Leading the rebirth of the rural obstetrician

In 2002, 30% of all Australian births occurred in non-metropolitan hospitals, and 57% of these hospitals did not provide specialist obstetric cover.1 Antenatal care led by general practitioner obstetricians is offered in 50% of South Australian and Victorian public hospitals and is the only public sector model in most non-metropolitan hospitals.2 GP obstetric care has been shown to provide safe care for pregnant women at low risk of complications, and access to such services in rural Australia is essential.3–8

A looming crisis in the provision of rural obstetric services in Australia was identified in 2007.9 An important study of survey data from 2003 reported that Victorian GPs were becoming less likely to provide obstetric management and that half of the existing GP obstetricians intended to cease practising in the next 5–7 years. In addition, they found that 71% of GPs who completed a Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (DRANZCOG) did not then go on to practise independent procedural general practice obstetrics.9

Factors contributing to the forecast deficit in GP obstetric services included a rise in specialisation, centralisation of services, concerns regarding indemnity and litigation, rural workload and difficulty maintaining competence.9,10–13 The problem of maintaining competence in rural environments has been compounded by reported difficulties in accessing appropriate locum coverage to allow attendance at upskilling courses, in addition to the time and travel required to participate.10

The impending shortage of GP obstetricians and the need for strategies to train, retrain and retain GP obstetricians in rural practice have been the integral considerations in developing a comprehensive training and support program offered in the Gippsland region of rural Victoria. The Gippsland region lies east of Melbourne, covering a land mass of 41 524 square kilometres, and has a population of around 240 000.14 The program by Southern GP Training (SGPT) combines training for registrars and upskilling of GP obstetricians with strategies aimed at overcoming the professional isolation confronting rural GP obstetricians. The program (outlined in the Appendix) expanded registrar training at the larger regional (specialist-led) units to include a 3-month rotation on secondment to a metropolitan hospital. Further training was extended to include a state government-funded 6- or 12-month placement in a GP-led obstetric practice (bridging post) with secondments to larger centres; provision of a clear, individualised postdiploma pathway with supported placement in a GP-led, community-based obstetric practice; continued professional development; upskilling of existing GP obstetricians through the DRANZCOG Advanced qualification, which includes competence in performing caesarean sections; regular GP obstetrician meeting days attended by both registrars and practising GP obstetricians; specialist-led support and mentoring through a regular email forum; and specialist involvement in subregional GP perinatal education and morbidity meetings. In this way, the model provides a supported transition from specialist-led hospital obstetric units to GP-led, community-based obstetric services and integrates this with support for practising GP obstetricians.

The program is continuing to evolve, with new developments such as rotations to the Northern Territory and Pacific islands,15 to enrich the experience of the trainees. The implementation of this program has been matched by a period of recovery for Gippsland maternity services with an increase from 31 GP obstetricians in 2007 to 39 in 2013, including an increase from 10 to 23 conducting caesarean sections. This represents a reversal of the pre-existing trend in service closures.9,16 Of the 39 currently practising GP obstetricians, 18 received their training in the SGPT Gippsland obstetric training program.17 Another three trainees went on to practise GP obstetrics elsewhere, meaning that 21/33 program graduands were active in procedural practice.17

Recent government initiatives have supported GP obstetricians through funding professional development, incentive payments for upskilling, annual incentives for continuing GP obstetric practice and indemnity insurance support. These developments have removed some of the structural disincentives identified as barriers to procedural obstetric practice.

The aims of our study were to understand the factors influencing the decisions of rural GPs and GP registrars to practise obstetrics, and to understand the impact of this innovative GP obstetric training and support program on these decisions.

Methods

Our research was conducted in Gippsland in July and August 2013. Within the region, there are three specialist regional centres that offer a GP-led model of obstetrics, and five hospitals with GP-led services only, all with the facilities for caesarean sections.

Participants were identified from training records and the GP database of the past 5 years for the SGPT GP obstetrician and registrar training and support program. Letters of invitation, explanatory statements and consent forms were sent to potential participants.

We adopted a qualitative approach using semistructured face-to-face interviews.18–20 The research questions examined were:

What challenges face rural GPs in practising obstetrics?
What impact has the Gippsland GP obstetric program had on GP obstetric career decisions?

A three-stage framework method of data analysis (data display, data reduction and data interpretation) was applied,21 and measures were employed to augment the validity and reliability of this research. To ensure correct and detailed collection of participants’ experience and views, all interviews were audiotaped, and copies of the transcripts were provided to participants to check for accuracy. Recorded interviews were analysed by two researchers for credibility and validation of the analysis. Analysis of the transcripts, once uploaded into NVivo 10 (QSR International), was conducted independently by two researchers to check interrater reliability of the emerging themes.

Ethics approval was obtained from the Monash University Human Research Ethics Committee for this research.

Results

Of the 60 potential participants contacted, 22 agreed to take part. The sample included registrars, GPs who were upskilling and established GP obstetricians who supported registrars in training. Interviews ranged from 40 to 90 minutes in duration.

Six major themes emerged: isolation, work–life balance, safety, professional support, structured training pathway and effective leadership.

The first three themes relate particularly to the first research question.

The theme of isolation included the subthemes of distance from specialist services, access to assistance, and access to professional development. The challenge of isolation came with the awareness that it was critical to have the confidence and competence to handle difficult situations and that access to assistance and advice was important. When experienced GPs talked about the impact of isolation, their comments were focused on managing a situation, often in the context of access to assistance from a local team.

Neonatal Emergency Transfer Service (NETS) can come down, [but due to] the weather, it may be several hours before they can … the GPs rally around and can keep working on the babies, intubate them, and keep breathing for them. It is not ideal, but it works well most times. (Participant t)

Comments about isolation from registrars and GPs who were at an earlier career stage focused on how access to assistance with the guidance and information available through the SGPT program ameliorated this isolation.

I’ve got someone to call on at the drop of a hat if I am out of my depth at any point, even if it’s just for advice over the phone. (Participant e)

The theme of work–life balance included the subthemes of impact of after-hours call out, the demands of emergency situations, dealing with scheduled patients at the clinic after being at deliveries during the night, and family commitments.

Obstetrics interrupts the rest of life, both clinical, family life, and sleep. You know to be woken up in the middle of the night … isn’t a particularly pleasant thing, and try getting back to sleep after all the excitement. (Participant g)

Being part of a team of GP obstetricians assisted in achieving an acceptable work–life balance.

The theme of safety was mentioned more often by doctors who were at an early point on their career trajectory. This theme included the subthemes of patient safety and practitioner safety. Patient safety was related to backup and competence, while practitioner safety was about feeling supported and having confidence in dealing with the unknown. The SGPT Gippsland program was seen to contribute to improving safety.

Because (obstetrics) is a high-risk area and people burn out. They [SGPT] don’t want us having disastrous situations when we are junior. (Participant a)

The second three themes —professional support, structured training pathway and effective leadership — relate particularly to the second research question. Professional support was mentioned by all 22 participants. Participants from all groups within the cohort commented on the quality and availability of professional support within the Gippsland program. This theme included the subthemes of professional backup, professional networks and a respectful learning culture. With regard to professional backup, the availability of backup from specialists was described as timely and appropriate, as nominated mentors assisted with advice on practice in the clinic, and teams were built to support the training experience. Doctors in training and doctors in independent practice perceived they were well supported professionally.

When you are training you are always first on call, which is fantastic because you have to deal with everything that walks in the door. But you are paired with a consultant on the day. You basically run your assessment with them and see if they are happy with your plan, and for any instrumental deliveries or complicated issues you contact them to come in. So, it is very well supported. (Participant d)

Involvement in the Gippsland program made available both formal and informal professional networks to participants. The professional networks provided an environment where people at all stages of their career received support and timely, up-to-date information. Regular professional development opportunities were a valuable component, strengthening these networks and providing opportunities to reflect on best practice.

Ongoing professional development offered is fantastic, as it keeps you abreast of new developments as well as provides an opportunity for professional networking. (Participant v)

A respectful learning culture with an emphasis on empowering and enabling participants was an important component of professional support.

Respect is a huge factor; the leaders in the program lead by example and are very inclusive and respectful of individuals’ experience and needs. (Participant u)

The structured training pathway theme emerged as an important component of the Gippsland GP obstetric program. This included the subthemes of community-based bridging posts for registrars; secondment for additional experience; and continuous professional development. Registrars rated the bridging posts as critical to offering a safe transition.

I think it is about fostering supported practice and this is a particular time of vulnerability in terms of support … the movement from hospital-based practice to being a new person in community-based practice. (Participant g)

The theme of effective leadership was apparent across all interviews. There was clearly the perception of supportive, knowledgeable and respectful leadership within the program, and this was highly valued.

They are definitely good mentors and good role models and that is part of the reason … to want to keep going with this pathway. (Participant f)

Discussion

The themes of isolation, work–life balance and safety for the practitioners and patients emerged in our study as substantial challenges for rural GPs in practising obstetrics. These findings are consistent with the findings of other researchers who have studied the challenges of rural and remote medical practice more broadly.22,23 Work–life balance is particularly important for sustainable practice24 and is vulnerable to the demands of isolated obstetric practice. Our study indicates that the Gippsland GP obstetric program has contributed to a recovery and retention of maternity units in Gippsland founded on its success in helping doctors deal with these challenges.

Participants found the obstetric program to be professionally supportive, with meaningful backup, advice and support of professional development. The program has also been instrumental in building and supporting professional networks. Reliable, relevant backup and advice ameliorates isolation and enhances patient and practitioner safety. Professional networks remove isolation and enable cooperative rostering, which is a means to improving work–life balance. In this way, the SGPT Gippsland GP obstetric program would seem to have become fundamental for sustaining GP obstetric practice in Gippsland.

Our study suggests that the structure of the Gippsland GP obstetric training enables its trainees to continue into active, independent procedural obstetric practice. The bridging post after the primary training was highly valued. A large decrease in use of procedural skills 1 year after their primary procedural training has been reported previously.9,25 Supported transition after completion of hospital-based training has been found to be an important factor influencing recently qualified GPs to continue into independent procedural practice.25 Structured, respectful clinical supervision by senior role models is vital to effective postgraduate medical education,26 with the supervision relationship being shown to be more important than the supervision method.27

Leadership was clearly a major factor in the impact and success of the SGPT Gippsland GP obstetric program. This leadership was provided by committed specialist obstetricians and active GP obstetricians.

There was a notable absence in the data of mention of financial disincentives to practising GP obstetrics. This suggests that disincentives identified previously1 have been largely removed by recent government initiatives in this area.

This study was conducted in a particular geographic area, so transferability of the results cannot be assumed. In particular, this program was introduced where a shortage of GP obstetricians was forecast but not yet apparent. The participation of GP obstetricians was key to the success of the program. Therefore, this program design may not be as effective where GP obstetrician shortages already exist. However, themes such as isolation, safety and leadership are likely to be relevant in most rural settings, and the strength of these themes across the different practitioner groupings and towns suggests that the findings are generalisable. The stratified sampling method used was a strength of the study.

Our study also suggests that the Gippsland GP obstetric program has had a substantial impact on trainees continuing into active obstetric practice and on GP obstetricians continuing in their obstetric practice. This innovative program was made possible by state and federal government funding, the support of local and metropolitan hospitals, and ownership by both specialist and GP obstetricians. Leadership, organisational support and administrative support by SGPT have provided the scaffolding for the program. Key features of this training include a supported transition into community-based GP obstetrics; adequate clinical exposure through secondments; a culture supportive of GP obstetrics; building and sustaining professional support networks; and inspirational leadership. The increase in numbers of practising GP obstetricians has enabled more acceptable rosters and greater flexibility in accommodating personal commitments. These key features should be foundational considerations in replicating this successful model elsewhere.

The meaning of seven Christmases

Working on Christmas Day at hospital provides insight into the complex reasons why patients are there

For Christmas, my auntie has always made an amazing dinner, full of crustacean goodies on the barbecue, roast pork crackling with a tympanic crunch, turkey with my favourite stuffing, a nostalgic smell percolating the air, and pavlova with sweet berries. The home always felt like Christmas — a beautiful tree lights up the corner with thoughtful gifts, a Swarovski cabinet glistens with crystal figurines, the swimming pool and trampoline in the backyard bring back memories of backyard cricket and childhood games with my siblings and cousins. For me, Christmas has always been about love, family and happy memories.

Over the past 7 years, the meaning of Christmas to me has been shaped by my working on Christmas Day. Don’t ask me how this consecutive rostering occurred — it’s not possible, I’ve been told by administration. One year, a radio station bestowed on me an award comprising a cruise and a hotel voucher for being the “most shafted at Christmas”. I have a feeling my auntie may not recognise me the next time we meet, but I am hopeful I will see her again one day.

The sad thing is that while Christmas may be a celebration for most, to a small cohort of vulnerable people, it emphasises life’s deficiencies. It is common during Christmas for older people to be “dumped” at a hospital so the rest of the family can enjoy the holiday season. Every Christmas, I see this happen.

Lonely people come to hospital to seek a human being to share the day with — even if it’s a health professional. I remember an old man coming to the emergency department with vague chest pain. This was the first Christmas he had spent alone, as his wife of 70 years had passed away that year. He came to the hospital because he didn’t want to be alone. He shared his life story with me and, sadly, later died in the ward from takotsubo cardiomyopathy. Yes, it is possible to die of a broken heart.

From the lonely to the reckless, many on Christmas Day end up in the resuscitation bay after alcohol-fuelled trauma, whether from fighting with the in-laws during Christmas lunch or from a motor vehicle accident. One year, I did two emergency thoracotomies and saw a young teen die.

Christmas may mean love and family to some, but to others it highlights a vast emptiness. I have learnt this from having had the privilege of looking after many vulnerable people over the past seven Christmases.

Perhaps on Christmas Day, we should not only care about family and friends but make an effort to be kind to everyone. Send Christmas cake to a neighbour you don’t know, because at some stage you thought it was a good idea to build a fence that looked like the cement slabs of Silverwater gaol. Take your grandmother with dementia on a road trip — remember she once changed your nappies and fed you milk. Instead of road rage, let the other vehicle in and don’t sweat the small stuff. This may also be good for your carotids and berry aneurysms.

This year, somehow I have again been rostered to work during Christmas. A colleague was also rostered with me, but his wife had just been diagnosed with breast cancer, so I told him to spend the day with her. I guess most people would be very upset that they have endured an unfair roster, and my own family have been disappointed that I haven’t been able to spend time with them at Christmas. Don’t get me wrong — I would prefer not to work on this important day. I would prefer to spend it with my mum and dad, my siblings and close family. One day, soon I hope, I would like to start my own family.

As I will be at the hospital, I will try my best to bring Christmas cheer where it is needed, to be the sunflower. Christmas should not only mean loving your family; it should also mean caring for all the human beings you have the privilege of meeting.

Rural patients travel for health care

A country doctor comes face to face with the devastating realities of needing specialist care in a distant city

Today, I entered the world of the chronically ill. I am forced to grapple with the shattering diagnosis of a life-threatening autoimmune disease. My medical career and life as I have known it are shelved for the foreseeable future. Hopes and dreams are buried under the rubble of severe illness. Suddenly, my husband is my carer, and his career hangs in the balance too. Roles within the family radically change in a moment, and nothing looks familiar. The devastation does not stop there, though. Being casually or self-employed means income ceases immediately for both of us. We have entered the unchartered waters of financial insecurity.

This is enough to swallow for one day. Tomorrow, I start the arduous task of planning and packing for the more than 1100 km round trip for treatment. Being sick, this is the last thing I feel like doing. The long drives are torture to stiff and painful joints, and severely challenge my ability to shut out the nausea. Why am I sentenced to travel for essential health care? I am guilty, like so many other Australians, of living in a regional area. This is the first of monthly journeys that are potentially a life sentence.

Initially, accommodation is provided by the hospital, charged at the state’s Patient Assisted Travel Scheme (PATS) rebate rate, making it affordable. The shared cooking and dining facilities allow for the building of a support network away from home. We are all in the same boat, and the camaraderie of fellow patients in this setting proves invaluable. Six months later, this accommodation closes and, suddenly, we are out in the cold with our comrades with nowhere to stay. In New South Wales this is the trend: country patient accommodation is slowly being closed down. The state government has said it is not its responsibility. The hospitals say accommodation is not an essential part of treatment, and therefore not their responsibility. One state government official told me the responsibility lies with non-government organisations (NGOs). NGOs built country patient accommodation in the city years ago, but these are being demolished or sold off by state governments and hospitals.

The situation for country patients is dire. The only accommodation that might be covered by the PATS rebate in NSW is a dorm bed in backpackers’ accommodation. Not the place for the severely immunosuppressed, nor the healing and restful environment needed by sick patients. For anyone like myself in a wheelchair, accommodation options are further restricted. Try searching the internet for wheelchair-friendly accommodation for less than $100 per night near major hospitals. This is some of the discrimination that people with a disability face when trying to find affordable and accessible accommodation in Australia.

The severely limited facilities provided for regional patients are frequently unaffordable and unfriendly to the sick, limiting their ability to participate in treatment or recovery. Regional Australians are frequently blamed for their plight because they choose to live in the country. Those treating us demand: “Why don’t you move to the city? It would be much simpler.” Simpler for who? Many regional Australians silently suffer every day, and have no voice on this issue because they are sick. They are the ones going into debt or giving up their homes to pay for travel, sleeping in their cars when there is nowhere affordable to stay, losing their jobs because they are away from home, suffering through family breakdown, foregoing treatment altogether, or even dying because no one will take responsibility for this problem.

Getting the levers right: a way forward for rural medicine

The government needs to develop better policies now to ensure a future for rural health care

Anyone who has spent time in the bush knows that if you have seen one rural town, you have only seen one rural town. Tamworth is not the same as Cooktown or Bendigo . . . or any of the towns in between.

Different locations across rural Australia vary in their level of attractiveness to doctors and what medical skills they may require. Regardless of a location’s attractiveness, without appropriate support services and incentives, the next generation of doctors is more likely to gravitate towards urban general practice or specialist practice than towards the bush. This is worrying, given that the iconic rural doctors who have been the backbone of rural medical care for decades are fast approaching retirement.

Generational changes are influencing the working patterns of younger doctors. They are increasingly mobile and want to work fewer hours generally, and more sociable hours overall. Many are daunted by the responsibility and commitment associated with owning a practice. However, many younger doctors still want to provide holistic care for a community as well as individual patients. This is something that rural practice can deliver in spades.

To seal the deal in getting these doctors into rural practice, these generational changes must be reflected in medical workforce policies and programs. A coordinated effort across governments, service providers and professional groups is required. It may take time to respond to these more complex challenges, but key changes must be made at the federal level now if rural practice is to successfully recruit younger doctors into the future.

It is urgent that the federal government fix the Australian Standard Geographical Classification — Remoteness Area (ASGC-RA) system, which continues to be a dead weight for small rural towns in competing for doctors against larger regional locations. While ever a well resourced regional city like Townsville has the same remoteness classification as a small town like Gundagai — resulting in doctors in both locations receiving the same level of federal recruitment and retention incentives — small country towns will find it virtually impossible to compete. Incorporating the Monash Model — developed by Emeritus Professor John Humphreys and his colleagues at Monash University1 — into a revised ASGC-RA system would mean rural towns are more realistically classified and have some chance of recruiting more doctors.

Larger rural towns need well trained specialists who can work across their disciplines rather than practising only within subspecialist areas. The medical colleges will need to identify strategies to train generalists within their specialties in rural areas to meet the needs of rural local health networks and their populations.

Government also needs urgently to reconsider rural general practitioner training strategies, particularly after the recent federal Budget. With the dismantling of General Practice Education and Training from the end of 2014, rural practices and medical graduates need clarity as to how rurally based GP training will be undertaken going forward.

If they are to help meet growing demand for rural GP training placements, rural practices will need to be better supported. This will be particularly important in ensuring that medical students who have undertaken their undergraduate studies in rural and regional areas can go on to undertake GP training in rural settings.

Similarly, the federal government should immediately reverse its decision to scrap the highly successful Prevocational General Practice Placements Program. This program has encouraged many medical graduates to take up careers as rural doctors.

But these are not the only problems affecting the future of GP training. Should the government’s anticipated GP copayment lead to a significant drop in the number of consultations, many practices will decide against taking on GP registrars, leading to a significant drop in the availability of GP training opportunities.

To be sustainable into the future, our health system must shift its focus from specialist medicine and acute care beds to better supporting generalist and team-based community care that is accessible to all Australians, regardless of where they live. In rural and remote Australia, the focus must also be on making the path to rural practice both compelling and easily navigable for the next generation of doctors.

Achieving these outcomes will significantly improve health outcomes in the bush — and will significantly reduce the overall health budget — by ensuring that treatment can be provided closer to home for rural and remote Australians.

The 4th Rural and Remote Health Scientific Symposium

Making the most of rural and remote health research through collaboration

Given its focus on ensuring that rural and remote health research leads to changes in policy, it was appropriate that the 4th Rural and Remote Health Scientific Symposium was held at Old Parliament House in Canberra on 2–3 September 2014.

It was an occasion when “data custodians” (an interesting term, much used throughout the 2 days) came together with rural and remote health consumers, service managers and researchers. With the National Rural Health Alliance as one of its organisers, the event was unashamedly focused on rural and remote health research and what it might do for health outcomes in those areas.

Members of the rural and remote health research sector are proud of what we have achieved. When it comes to providing specialist health services, there is an accepted dependence on large regional centres and metropolitan areas. But where research is concerned, there is an emotional and intellectual belief that the best work for rural and remote areas can only be done in those areas.

In the final session, several suggestions were made for inclusion in what might be seen as a plan of action:

regular meetings of the parties that attended the symposium would add value to the rural health research sector, particularly if they progressively include agencies responsible for data series relevant to the social determinants of health, such as those associated with the Department of Social Services. By including such interests, the health data and research sector can help demonstrate an approach to wellbeing based on the social determinants of health;
rural and remote health researchers should talk with data custodians early, to help shape their research proposals and to be clear about what data they really need;
policymakers can be enlisted to help identify “best bets”, including evidence about health interventions that do not provide good value for money;
the case for more focused investment through the National Health and Medical Research Council in rural and remote research should be pursued;
the rural and remote health research sector should consider producing a publication on best-practice approaches to Indigenous health research and play a leading part in ongoing work to promote the elements of such an approach;
a strong case must be made for the fourth phase of the Primary Health Care Research, Evaluation and Development (PHCRED) strategy (the first three phases of the PHCRED strategy have been described,1 and a review of PHCRED is being completed in anticipation of Phase 4); and
further consideration should be given to the establishment of a virtual academy of rural and remote health research.

The key element in this list is perhaps the last: an idea whose time has now come. A virtual academy would support health researchers working in rural and remote areas, and be a clearinghouse for research proposals and an advocate for resources. It would also support collaboration on ethics approvals, and help remove barriers to data access and sharing.

For information about the symposium, including the associated communiqué and links to the presentations, visit the symposium website at http://www.ruralhealth.org.au/symposium2014.

Rural clinical school outcomes: what is success and how long do we wait for it?

In reply: Garne and colleagues raise the important matter of whether the current quota of rural students in medical schools (25%) should be increased, given the positive impact of rural background on future rural practice. We agree that this warrants serious consideration, but suggest that there should not only be an increased national quota for rural students but also consideration of the distribution of these students between different medical schools.

Medical schools are not all the same. They have differing staff expertise and facilities, and also recruit students in a number of different environments and populations. These factors facilitate student recruitment and training, and hopefully influence students’ future career choices to serve in disadvantaged communities (such as underserved urban or ethnic communities), and also in underserviced subspecialties (such as dermatology and otorhinolaryngology) and other health priorities (such as public health and research leadership). Perhaps individual medical school quotas for rural students should vary depending on their staff expertise, facilities and environments.

We are not frustrated. We are proud of our achievement in training rural practitioners and congratulate the University of Wollongong on theirs.

Cytomegalovirus disease in immunocompetent adults

Cytomegalovirus (CMV) is an internationally ubiquitous human herpes virus with a worldwide seroprevalence ranging from 45% to 100%.1 A national serosurvey in 2006 estimated that 57% of Australians between the ages of 1 and 59 years were seropositive.2 While primary CMV infection is common in the general community, it is usually asymptomatic or causes a mild mononucleosis-like syndrome.3 The viraemic phase is generally self-limiting in healthy adults, and is followed by a lifelong bloodborne latent phase within peripheral monocytes and CD34+ myeloid progenitor cells4 (Box 1).

However, in certain circumstances CMV infection is capable of producing severe, life-threatening disease, including a wide range of potential clinical manifestations, owing to systemic haematogenous dissemination and a very broad tissue tropism6 (Box 2). Typically, severe CMV disease occurs in the context of an immature, suppressed or compromised immune system, and can lead to death or permanent major sequelae.7 As such, severe CMV infection is a well recognised cause of morbidity and mortality in neonates and immunocompromised adults, such as pharmacologically immunosuppressed transplant recipients and patients with AIDS.7

CMV disease in immunocompetent adults

While CMV is a well recognised pathogen in neonates and immunocompromised adults, the burden of CMV disease in immunocompetent adults is less well understood. This is because severe CMV disease is of considerably lower incidence in this population. However, it is far from non-existent; over 380 published case reports document instances of severe tissue-invasive CMV infection in immunocompetent adults. Similarly to CMV disease in immunocompromised individuals, these cases show a wide range of manifestations, including colitis,9 vascular thrombosis,10 pneumonia11 and myocarditis.12

The most comprehensive evaluation of severe CMV infection in immunocompetent adults to date included a systematic meta-analysis of case reports and reviews documenting 290 instances, across all manifestations.8 This study found that CMV infection most commonly involved the gastrointestinal tract (primarily colitis), followed by the central nervous system (including meningitis, encephalitis and myelitis) and then haematological abnormalities (including haemolytic anaemia and thrombocytopenia). CMV disease of the eye, liver, lung and vasculature were also documented, among other conditions. The authors ultimately concluded that the incidence of severe manifestations of CMV infection in immunocompetent individuals appeared to be significantly more common than previously appreciated.8

It should be noted that the definition of immunocompetency in this analysis, like most published reviews and case reports, excluded only individuals with profound loss of immune function, including patients who had AIDS, pharmacologically immunosuppressed transplant recipients and chemotherapy recipients. However, many case reports of CMV disease in “immunocompetent” adults document comorbidities that may be associated with a degree of immune dysfunction, such as diabetes mellitus or renal failure. Indeed, studies have also shown an increased risk of CMV-related morbidity and mortality in “immunocompetent” critically ill patients.13 It is therefore highly feasible that partial immune dysfunction may represent a currently overlooked risk factor for severe CMV disease. As such, further studies are needed to evaluate the risk of CMV disease in these populations. Nonetheless, this possibility reinforces the importance of considering CMV as a potential infectious agent even in patients with a low degree of immune dysfunction.

Diagnostic challenge of CMV disease

Although uncommon, severe CMV infection in immunocompetent adults often poses a significant diagnostic challenge, and a number of case reports have documented considerable delay to diagnosis.14–16 Some patients with CMV colitis, in particular, have had protracted hospitalisations and have undergone surgery to investigate persistent and undiagnosed disease.

The diagnostic difficulty in CMV disease arises from three factors. First, the low incidence of severe CMV disease in immunocompetent individuals warrants a lower index of clinical suspicion for CMV infection at initial presentation. Second, CMV disease can present with a wide array of potential clinical manifestations, owing to broad tissue tropism. Third, certain presentations of CMV disease strongly mimic other diseases, potentially causing diagnostic confusion and delay in diagnosis. Indeed, case studies have documented initial misdiagnoses of colon carcinoma,14 ischaemic colitis,15 inflammatory bowel disease,16 dengue fever17 and lung cancer,18 among others.

Notable case studies

Siegal and colleagues documented the case of an 82-year-old man presenting with a 2-day history of diarrhoea and epigastric pain.15 Non-contrast computed tomography (CT) showed faecal impaction and thickening of the wall of the distal colon, with generalised large-bowel dilatation. Despite repeated negative results from assays for Clostridium difficile toxin, antibiotics were administered. There was no clinical improvement. Sigmoidoscopy and biopsy during the second week of admission showed acute inflammation and lymphoid aggregates, but did not lead to a diagnosis. The patient was treated with mesalamine for suspected ulcerative colitis, with minimal effect. A positive faecal occult blood test result raised the suspicion of ischaemic colitis. However, repeat sigmoidoscopy and biopsy at 1 month after admission showed mucosal ulceration with viral inclusions diagnostic of CMV infection, and treatment with intravenous (IV) ganciclovir was commenced. The authors concluded that CMV should be considered as a potential aetiological agent of severe colitis in immunocompetent individuals when other differentials have been excluded.15

A case study by Falagas and colleagues highlighted the diagnostic difficulty posed by CMV disease in non-immunocompromised adults.14 In this instance, a 57-year-old, HIV-negative man with chronic renal failure presented with acute abdominal pain, diarrhoea, and per rectal bleeding. Colonoscopy showed a large polypoid mass in the hepatic flexure, suspicious for colorectal carcinoma, although a colonic biopsy specimen did not show neoplastic changes. The results of subsequent CT scanning, stool examination and a C. difficile toxin assay were normal. Recurrent symptoms prompted an exploratory laparotomy and right hemicolectomy on Day 9 of admission, at which time histological analysis showed intranuclear inclusions diagnostic of CMV disease. The patient commenced a 2-week course of IV ganciclovir, and his symptoms subsequently abated. The authors concluded that the endoscopic findings of CMV colitis may resemble colon carcinoma and should be considered as a differential diagnosis, even in patients without severe immunosuppression.14

Yu and colleagues published a case report of a 39-year-old woman with a 6-week history of fever of unknown origin who was referred to a tertiary hospital.19 Her liver enzyme levels were elevated, and an abdominal CT scan was consistent with acute hepatitis. Results of serological screening for hepatitis A, B and C viruses, Epstein–Barr virus and HIV were negative. The result of a CMV-polymerase chain reaction (PCR) analysis was positive, and other causes (including drug-induced and autoimmune) were excluded. The severity and progressive nature of the disease necessitated urgent living-donor liver transplantation. A biopsy specimen from her explant liver showed widespread hepatic necrosis and stained positive for CMV protein. Initially, no antiviral therapy was commenced. The patient’s postoperative course was characterised by a rising serum bilirubin level and CMV antigenaemia. A liver biopsy specimen taken on Day 14 after the operation showed moderate degenerative changes and stained positive for CMV protein, at which point IV ganciclovir therapy was initiated, leading to improvement in her clinical condition and liver function. The authors concluded that CMV should be investigated as a potential cause of severe hepatitis, regardless of the patient’s immune status, after more common aetiologies have been excluded.19

Clinical implications

Delayed diagnosis of CMV disease in immunocompetent adults creates the potential for numerous adverse outcomes. Delay in initiation of targeted therapy leads to increasing morbidity and mortality as a result of disease progression. Prolonged hospitalisation is associated with health risks such as nosocomial infection and venous thromboembolism. Patients may also receive unnecessary radiation exposure from repeated CT imaging and be exposed to risks associated with surgical interventions. In addition, financial costs associated with extended hospitalisation and the potential for numerous investigations, surgery and intensive care unit admission are substantial. These consequences of diagnostic delay are of particular note, given the availability of non-invasive diagnostic testing for CMV infection, including serological tests, CMV-PCR and viral culture.20

Treatment of CMV disease in immunocompetent adults

While ganciclovir or valganciclovir are currently recommended as first-line treatment for severe CMV disease in immunocompromised adults, few studies have appropriately evaluated the use of these antiviral agents for the treatment of severe CMV disease in immunocompetent adults. These agents may have major side effects, including myelosuppression and potential carcinogenicity. However, untreated CMV disease is associated with considerable morbidity and mortality, and published case studies and reviews provide consistent case-based evidence of rapid clinical improvement after commencement of therapy in this clinical setting.3,11,17,21–23 Furthermore, a recent study found ganciclovir to be a safe and effective treatment for CMV-associated pneumonia in immunocompetent children.24 Therefore, the continued use of antivirals for the treatment of very likely or proven CMV disease in immunocompetent adults appears justified at present. While formal studies evaluating the efficacy and utility of these therapies in the context of immunocompetency would be beneficial, such studies would be difficult to pursue, given the low incidence of severe CMV disease in this population.3

Conclusion

Although severe CMV disease primarily occurs in neonates or severely immunocompromised adults, the burden of disease in immunocompetent adults appears to be greater than previously understood. This may be partly owing to underrecognised risk from immune dysfunction associated with comorbidities such as renal failure or diabetes mellitus. It also appears that diagnostic delay is more likely in this clinical setting, especially for instances of CMV colitis, creating the potential for a range of adverse outcomes. Severe CMV disease in immunocompetent adults is likely to remain a diagnostic challenge in many circumstances. However, earlier consideration of CMV as a potential aetiological agent in individuals with atypical or refractory disease, regardless of immune status, may facilitate early non-invasive diagnosis and the initiation of appropriate directed antiviral therapy.

1 Overview of primary and secondary cytomegalovirus (CMV) infection and disease4,5

2 Non-exhaustive list of recognised potential manifestations of cytomegalovirus disease7,8

Direct effects

Gastrointestinal

Cardiovascular

Colitis

Myocarditis

Enteritis

Venous thrombosis

Gastritis

Neurological

Hepatitis

Meningitis

Pancreatitis

Encephalitis

Cholangitis

Myelitis

Respiratory

Retinitis

Pneumonitis

Uveitis

Haematological

Urological

Thrombocytopenia

Nephritis

Leukopenia

Prostatitis

Anaemia

Disseminated intravascular coagulation

Myelodysplastic change

Indirect effects

Atherosclerosis acceleration

Accelerated AIDS progression

Graft dysfunction and rejection

Increased opportunistic infections

Modern challenges in acute coronary syndrome

Despite a growing evidence base, gaps in knowledge and practice leave room for improvement in the treatment of acute coronary syndrome

A few decades ago, there was still controversy about the importance of interruption of blood flow versus myocardial tissue oxygen demand in causing myocardial infarction.1,2 It is now universally accepted that coronary thrombosis at the site of an unstable atherosclerotic plaque is the usual cause of coronary occlusion3 and the cluster of conditions of unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) comprise the clinical complex now called acute coronary syndrome (ACS).

An important observation from the investigations at the start of the “reperfusion era” was the recognition that STEMI and NSTEMI, while both due to coronary thrombosis, had quite different presentations and natural histories.4 Important differences between the pathophysiology of STEMI and NSTEMI determine the focus of treatment. In STEMI, the complete occlusion of the coronary vessel initiates a cascade of myocardial necrosis, which can be prevented by early reperfusion with percutaneous coronary intervention or fibrinolytic therapy.5 In NSTEMI, the less complete occlusion of the coronary vessel means there is less immediate urgency to salvage myocardium, and the initial focus is on antithrombotic therapy to limit the size and instability of the thrombosis in the coronary artery. In this situation, the size, shape and location of the coronary thrombosis are highly variable. The patient’s clinical course can be unpredictable, and progression to STEMI is a pervading concern. In patients with NSTEMI who are at high risk, an early invasive approach has been shown to be superior to a conservative approach,6 but the optimal timing of this remains controversial.7 These major advances in understanding this symptom complex have driven quantum shifts in management approaches and greatly improved outcomes for patients who have suffered a heart attack. However, it remains a condition which can be unpredictable and, despite the best of modern treatments, can still be lethal. As ACS is a symptom of underlying coronary heart disease, long-term management is often more important than the acute phase. This supplement focuses on the many challenges in managing ACS.

The first two articles in this supplement deal with managing the acute stage of ACS. The many valuable guidelines on this topic,8–12 not reiterated in detail in the supplement, all concur on the basics of modern therapy. The use of potent antithrombotic agents is central to tackling the coronary thrombosis, albeit with an increased risk of bleeding. While controversies continue over the ideal duration of antiplatelet therapy, the evidence to support routine early and post-hospital use of potent antiplatelet agents is overwhelming. Statin therapy is also central to the management of the acute episode and for long-term management, irrespective of the low-density lipoprotein cholesterol level at the time of the episode. The role of β-adrenergic blockers and inhibitors of the renin–angiotensin–aldosterone system remain important, but perhaps better targeted to patients at higher risk. The guidelines, while sometimes exhaustingly complete, do not cover all aspects of management.

In the first article in the supplement, Brieger focuses on the identification of patients with ACS who are at high risk (https://www.mja.com.au/doi/10.5694/mja14.01249). He argues that routine risk stratification as soon as possible after presentation will determine the clinical pathway, and that this practice should be embedded in the hospital system — it is too important to leave to ad-hoc and potentially unreliable clinical judgement. This is a challenging change in approach for the hospital system, but bound to be fruitful in reducing decision time when early revascularisation is needed, and avoiding unnecessary intervention when it is not.

Next, McQuillan and Thompson review the limited evidence to guide management in four important subgroups: female, older, diabetic and Indigenous patients (https://www.mja.com.au/doi/10.5694/mja14.01248). These subgroups have been underrepresented in clinical trials, in contrast with the evidence base that guides the care of most other patients with ACS, which is rich and detailed. There is also evidence that these subgroups are at particular risk, and clinical decisions must often be based on extrapolation from the results of clinical trials without absolute certainty that the evidence is applicable.

The other articles in the supplement deal with the challenges in caring for post-ACS patients at the time of discharge from hospital and handover to the general practitioner. This transition can lead to confusion for the patient and frustration for the GP in dealing with patients returning to their practice with major changes in their management incompletely documented and uncertainty about how best to access the services available to their patients.

Redfern and Briffa use data from three registries to describe common shortfalls in the transition from hospital to primary care (https://www.mja.com.au/doi/10.5694/mja14.01156). The challenges in improving access to effective secondary prevention are concisely summarised, with positive guidance on how to improve secondary prevention in primary care, raising awareness of the need for lifelong secondary prevention, better integration and use of existing services, consideration of the use of registry data in data monitoring and quality assurance, and the potential in embracing new technologies such as automated texting reminders to patients, already outlined in a summit on this topic last year.13

Thompson and colleagues summarise the extensive evidence base for ideal post-hospital therapy (https://www.mja.com.au/doi/10.5694/mja14.01155), focusing on the 50% of patients who do not receive coronary intervention or revascularisation at the time of their acute episode.14 The extensive collaboration on clinical trials and registries that has gone into developing the rich evidence base is a source of pride in modern cardiology, but many gaps in evidence remain.

Thakkar and Chow reassert the truism that drugs do not work in patients who do not take them (https://www.mja.com.au/doi/10.5694/mja14.01157); there is evidence that non-adherence among post-ACS patients is common and associated with adverse outcomes.15 Their review summarises strategies to improve adherence to prescribed medications, and touches on the future possibility of a polypill to include a combination of evidence-based therapies to improve adherence.

Finally, Vickery and Thompson take the GP’s perspective in managing the post-ACS patient and describe eight common challenges that GPs face in this setting (https://www.mja.com.au/doi/10.5694/mja14.01250). The need for courteous, detailed communication between the hospital and primary care is highlighted.

The common theme of each article in this supplement is that progress has been impressive, but much has to be done to continue the improvements in understanding and in translating the knowledge we already have into further improvements in outcomes. The disturbing evidence from recent Australian nationwide surveys that the application of proven evidence-based therapies remains less than optimal16 is a concern and presents a major challenge in the modern management of ACS.

The transition from hospital to primary care for patients with acute coronary syndrome: insights from registry data

In Australia, acute coronary syndrome (ACS) accounts for about 75 000 hospital separations annually, and in 2010 cost more than $8 billion.1 Those who survive are at high risk of recurrent events; in 2010, more than 25 000 Australian hospital separations were associated with repeat ACS2,3 at a cost of more than $600 million (direct costs only).1 Between 2000–01 and 2008–09, the largest expenditure increase, by health care sector, was for hospital-admitted patient services, where cardiovascular disease expenditure increased by 55%, from $2907 million to $4518 million.4 A recent report projected that by 2020 there will be around 102 363 separations associated with ACS in Australia, and about half of these will be due to repeat events.1 These statistics highlight the growing importance of secondary prevention as more people survive initial events. Further, it underscores the need for a health system that has an inbuilt process for commencing prevention during acute admissions, and the need to ensure an effective transition from hospital to primary care.

Favourable modification of coronary risk factors is responsible for at least a 50% reduction in mortality from cardiovascular disease.5,6 Further, participation in secondary prevention programs leads to improved clinical, behavioural and health service outcomes, including fewer hospital readmissions, better adherence to pharmacotherapy, enhanced functional status, improved risk profile, less depression, and better quality of life.7–9 However, only a minority participate,10 systematic follow-up is fragmented,11 and questions remain about how well the health system facilitates transition from hospital to primary care. Overall, with ACS dominating expenditure and gaps in secondary prevention widely documented, addressing the delivery of care at the point of hospital discharge is a priority.

Modern cardiology has seen significant advancements in diagnosis, revascularisation, pharmacotherapy and overall more successful treatment of acute illness.12 This ultimately means that more people are surviving their initial ACS event and are having shorter hospital stays, which has resulted in more people returning to the community and resuming their everyday lives.13 However, one-quarter of survivors will be readmitted to hospital within 1 year of the index event, and a significant number of readmissions will end in death.2,3 Consequently, the demand for effective, continuing post-hospital preventive care is intensifying; the foundations of this are built during the acute episode.14

The purpose of this article is to provide insights from registries, and their implications for secondary prevention in Australia.

Gaps in secondary prevention: data from Australian ACS registries

Three large-scale Australian ACS registries — namely, SNAPSHOT ACS, the Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events (CONCORDANCE) and the Acute Coronary Syndrome Prospective Audit (ACACIA) registry — have provided contemporary data about secondary prevention and resource gaps.

The SNAPSHOT ACS audit provides recent data pertaining to pre- and inhospital ACS care in Australia and New Zealand.12 The audit involved the collection of detailed information about 4398 consecutive patients admitted to 483 public and private hospitals across the two countries over 2 weeks in May 2012.12 The ACACIA registry enrolled 3402 ACS patients from 39 hospitals across Australia (25% rural, 75% metropolitan).3 CONCORDANCE is an ongoing (prospective) clinical initiative that provides continuous real-time reporting on the clinical characteristics, management and outcomes of hospitalised ACS patients to clinicians, hospital administrators, sponsors, interested stakeholders and government.15 CONCORDANCE currently includes about 5200 patients from more than 40 hospitals.

As a group, the Australian ACS registries provide detailed and contemporary information about inhospital care. All three registries show suboptimal rates of pharmacotherapy and cardiac rehabilitation referral. The proportion of patients prescribed at least four of the five indicated pharmacotherapies at discharge was 68% in CONCORDANCE16 and 65% in SNAPSHOT ACS.1 2 In terms of cardiac rehabilitation, 58% were referred in CONCORDANCE17 and 46% in SNAPSHOT ACS.12

A recent article resulting from SNAPSHOT ACS reported that only 27% (628/2299) of Australian and New Zealand patients admitted to hospital for ACS received a combination of guideline-recommended medications, referral to rehabilitation and basic lifestyle advice before hospital discharge.11 The authors suggested that a greater focus on inhospital delivery of preventive care is needed to provide the essential foundation for lifelong secondary prevention.11

However, it should also be noted that registries have limitations, such as the reliance on inhospital documentation, and they may not be able to determine individual contraindications.

The challenges in implementation of secondary prevention

There are well known limitations in the implementation of secondary prevention after ACS. Despite proven effectiveness and clear recommendations in best-practice guidelines,18 there is poor use of effective medications, cardiac rehabilitation and adherence to lifestyle recommendations.19 In the recent AusHEART survey of more than 5000 Australian general practice patients, 1548 had clinically expressed cardiovascular disease, and only half of these were following recommended treatments.20 Valid national data on participation in cardiac rehabilitation and exercise therapy are not available, but estimates from local and international reports indicate that less than 30% of eligible patients participate in such programs.10,2 1 Compliance with lifestyle change is no better. It was recently reported that among 18 809 patients from 41 countries who had experienced ACS, only 30% of patients adhered to diet and exercise recommendations, and about two-thirds of smokers had quit smoking 6 months after their event.22

Overall, it is difficult for a coherent strategy to emerge when the volume of evidence describing and reporting disparate models of delivery continues to expand.13 In reality, about 70% of Australian secondary prevention programs continue to follow the traditional cardiac rehabilitation model of structured and group-based exercise with education sessions.19 These programs are associated with well documented barriers, including the need for transport, poor health provider support, limited time frames and minimal individualisation. Thus, policymakers, health professionals and researchers are confronted by the need for increased services to improve access and equity, but often with significant challenges coupled with finite and declining resources.13

Opportunities for improved access to and uptake of secondary prevention

A recent blueprint for reform summarises the outcomes of a national summit that aimed to improve implementation of secondary prevention in Australia.23 The report identifies stakeholder consensus for an approach where each patient’s acute episode of care, particularly at discharge and follow-up, is patient-centred. The report also highlights the current challenges associated with the existence of a divide between hospital and general practice care. That divide is apparent in terms of a definition of prevention and rehabilitation, patient communication, service provision, funding and data collection. The summit report also summarises opportunities for improved implementation of secondary prevention.23 Although not exhaustive, the published opportunities present practical suggestions that cover a range of issues, including public health support, better coordination and use of existing strategies, workforce, quality assurance and technology, as follows:

Increased delivery of comprehensive secondary prevention in primary care
- Provision of connected care through a case-management approach, improved communication, and greater provider education relating to secondary prevention, behaviour change techniques and self-management strategies.
- This model of care should be coupled with specific incentive programs similar to those already available for diabetes and asthma management.
- Possible development of a role for cardiac care coordinators, who would ideally be recognised by Medicare. These coordinators could collaborate with the person with ACS and other members of the care team to achieve mutually agreed clinical targets, good health and wellbeing.
Increased focus on and awareness of the need for lifelong secondary prevention
- Potential for widespread media and public awareness campaigns to raise the profile and understanding of ACS as a chronic condition requiring lifelong management.
- Requires linking with and engagement of state and federal governments, Medicare Locals, consumers and private health funds to facilitate sustainability.
Better integration and use of existing services
- Better use of existing initiatives, such as cardiac rehabilitation, chronic disease management plans, private health insurance programs, and other initiatives including the Home Medicines Review, Heart Foundation programs (eg, Heartmoves) and Quitline.
- Better use and awareness of these existing programs may require development of a comprehensive inventory, database or website, and could be the domain of a national preventive agency, ideally in collaboration with state governments, Medicare Locals and non-government organisations, but could otherwise be housed by an established non-government organisation such as the National Heart Foundation.
Data monitoring and quality assurance
- Identification of performance measures to enable cross-national comparison is needed for post-hospital care. This should incorporate measures of service delivery as well as health outcomes, including hospital readmissions and coronary heart disease deaths.
- This could occur via an online registry and/or electronic medical records and data linkage.
Embracing new technologies
- New technological developments have seen a rapid rise in devices and trials aimed at managing cardiovascular disease risk factors, medication adherence and providing coordinated care.
- Ongoing development and testing of technological advances may facilitate greater access to secondary prevention.
- Examples of e-health approaches include the use of text messaging, telephone-delivered care, development of websites and smartphone apps and remote monitoring and remote delivery of programs.

The increasing role of primary care in ACS management

ACS requires lifelong management, and primary care is ideally positioned to provide this care to patients.23 There is a need to go beyond giving patients a discharge summary and advising them to make an appointment. In one study, about 20% of patients did not have a discharge summary forwarded to their general practitioner, and 68% of GPs rated the information in the summaries they received as “very good” to “excellent”.24

In Australia, there has been a substantial shift in the payment system for GPs towards incentives that encourage evidence-based care of patients with chronic diseases in line with a disease management framework that emphasises systematic, coordinated care and self-management. The Australian Government’s commitment to a National Primary Health Care Strategic Framework provides an opportunity to establish primary care systems and funding models to enable people who are at high risk of a cardiovascular event to be identified early for preventive care.25 The National Heart Foundation maintains that a well developed primary care framework for secondary prevention will increase referral and access rates to secondary prevention services, enhance continuity of care and improve coordination of services between hospitals and the community.26

Conclusion

Despite guideline advocacy, uptake of proven secondary prevention strategies for heart disease is suboptimal. Australian registries provide contemporary data that reinforce the evidence–practice gaps in secondary prevention. Trial and cohort data highlight the need to commence prevention early if we are to narrow the divide between hospital and the community, thereby achieving better individual, provider and system-level outcomes. Patients often leave hospital without systematic follow-up and with an unclear picture of how and if they will be managed and supported on the next phase of their chronic disease journey. Potential opportunities to bridge the divide include development of an incentive scheme in primary care, development of a cardiac care coordinator role to work in concert with treating doctors and patients, better use of existing services, effective data monitoring and embracing new technologies.

Reducing dietary salt intake and preventing iodine deficiency: towards a common public health agenda

Public health advocates coordinate programs to reduce salt intake and prevent iodine deficiency

After decades working in parallel, public health advocates for dietary salt reduction and those seeking to achieve the elimination of iodine-deficiency disorders through salt iodisation have harmonised their agendas.

The World Health Organization (WHO) promotes reducing dietary salt intake as a cost-effective strategy to reduce the burden of non-communicable diseases,1 but it also recommends universal salt iodisation to prevent and control iodine-deficiency disorders. Parallel implementation of both policies could be counterproductive.2 However, a meeting convened by the WHO and the George Institute for Global Health, in collaboration with the International Council for the Control of Iodine Deficiency Disorders Global Network (ICCIDD–GN), in Sydney in March 2013, agreed on a new approach to consolidate the two agendas. Technical experts came together with WHO representatives to discuss the potential for maximising the impact of dietary salt reduction and iodine-deficiency elimination programs through improved coordination.3

High salt intakes are a primary cause of high blood pressure, one of the main risk factors for heart attack, kidney disease and stroke, which are leading causes of death and disease worldwide. Member states of the United Nations endorsing the global monitoring framework and voluntary global targets for the prevention and control of non-communicable diseases at the United Nations World Health Assembly in 20134 agreed to achieve a 30% reduction in population salt intake by 2025. Working with the food industry to reduce the amount of salt added to processed foods and restaurant meals, campaigns to change consumer behaviour and efforts to improve the food environment through work in schools and the workplace will be the cornerstones of these efforts.5

Iodine-deficiency disorders are another major global health problem; they cause impaired cognitive development, reduced intelligence quotient (IQ), congenital anomalies, cretinism, and endemic goitre and other thyroid conditions. It is estimated that 1.9 billion people worldwide remain at risk of insufficient iodine intake. The WHO, United Nations Children’s Fund (UNICEF) and the ICCIDD–GN recommend an intake of 150 µg iodine daily for non-pregnant, non-lactating adults and 250 µg daily for pregnant and lactating women. Food-grade salt is the primary vehicle for dietary iodine fortification and is preferred because the technology is simple, iodine levels in salt can be easily monitored, salt consumption is mostly stable throughout the year, and salt is affordable. The estimated annual cost attributable to iodine-deficiency disorders in the developing world is $36 billion with just $0.5 billion required to deliver effective salt-iodisation programs.6

The public health goals of salt reduction and salt iodisation can both be achieved if the concentration of iodine in salt is increased as salt intake is reduced. The inherent challenge that salt will continue to be viewed as healthful for the iodisation program may remain, but can be overcome by full implementation of the universal salt iodisation strategy such that all salt used in both human and animal foods is iodised so that notionally ‘‘healthy” iodised salt does not have to be sought out by the population.

To date, dietary salt-reduction efforts and iodine-deficiency disorder elimination programs have largely operated independently. Improved coordination between programs will help to ensure consistent messaging, enhance implementation and reduce costs for monitoring. Both programs are also based on multistakeholder engagement, including close links with the food industry and civil society. Specific areas for future coordination of the two programs were identified as: policy development; research, monitoring and evaluation; and advocacy and communication.

It was proposed that the WHO and UNICEF would lead the development of the coordinated program, working with ICCIDD–GN, the World Health Organization Collaborating Centre on Population Salt Reduction at the George Institute for Global Health in Sydney and other technical advisers. The priority action will be to encourage national governments to develop strategies that ensure universal salt iodisation, reduce population salt consumption, and track levels of salt and iodine intake such that both sets of public health goals are achieved.

The Sydney forum was the last in a series of WHO meetings to provide countries with tools to reduce population salt intake. The collaborative program of work on salt reduction and iodine-deficiency elimination is the final plank in the strategy. A series of regional initiatives have since been held, and iodine levels are now being monitored as part of several national dietary salt-reduction projects. The coordinated approach has also been incorporated into the “SALT Toolkit” currently being developed by the WHO to provide practical advice to support countries to achieve the new global salt-reduction targets.

In 2009, we saw the introduction of mandatory iodine fortification of salt in bread in Australia to help solve the problem of re-emerging iodine deficiency.7 While this is a step in the right direction and has already corrected iodine deficiency in children and adults, although not in pregnant women, it will not detract from ongoing salt-reduction efforts in Australia. The fortification of all food-grade salt with iodine (universal salt iodisation) would be the most effective approach to ensuring that the benefits of fortification reach at-risk groups in Australia while remaining in harmony with initiatives to reduce dietary salt intake.8