AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.

Germanwings tragedy prompts mandatory reporting calls

The AMA has warned that calls for the mandatory disclosure of information around the mental health of airline flight crew could dissuade troubled pilots from seeking necessary treatment.

There have been proposals to require treating doctors to report airline pilots and flight engineers who have mental health problems following the deliberate downing of a Germanwings airliner carrying 150 passengers and crew in the French Alps late last month.

Investigators have concluded that 27-year-old co-pilot Andreas Lubitz deliberately flew the Airbus A320 plane into the side of a mountain on 25 March after locking the plane’s captain out of the cockpit. All on board were killed.

It has been reported that Mr Lubitz suffered bouts of depression, was concerned about his eyesight, and had received treatment for suicidal tendencies before obtaining his pilot’s license.

Last week Germanwings’ parent company Lufthansa revealed that Mr Lubtiz had notified the company of his struggle with depression during his pilot training course in 2009.

The case has prompted some to call for laws requiring medical practitioners to report pilots being treated for mental illness to aviation authorities.

But the AMA and other medical experts have questioned the necessity or usefulness of such a measure.

Australasian Society of Aerospace Medicine President Dr Ian Cheng told Medical Observer Designated Aviation Medical Examiners who gave pilots their compulsory annual health checks were already legally obliged to report any significant health condition.

Dr Cheng said that before Australian aviation authorities decided several years ago to allow pilots to continue flying after a depression diagnosis, as long as they were receiving treatment and met strict conditions, the problem had been driven underground because pilots with depression were afraid of losing their license.

AMA Vice President Dr Stephen Parnis warned against any rush to institute mandatory reporting obligations for airline pilots receiving medical treatment.

“Doctors may disclose information about a patient’s medical record if they judge there is a serious threat to the life, health or safety of an individual or the public,” Dr Parnis told Medical Observer. “The last thing we want is a shopping list of things requiring mandatory reporting. That would undermine the confidence of the patient in the doctor.”

The AMA Vice President said mandatory reporting rules for medical practitioners had been blamed for deterring some doctors from seeking help, and there could be a similar risk with such rules for pilots.

Revelations that Mr Lubitz had notified Lufthansa about his battles with depression is likely to intensify the focus on how to best monitor and manage pilots with mental health issues.

Adrian Rollins

Missing malaria? Potential obstacles to diagnosis and hypnozoite eradication

Poor specimen collection and limited availability of primaquine may be putting patients at risk

Recently, one of us experienced an episode of probable malaria on returning from fieldwork in the Solomon Islands. Although a clinical diagnosis of malaria was made, and the illness responded to empirical therapy with artemether–lumefantrine (Riamet, Novartis), a laboratory diagnosis was not achieved.

Suspected malaria in travellers who have returned to Australia from overseas will present without notice and, owing to the often severe nature of this illness, will require immediate attention. This may occur in localities where personal consultation with an infectious diseases physician is not possible. Primaquine for the eradication of malarial hypnozoites from the liver may not be readily available. In this article, we aim to provide brief expert guidance on the diagnosis of malaria, the use of primaquine for eradication therapy and the implications of the limited availability of this treatment in Australia.

Patients presenting with fever should be questioned about their travel history. Clinicians should be mindful that malarial relapse (Plasmodium vivax and P. ovale) or recrudescence (P. malariae) may occur months, or even years, after primary infection. Further, relapse may be the first symptomatic presentation.1 Therefore, any patient with pyrexia and a history of travel to an endemic area in the past 3 years might be considered as potentially having malaria.2

Initial investigation

Clinical suspicion should be raised in patients who demonstrate specific symptoms associated with the disease, such as relapsing fever, rigors or chills. Note that immune-naive people may not always present with the typical cyclical fevers of malaria.2,3 Unless a separate, simultaneous, pathological process is present (such as concurrent dengue fever, other infections or a non-infectious cause), the presence of localised symptoms, a rash, or the onset of symptoms within the prepatent period (7 days) after initial travel to an endemic area may assist in excluding a diagnosis of malaria.3

Laboratory investigation of patients who potentially have malaria requires blood collected in EDTA anticoagulant tubes immediately on presentation. Both thick and thin film microscopy should be requested. As morphological changes in parasites will develop within hours, blood should be delivered to the laboratory within an hour of collection. Immunodiffusion-based rapid diagnostic antigen tests should also be performed if available, but these tests do not supplant microscopy.4 Currently, there is no consensus regarding the correct timing and number of specimens required to exclude a diagnosis of malaria. It appears that a single collection is often sufficient for diagnosis.3 However, further specimen collections taken shortly after the onset of febrile paroxysms may be necessary for the detection of P. falciparum malaria, as this species is sequestered in the deeper microvasculature at other times during its life cycle.2,3

Returned travellers who have used malaria prophylaxis may occasionally still acquire malaria, even when they strictly adhere to the dosage regimen.1 In such cases, the parasitaemia is often very low, requiring multiple blood collections for diagnosis, but individuals with little or no prior exposure will still be significantly unwell. Very rarely, malaria may be acquired during short stays in endemic areas; for example, during airport stopovers.5

The role of PCR

Polymerase chain reaction (PCR) testing represents a more recent and highly efficacious method for the detection and speciation of malaria in febrile patients. Nevertheless, specimen collection during an afebrile period may lead to a false-negative PCR test result. Due to its expense and limited availability, PCR testing is currently restricted to confirmation and speciation, or cases where a malaria diagnosis is strongly suspected but microscopy and antigen testing are negative.

Primaquine

Infection with relapsing species of malaria (P. vivax and P. ovale) requires eradication of hypnozoites from the patient’s liver using primaquine. P. ovale malaria requires half the dose of primaquine used in cases of P. vivax. Some strains of P. vivax acquired in the South Pacific and South-East Asia may need higher doses of primaquine for eradication.6 Tests for glucose-6-phosphate dehydrogenase deficiency should be performed on all patients before primaquine therapy, in order to avoid potentially life-threatening oxidative events in enzyme-deficient individuals. Currently, primaquine is erratically available in hospital pharmacies and may not be stocked at all in smaller, regional facilities. Also, it cannot be accessed under the Pharmaceutical Benefits Scheme, despite being indicated in Australian therapeutic guidelines.6 These factors limit its availability to hospitals and community pharmacies. For example, when malaria presents and is treated in general practice, the limited availability of primaquine could result in this important therapy not being administered, especially in regional, rural and isolated areas.

In summary, given increasing rates of travel to endemic areas by Australians, clinicians may be faced with a case of malaria at any time. Hence, it is important that they have the correct specimen-collection and treatment protocols at hand. Primaquine should be available through the Pharmaceutical Benefits Scheme to patients treated in a community setting.

Measles: an important cause of fever and rash in a returned traveller

Clinical record

A previously well 21-year-old woman went to her general practitioner in September 2013, before a holiday to Bali, Indonesia, and was vaccinated for hepatitis A and typhoid. Malaria prophylaxis was not prescribed, as her intended destinations were deemed to confer a low risk of acquiring malaria. Notably, she had not received routine childhood vaccinations because of parental preference, receiving only “homeopathic immunisation” in infancy.

During October 2013, she spent 11 days in Bali, primarily in large holiday resorts in the Kuta district, but she did travel to a rural village. She reported receiving several mosquito bites during her trip.

Two days before her return to Australia, she developed fever, vomiting and diarrhoea. These symptoms continued until she presented to her GP 1 day after returning to Australia. She was prescribed metronidazole and loperamide and her diarrhoea resolved, but nausea and lack of appetite persisted. The following day she developed chills with associated headache, myalgias and cough — these symptoms continued until she presented to hospital 7 days after her return to Australia.

On initial review in hospital, 9 days after the onset of her illness, the patient was febrile (38.5°C) and had a faint, blanching maculopapular rash over her torso, which became more confluent over the following days (Figure A). A full blood examination showed mild lymphopenia (lymphocyte count, 0.6 × 109/L [reference interval (RI), 1.0–4.0 × 109/L]). Mild hepatitis was also noted with an elevated alanine aminotransferase level of 120 U/L (RI, < 33 U/L). Three sets of thick and thin blood films were sent to the laboratory, as were three sets of blood cultures along with stool and urine samples for culture and microscopy. Serological tests were performed for dengue fever virus and NS1 antigen as well as for chikungunya virus. A throat swab was sent for respiratory virus multiplex polymerase chain reaction (PCR) testing, and droplet contact precautions were instituted in managing the patient.

Two days after she presented to hospital, the patient developed conjunctivitis, associated with progression of the rash to involve her face. Examination of the buccal mucosa at this stage revealed clusters of white granules (Figure B) consistent with classic Koplik spots, allowing a clinical diagnosis of measles to be made. A throat swab for measles virus PCR testing was subsequently taken, and the diagnosis was confirmed. The genotype of the measles virus was consistent with that of other index cases originating from Bali.

In accordance with the guidelines of the Victorian Department of Health (DOH),1 contact tracing was performed on 128 patients and their family members potentially exposed in the emergency department before the patient was isolated. Under DOH protocols, 18 contacts received prophylactic vaccination with the measles, mumps and rubella (MMR) live attenuated vaccine and four received normal human immunoglobulin 0.5 mL/kg (maximum, 15 mL). To date, the DOH has not identified any secondary cases.

Two days later, the patient’s condition had improved clinically and the Koplik spots on the buccal mucosa had resolved (Figure C). She remained in hospital for 5 days for monitoring of probable measles hepatitis and to prevent further community exposure. Stool culture subsequently grew Campylobacter jejuni; this did not require antibiotic therapy and explained the initial clinical presentation with a diarrhoeal illness that preceded the onset of the typical measles rash and conjunctivitis.

Measles is a highly contagious RNA virus transmitted via respiratory secretions and aerosol. The incubation period is typically of 10–14 days duration, and it is followed by a prodrome of 2–4 days with the development of fever, cough, conjunctivitis and coryza. At this stage, Koplik spots may be visible on the buccal mucosa and may persist for a few days before coalescing or sloughing. Koplik spots are a pathognomonic sign of measles and were first described in 1896 by paediatrician Henry Koplik.2 They have been described as “grains of salt on a red background”.3 The exanthematous phase that follows is characterised by a maculopapular rash, usually beginning on the face before becoming generalised. A number of complications can occur, the most serious of which include measles encephalitis or the much rarer delayed-onset subacute sclerosing panencephalitis.

In our case, concurrent Campylobacter gastroenteritis was thought to be the reason for the unusual initial presentation with diarrhoeal symptoms, and why measles was not initially considered. Consequently, there was substantial exposure of staff and patients in the emergency department to this patient’s infection. The development of conjunctivitis, progression of the rash, and the presence of Koplik spots prompted the initiation of contact tracing based on a clinical diagnosis, and before the confirmatory PCR result. This proved to be crucial in being able to administer the MMR vaccine to susceptible contacts in the 72-hour postexposure window.

Endemic measles has been eliminated from Australia for some time.4 However, sporadic cases continue to occur in non-immune travellers, their immediate contacts, and others in subsequent chains of transmission.

Measles vaccination was licensed in Australia in 1968, and people born before 1966 may generally be considered immune because they are likely to have been exposed to circulating wild-type virus.5 In Australia, about 92% of children have received two doses of MMR by 60 months of age, but vaccination coverage is lower in certain regions.6 There have been recent measles outbreaks in several European countries because of a decline in vaccination rates.7 As measles is one of the most highly transmissible infectious diseases known, with an estimated basic reproductive number (the average number of cases generated by one case in a susceptible population) of 12 to 40,8 very high rates of vaccine coverage are required to prevent local outbreaks.9

Measles notifications in Australia have been trending upwards in the past few years (Box). Of the 37 Victorian cases notified in 2013, 16 were imported cases and 20 were secondary or tertiary cases linked to an overseas-acquired case. None of the Victorian patients with notified cases were known to be fully vaccinated. The most common countries of acquisition were Indonesia and Thailand (Victorian DOH, unpublished data, April 2014). From January to May 2014, 209 cases have been notified in Australia, with all states and territories apart from Tasmania reporting cases. This already exceeds the highest number of cases reported per year in Australia since 1999.

As was the case in our patient, ensuring that two documented doses of MMR vaccine are administered before travel is an often forgotten part of the pretravel consultation. A verbal recollection of vaccination or prior infection is often inaccurate. An alternative option is serological testing for the presence of measles IgG.

If diagnosis and appropriate infection control measures11 are delayed, follow-up of contacts can be resource intensive. In Victoria, the DOH traces and manages community contacts. However, health care-associated exposures remain the responsibility of the individual institution. In cases such as ours, the cost and resources involved can be substantial.

Lessons from practice

Measles is an important and often missed part of the pretravel consultation; it should be considered a routine aspect of travel vaccination decision making.
Consider measles as a differential diagnosis in febrile returned travellers born after 1966, especially if vaccination records are incomplete and the incubation and clinical presentation are consistent.
Early isolation with airborne precautions is recommended in all potentially measles-susceptible patients who present with fever and rash. It can help to minimise the cost of subsequent contact tracing and measles prophylaxis.

Notifications of cases of measles in Australia by year, 2002–201310