 deaths were identified in persons notified with influenza in 2011 and 2012, respectively, only 13 cases have been identified to date in 2013. Ten influenza outbreaks have been reported in residential aged-care facilities to this point in 2013, but there appears to have been relatively little spread within these facilities, probably reflecting generally high vaccine coverage in residents and effective control strategies, including infection control measures and use of oseltamivir for treatment of cases and targeted prophylaxis in other residents.

Virus surveillance has indicated continuing high sensitivity of circulating influenza virus strains to oseltamivir and a reasonably good match to the 2012 southern hemisphere trivalent influenza vaccine formulation.

Readers interested in further progress of the 2013 influenza season can access up-to-date surveillance data in the weekly Virus WAtch publication.

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Provider data give insight into vaccination rates

Australian Childhood Immunisation Register (ACIR) data, provided in April, show that childhood immunisation rates continue to be lower in Western Australia than in other Australian states and territories (Figure 1).

Information on immunisation providers for overdue children has been analysed to help strengthen strategies for improving childhood immunisation rates in WA.

Figure 1 - Percentage of children fully immunised, by age at 4th quarter 2012, by state or jurisdiction

Figure 1 - Percentage of children fully immunised, by age at 4th quarter 2012, by state or jurisdiction

In April 2013, 33,363 children in WA were recorded in ACIR as being overdue for vaccination by one or more months. The majority of these children had received their most recent vaccination from a GP (60.5%)(Figure 2). Fewer than 10% of overdue children had had their most recent vaccination at a community health centre, and 7.9% at a range of other providers (such as local government, hospitals and population health units). Close to 22% of overdue children were recorded on ACIR as having received no vaccinations.

In the remote public health regions of WA (Kimberley, Pilbara and Goldfields) the spread of “most recent previous provider” was different from the rest of the state, with community health centres being the most recent provider of vaccination for 50% of overdue children while GPs provided just 21.5% of most recent vaccinations (Figure 3). For the majority of overdue children in rural areas, GPs were the most recent provider (52%).

Overdue children who received their most recent vaccination from a metropolitan GP made up the largest group of overdue children in WA (54% of all overdue children). To achieve any significant improvement in WA immunisation rates, a greater proportion of this group of children will need to catch up with their missing vaccinations. GPs can help lift immunisation rates by recalling overdue children. In addition, the WA Health Department is developing a strategy for following up the families of children who have never been vaccinated, and who therefore have no previous provider recorded on ACIR.

Figure 2 - Number and percentage of children overdue, by most recent provider, all of WA

Figure 2 - Number and percentage of children overdue, by most recent provider, all of WA

Figure 3 - Percentage and number of overdue children, by region and provider type

Figure 3 - Percentage and number of overdue children, by region and provider type

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Checking the school entry immunisation status of children

Western Australia's Department of Health has developed an Immunisation Strategic Plan in an effort to turn around the State's low immunisation rates.

The plan is seeking to strengthen support and collaboration from agencies across health as well as other relevant parties including WA's Department of Education.

Australian Childhood Immunisation Register (ACIR) reports show that WA's lowest immunisation rate is in its four year olds so the Department's efforts to lift the State's immunisation rate will focus on this age group.

The new strategy will try to renew parents' commitment to immunisation at the point of school entry. It will encourage parents to check their child's immunisation records and catch up on any outstanding vaccinations.

The Department has been negotiating with the WA Department of Education to inculcate a process by which school registrars check the immunisation record of each student on enrolment. Both the Health and Education departments have agreed to use the ACIR history statement as a universal record that all schools can accept as proof of immunisation history. To assist in this process, the Department of Health has developed an information brochure Starting School that the Department of Education will include in school enrolment packs for the 2013/2014 school year. The brochure impresses on parents the importance of sharing immunisation records with their child's school and shows them how to access their child's ACIR immunisation record. Department of Health community school nurses will work with primary school staff to gather students' immunisation status and assist in interpreting technical anomalies.

WA can improve its four year old immunisation rates only if all immunisation service providers support this strategic priority by:

  • encouraging parents to immunise their children on time
  • providing balanced information to parents who express concern about immunisation
  • doing regular recalls of all four year olds on their books with overdue vaccinations
  • checking a child's immunisation status in ACIR when they present for other health issues
  • providing opportunistic immunisation to four year olds when they present for other health issues (if appropriate)
  • entering the immunisation encounter into ACIR to ensure that the child's immunisation status is up to date.

There is significant evidence that vaccination programs within Australia and around the world are working. Data show overwhelmingly that children benefit from vaccination.

In Australia, children rarely die from vaccine-preventable diseases but it is important that health professionals continue to promote more timely completion of vaccination in our four year olds.

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Providers urged to keep ACIR up to date

The Australian Childhood Immunisation Register (ACIR) was established by Medicare in January 1996 as a repository of immunisation records that detail the vaccinations given to children up to the age of 7.

The register's establishment recognised the importance of maintaining accurate immunisation data.

Linked to Medicare, ACIR now provides:

  • infinite, electronic storage of individual vaccine records
  • data used to estimate vaccination coverage at both state and federal levels
  • vaccination data used to determine eligibility for government financial assistance schemes such as Family Tax Benefit part A, Child Care Benefit and Child Care Rebate.

In ACIR's early years, most GPs entered data on to the register manually.

To help GPs meet the labour costs arising from updating the register regularly, the Commonwealth provided an incentive payment of $6 per ACIR vaccine entry. Though most practices now enter their vaccination records electronically, the $6 ACIR update incentive payment remains in place.

Despite commitment from vaccination providers to keep children up to date with their scheduled vaccines, Western Australia continues to have the lowest vaccination coverage rates in the country. Maintaining accurate records on ACIR is vital.

Failure to provide timely updates will skew WA's coverage rates.

Post code specific coverage can be particularly distorted, especially in areas where it can take only a small number of incomplete records to significantly lower the area's vaccination performance.

Incomplete ACIR records may also prevent families from receiving government benefits. Guardians of children who are falsely listed as not being fully vaccinated on ACIR are required to contact their vaccination provider for the records to be updated. This process can take time and cause needless distress to financially burdened parents.

Providers are urged to maintain the integrity of ACIR by ensuring all vaccinations are entered promptly on to the register.

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New treatment guidelines for Neisseria gonorrhoeae

In 2012, 2,126 Western Australians were found to be infected with gonorrhoea. Since 2009, gonorrhoea notifications have more than doubled in the metropolitan area.

Gonorrhoea notifications in WA, 2009 to 2012

Gonorrhoea notifications in WA, 2009 to 2012

The emergence of multidrug-resistant Neisseria gonorrhoeae is a major public health concern worldwide. The USA's Centers for Disease Control and the British Association for Sexual Health and HIV have responded to the issue by changing their gonorrhoea treatment recommendations from ceftriaxone alone to ceftriaxone and azithromycin.

Western Australia is fortunate not to have multidrug-resistant Neisseria gonorrhoeae. To ensure these organisms do not become established in WA, the gonorrhoea treatment recommendations in WA Health's Guidelines for Managing Sexually Transmitted Infections (Silver Book) have been changed to include the addition of azithromycin.

Condition Treatment

Uncomplicated gonorrhoea contracted in the Perth metropolitan area; Great Southern, South West and Wheatbelt regions of WA; interstate; overseas; or where place of acquisition is not known.
OR
Anorectal or pharyngeal gonorrhoea

  • Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly
    AND
  • azithromycin 1 g (oral) given together as a single dose

Uncomplicated gonorrhoea contracted in the Goldfields, Kimberley, Pilbara or Midwest regions of WA*

  • amoxycillin 3g orally
    AND
  • probenecid 1g orally given together as a single dose

* A ZAP pack (azithromycin 1g, amoxycillin 3g and probenecid 1g single dose, directly observed therapy) should continue to be used for empirical treatment of uncomplicated gonorrhoea and/or chlamydia infections contracted in the Goldfields, Kimberley, Pilbara or Midwest regions of WA.

Antimicrobial surveillance is a vital public health measure so any patient with a purulent discharge who is suspected of having gonorrhoea should be swabbed for culture and antibiotic sensitivity testing.

Learn about the management of gonorrhoea and other sexually transmitted infections by visiting the Silver Book webpage.

For continuing professional development about managing sexually transmitted infections, visit Edith Cowan University's STI online learning program. The program is free and accredited with the Royal Australian College of General Practitioners and the Royal College of Nursing, Australia.

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An approach to refugee health assessment

Invited contribution by:
Dr Aesen Thambiran, Medical Director Humanitarian Entrant Health Service and Dr Veronica Hoad Public Health Registrar, North Metropolitan Public Health Unit

In 2010-2011, 2,248 humanitarian entrants (refugees) settled in Western Australia (WA), representing 6.7% of permanent migrants to WA that year.1 While few in number, refugees and asylum seekers may have significant health issues including communicable diseases, nutritional deficiencies, under-diagnosed medical conditions, reproductive conditions, poor oral health and the consequences of trauma, both physical and psychological.

Specifically for infectious diseases, the Commonwealth Government requires that refugees being considered for migration to Australia undergo a limited health assessment before being issued with a humanitarian entrant visa.

For those aged 15 years and over, this only involves screening for human immunodeficiency virus (HIV) and active tuberculosis. Therefore, it is essential that screening for infectious diseases and other issues is undertaken as part of a comprehensive health assessment soon after arrival in Australia

The Australian Society for Infectious Diseases (ASID) recommends that all refugees be offered a comprehensive health assessment after arriving in Australia.2 Most refugees settling in WA are referred to the Humanitarian Entrant Health Service (HEHS), administered by the North Metropolitan Health Service's Public Health and Ambulatory Care, for a voluntary health check. However, some refugees may choose to immediately join friends and family in rural areas and present to their local GP for a health check.

Conducting a comprehensive refugee health assessment may be a daunting experience for Australian GPs unfamiliar with the conditions prevalent in refugee populations. The health consultation may be challenging for both the doctor and patient due to likely differences in the parties' understanding of the medical system, cultural beliefs about illness and expectations of treatment.3 This article outlines an approach that primary care practitioners can take in assessing the health of newly arrived refugees.

Obtaining a history

Refugees are not an homogenous group and will come from a variety of cultural, social and occupational backgrounds. Asking the patient about his or her educational attainment prior to migration will help to determine their level of literacy and health literacy. This will assist you in tailoring health advice and education. Your patient may turn out to have been a health professional in their own country.

Communication is the cornerstone of a good refugee health assessment. It is imperative to use a professional interpreter when seeing a patient who does not speak English. The Commonwealth funds the Telephone Interpreter Service, which is free to GPs. Using friends and family to interpret is inadvisable from a clinical and legal perspective. Errors made by untrained interpreters may result in adverse outcomes.

Obtaining the patient's family history is important and can offer important clues about inherited conditions, such as sickle cell anaemia or exposure to tuberculosis or hepatitis B. It is also useful to ask about his or her family unit because this may reveal that family members are missing or dead due to conflict. In women, obtaining an obstetric history is very important. Women from Africa and South East Asia may have experienced post-partum haemorrhage, multiple pregnancy and neonatal losses as well as losing older children to disease, malnutrition and war. Women from East and West Africa may have also experienced female genital mutilation.

Communicable diseases

Communicable diseases are common in refugee populations. The prevalence of these varies depending on the patient's country of birth and the countries through which they have travelled to reach Australia.4 Therefore, it is important to take an accurate history of the patient's journey to determine risk of exposure to disease.

Tuberculosis

New refugee arrivals are unlikely to have active tuberculosis disease due to stringent pre-migration screening. About a third, however, will have latent tuberculosis infection. The ASID guidelines recommend that all refugees be screened for tuberculosis.2 While mantoux testing is still considered the gold standard, it may be more practical to request an Interferon-Gamma Release Assay (IGRA), such as Quantiferon Gold, on patients under the age of 35. Those who screen positive should be referred to the WA Tuberculosis Control Program. In WA, those over the age of 35 are generally not screened with an IGRA because they are unlikely to be offered preventative therapy due to the potential for adverse drug reactions.

Malaria

Refugees from sub-Saharan Africa and South East Asia should be screened for schistomiasis (serology) and malaria (thick and thins films and P.falciparum antigen test). People who have lived in rural areas, refugee camps and other areas with poor sanitation should have strongyloides serology checked.

Sexually transmitted infections

Recent data from the HEHS showed that prevalence estimates for chlamydia and gonorrhoea in the WA refugee population were considerably lower than in known high-risk populations in Australia.5 In a total of 2610 refugees over 15 years of age screened during the period 2006 to 2009, the prevalence of chlamydia was found to be only 0.8%, and no gonorrhoea infections were detected. It is recommended that all sexually active adults up to 39 years be screened for gonorrhoea and chlamydia, taking into account an appropriate sexual history, but otherwise following guidelines for the general population.6

Syphilis is prevalent in some parts of Africa and Asia and serologic testing for treponemal infection should be offered to all clients, with an intention to treat all those with positive results where there is no documented history of prior treatment.2

Blood-borne viruses

The ASID guidelines recommend that all refugees be screened for HIV, hepatitis B and hepatitis C, which should include HIV antigen/antibody, HBcAb, HBsAg, HBsAb, and HCV antibody.2 While all refugees are screened for HIV as part of their initial visa application, some could seroconvert or be infected after their visa is granted. Hepatitis B and C are common in many parts of Africa and Asia and are leading causes of hepatocellular carcinoma in those regions. A recent study in WA highlighted the increasing burden of chronic hepatitis B in people from endemic countries being referred to Royal Perth Hospital hepatology clinic. 7

Dietary aspects

A dietary history should be taken of all patients and especially in families with children. Refugees may have experienced malnutrition and food insecurity prior to migration and may need education about healthy eating in Australia. All patients should have their iron and vitamin D levels checked. Adults should have their body mass index calculated and children should have their height and weight plotted on World Health Organization growth charts.

Mental health

Assessing mental health is another important aspect of the refugee health screen. While some refugees experience post-traumatic stress disorder, other mental health conditions are also common, including anxiety and depression.3 Once in Australia, these symptoms may be exacerbated by detention, social isolation, loss of peer and family supports, language barriers and unemployment.4 At HEHS, all adults are screened using the Kessler Psychological Distress Scale (K10). This is a simple and easy mental health assessment tool commonly used in primary care. Where indicated, clients are referred to the Association for Survivors of Torture and Trauma Survivors (ASeTTs) for trauma counselling.

Physical examination

A thorough physical examination is important and may reveal hypertension, cardiac murmurs, perforated tympanic membranes, cataracts and thyroid enlargement. Inspection of the skin should not be overlooked because children from the tropics may have fungal skin and scalp infections. Some people from the Middle East and Central Asia may have indurated skin ulceration due to cutaneous leishmaniansis, a parasitic disease caused by Leishmania species and transmitted by sandfly bites.

Immunisation status

The immunisation status of all refugees should be checked. Most children born in refugee camps will have had primary courses of measles-mumps-rubella (MMR) and polio vaccines provided in the camps. Their parents will usually have their immunisation cards with them. It is often older children and adults who are under-immunised. In the absence of reliable records, it is often necessary to rely on the patient's memory or knowledge about the public health programs in their countries. On occasion, an individual's catch-up immunisation needs to be commenced from scratch.

Linking in with other mainstream preventative health services

Finally, it is important to ensure that all new arrivals are linked in with other mainstream preventative health strategies like cervical cancer screening and breast cancer screening.

Further information about refugee health screening can be downloaded from the HEHS web site

References

  1. DIAC. Population Flows 2010-2011. 2012; Available from the Department of Immigration and Citizenship website.
  2. Murray, R.J., et al., The Australasian Society for Infectious Diseases guidelines for the diagnosis, management and prevention of infections in recently arrived refugees: an abridged outline. Med J Aust, 2009. 190(8): p. 421–5.
  3. Benson, J. and M. Smith, Early health assessment of refugees. Australian Family Physician, 2007. 36(1/2): p. 41–3.
  4. Harris, M. and N. Zwar, Refugee health. Aust Fam Physician, 2005. 34(10): p. 825–9.
  5. Hoad V and Thambiran A. Evaluating the chlamydia and gonorrhoea screening program in the Humanitarian Entrant Health Service, Western Australia. Med J Aust, 2012;197 (1): 47–49.
  6. Sexual Health Society of Victoria. National management guidelines for sexually transmissible infections. Melbourne: SHSOV, 2008. http://mshc.org.au/Portals/6/NMGFSTI.pdf.
  7. Subramaniam, K., et al., Hepatitis B status in migrants and refugees: increasing health burden in Western Australia. Intern Med J, 2012. 42(8): p. 880–6

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Chronic hepatitis B contact tracing in metropolitan Perth

Chronic hepatitis B (CHB) is associated with significant morbidity and mortality. People with CHB are a potential source of disease transmission.

Contacts of people with CHB are a national priority population for hepatitis B testing and vaccination. The Western Australian Department of Health recommends that:

  • all household and sexual contacts of CHB cases be tested for hepatitis B infection
  • non-immune household and sexual contacts be offered free hepatitis B immunisation1
  • metropolitan public health units (PHUs) write to notifying doctors offering free hepatitis B vaccination for non-immune household and sexual contacts and assistance with contact tracing.

The success rate of contact tracing was audited by the Department which surveyed the GPs of 31 randomly selected patients notified with CHB between the 1 September 2011 and 1 September 2012. It interviewed 40 randomly selected patients notified with CHB during the same time period. Successful contact tracing was defined as:

  • contacts who, on testing, were immune or infected
    or
  • contacts who were tested and completed a course of hepatitis B vaccination.

Data were collected in March 2013 to allow at least 6 months for contacts to be traced and complete a hepatitis B vaccination course.

The contact tracing success rate was 75% overall and was found to be similar in adult and child contacts. Success rates for nurse (used by one state government-funded clinic), doctor and patient-facilitated contact tracing were 100% (19/19), 60% (6/10) and 56% (10/18), respectively.

More than three-quarters of doctors (77%) remembered receiving a letter and/or phone call from a PHU with advice on contact tracing, and 74% knew that the Department provided free vaccines for contacts.

Two patients with CHB did not disclose their CHB status to their household contacts because they were students in shared accommodation. Under the current operational directive1, no distinction is made between household contacts who are sexual contacts and/or family members (who are at risk of contracting hepatitis B from the case) and adult housemates to whom the case is no more likely to transmit hepatitis B than to a workmate. Accurate assessment of contacts could increase contact-tracing efficiency through focusing resources on people whose type of contact with the case puts them at risk of contracting hepatitis B.

Nurse-facilitated contact tracing had the highest success rate. However, this option may not be feasible in private practice because contact tracing involves telephoning and/or sending letters to people who may not be patients of the case's GP and therefore do not generate Medicare payments. There were 463 CHB notifications in metropolitan WA during the one-year audit timeframe, meaning that most of WA's 9436 doctors would only be likely to notify a case every few years. Given the infrequent nature of this occurrence, doctors and nurses may feel unskilled at contact tracing. These structural barriers in private practice underscore the importance of PHU resources and expertise continuing to be available for doctors who require assistance with contact tracing.

Reference

  1. Department of Health, Western Australia. Hepatitis B vaccination program. 2009 Operational Directive/IC No: OD 0237/09.

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Video promotes benefits of HPV vaccination for young males

The Department of Health has produced a short video on the Human Papilloma Virus (HPV) to highlight the benefits of vaccinating young males against the virus.

The video’s production follows extension of the school-based HPV vaccination program to include year 8 boys and a one-off “catch-up” initiative for males in years 9 and 10.

When the Commonwealth-funded vaccination program was introduced in 2007 it was targeted exclusively at teenage girls, with promotion focussed on prevention of cervical cancer.

With boys entry into the program in February this year it became necessary to broaden promotion to include additional cancers, such as throat and penile cancers, and warts.

The new 4-minute video features Fremantle Hospital sexual health physician Dr Lewis Marshall talking about the risks of HPV-related cancers in the male population.

Dr Marshall also discusses the high prevalence of HPV infection among Australians and reveals that most people with HPV infections do not present with symptoms so can inadvertently pass the virus on to others.

In the video, Dr Marshall also shares the findings of data collated from cervical screening programs which shows that HPV-related diseases have declined significantly since the HPV vaccine was introduced for females.

The video also:

  • provides parents with information on accessing the vaccine for their teens
  • highlights the importance of completing the course (3 doses)
  • encourages parents to take advantage of the one-off free catch up school vaccination program for boys in years 9 and 10 (which ends this year).

The HPV video can be viewed on the public health website

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New multi-lingual digital fact sheets on sexual health and blood-borne viruses

A new suite of digital fact sheets on sexual health and blood-borne viruses in seven languages has been produced by the WA Department of Health.

These fact sheets were produced through a process of community and government sector consultation as part of the Sexual Health and Blood-borne Virus Program's ongoing commitment to the needs of Culturally and Linguistically Diverse communities in WA. They are available online in the following language groups:

  • Arabic
  • Burmese
  • Chinese (Simplified Chinese Characters)
  • French
  • Indonesian
  • Thai
  • Vietnamese.

The fact sheets are also available by subject matter, covering the following infectious diseases:

  • chlamydia
  • genital herpes
  • genital warts
  • gonorrhoea
  • hepatitis A
  • hepatitis B
  • hepatitis C
  • HIV/AIDS
  • syphilis.

The digital fact sheets are available in pdf format online as part of the Multicultural Sexual Health section of the WA Health website.

Multicultural Sexual Health logo

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