COPD is significantly underdiagnosed
Associate Professor Debbie Rigby FPS[/caption]
Nicolette Ellis MPS[/caption]
A national education program for pharmacists funded by the Australian Government under the Quality Use of Diagnostics, Therapeutics and Pathology program.[/caption]
Both these disorders can occur separately, but if they co-occur, this is termed COMISA. Approximately 30–50% of people with OSA have comorbid insomnia, and 30–40% of people with chronic insomnia have comorbid OSA.9,12 A recent population-based study reported that 11% of Australian adults report symptoms of COMISA.13
The ‘gold standard’ measure of OSA presence and severity is an overnight sleep study (Table 1).25 The most common single metric to determine OSA presence and severity is the apnoea-hypopnoea index (AHI), representing the average number of airway narrowing and closure events occurring per hour of sleep.24 Identifying the most appropriate management approaches for OSA also requires consideration of lifestyle factors, symptoms and consequences, occupation, chronic conditions, and other sleep conditions. Self-report questionnaires may be used to screen for a high-risk of OSA and identify patients suitable for referral and consideration of overnight sleep study assessment (Table 1).24
Although evidence-based guidelines unanimously recommend avoiding long-term use of hypnotics, they are indicated for a minority of patients that present with severe acute insomnia that is causing significant psychological distress or functional impairment.29 Most people who experience short-term insomnia symptoms (1–2 weeks) can be reassured that sleep will return to ‘normal’ after the underlying precipitant has subsided, without targeted treatment (i.e. hypnotic medicines).29,33 For those who experience persistent insomnia, cognitive behavioural therapy for insomnia (CBTi) is the first-line treatment. Pharmacotherapy may be considered in patients with severe insomnia that is causing significant impairment or distress (e.g. times of acute work/exam stress, bereavement).34
Tailored recommendations for non-CPAP therapies may also be provided to patients with different levels of OSA severity and presenting features.17 For example, weight management advice where indicated, positional devices (in the presence of supine-predominant OSA), mandibular advancement splints (in patients with mild-to-moderate OSA), and upper airway surgery are effective treatments that may be tailored to each individual patient.24
Dr Alexander Sweetman (he/him) PhD
Senior Program Manager, and chair of the psychologist education subcommittee at the Australasian Sleep Association.
Associate Professor Sutapa Mukherjee (she/her) MBBS, FRACP, PhD
Respiratory and sleep physician, Associate Professor of Respiratory and Sleep Medicine at Flinders University and past President of the Australasian Sleep Association.
Professor Garun Hamilton (he/him) MBBS, FRACP, PhD
Respiratory and sleep physician, clinical professor at Monash Health and Monash University and President of the Australasian Sleep Association.
Professor John Turnidge AO[/caption]
Outbreaks of whooping cough, meningococcal B as well as increased incidence of antibiotic-resistant infections are placing Australian children at risk.
Australian Pharmacist explains how pharmacists can drive patient education and vaccination campaigns to increase vaccine uptake and help curb antimicrobial resistance.
Whooping cough cases spike
Australia is in the midst of a whooping cough wave, with 28,437 cases reported this year. This is the highest recorded number of pertussis cases since 2011, when 38,749 new cases were reported.
There is normally an outbreak of pertussis every 3–4 years as immunity wanes, said Associate Professor Sanjaya Senanayake, Infectious Diseases Physician and Director of Hospital at Canberra Hospital.
‘The last big one we had was in 2016 [due to] COVID-19, because of social distancing, [leading to] a huge drop in a lot of respiratory infections such as influenza and RSV,’ he said.
‘[But now] people have been infecting each other with whooping cough, with our immunity lower than it’s ever been.’
Since we have moved to an acellular diphtheria, tetanus, and pertussis vaccine, which has a better adverse effects profile than whole cell vaccines, it’s important that patients are aware that the immunity of these vaccines is less effective, said A/Prof Senanayake.
‘After about 10 years, your immunity from that vaccine wanes, and that probably starts within a couple of years of having the vaccine,’ he said.
To boost immunity to whooping cough, limit spread of the virus and reduce harm, pharmacists should promote vaccinations and booster doses in accordance to the National Immunisation Program (NIP) to:
- pregnant women between 20 and 32 weeks gestation
- babies who are 2,4,6 and 18 months of age
- children who are 4 years of age
- adolescents who are 12 to 13 years of age.
Pharmacists should check the Australian Immunisation Register (AIR) to identify people who have missed doses of pertussis-containing vaccines.
‘It’s also important that all people in contact with newborn babies have had a pertussis vaccine within the previous 10 years,’ said NSW Health’s Director of Communicable Diseases Dr Christine Selvey. ‘People aged 5 years and over can receive pertussis vaccination from GPs, pharmacist immunisers, and Aboriginal [health] services.’
Meningococcal B spreads
There have been more than 92 cases of meningococcal disease reported this year. Numbers have decreased since the meningococcal C vaccine was introduced in 2023, with Australia achieving strong community immunity against serogroups A, C, W and Y, with the vaccine covered under the NIP.
However, there is less protection against serogroup B – which is fuelling an outbreak in Far North Queensland, with three children recently infected. Two cases were also recorded in Western Australia, although one was in an adult infected with serogroup Y.
The meningococcal B vaccine is only free under the NIP for:
- Aboriginal and Torres Strait Islander children aged 2, 4, 6 (with eligible medical conditions) and 12 months of age.
- people of all ages with asplenia and hyposplenia, complement deficiency and those receiving treatment with eculizumab.
There are some jurisdictions that also provide state-funded meningococcal B programs, including:
- South Australia for infants aged 6 weeks to 1 year of age and year 10 students via a school program
- Queensland to all infants and children aged six weeks to two years, and adolescents aged 15 to 19.
However, uptake of the vaccine is yet to take off in Queensland after it rolled out this year, with 40,000 children under two years old and 386,000 adolescents aged 15–19 not fully immunised.
Community pharmacist and PSA WA Branch Committee Member Negar Almassi MPS said she has encountered an increase in vaccine hesitancy across the board.
‘We engage with patients about [whether] they could benefit from a booster for their children, or if they’ve never had a vaccine before, would they like to consider it,’ she said. ‘And they often respond with a quick dismissal that they’ve “been vaccinated for everything”.’
This can sometimes mean gaps in protection are prolonged before another healthcare provider can engage with them again, Ms Almassi said.
By accessing patients’ Australian Immunisation Register (AIR) records, pharmacists can explain where the gaps are according to the immunisation schedule – including for meningococcal vaccines.
‘Then a lot of people, especially now with the accessibility of pharmacist vaccination, go away, think about it, make a booking and come back,’ Ms Almassi said.
If pharmacists know their patients have children, they should ensure they are initiating conversations about childhood and adolescent boosters, and if they might have accessed those through outreach programs in schools, for example.
But they should bear in mind that the cost of the three-dose meningococcal B vaccine, which can be up to and over $100 per dose, is often a barrier to access, she said.
‘We generally end up engaging with patients about the benefits of the vaccine, starting the conversation by explaining why something’s good for the patient,’ she said.
Patient education on the cost versus benefits is key – particularly for at-risk groups. This can include people whose immune response may have waned over the years due to medicines or other illnesses.
‘Adults who are, for example, working directly with patients in the medical field, taking care of patients who are immunocompromised, or those who work with students and/or in boarding houses should consider the additional risks from exposure and transmission and may benefit from having the vaccine,’ Ms Almassi said.
‘At the end of the day, it comes down to [whether] it’s something they can afford,’ she said. ‘And if they can’t afford it, they take the education with them about the risk factors, so if their circumstances change they can come back for the vaccine.’
Antibiotic-resistant infections grow in children
New Communicable Diseases Intelligence research found that almost one in 10 children who have a bloodstream infection are caused by a multi-drug resistant organism – with Staphylococcus aureus being the key culprit in children aged 1 year and older.
Despite a gradual decrease in antimicrobial use in the community, overprescribing remains an issue, said Dr Brian Chia MPS, community pharmacist, lecturer in Pharmacy and Pharmacology at the University of South Australia and member of the PSA SA Early Career Pharmacist working group.
‘According to the 2023 AURA report, approximately 50% of children under 9 years of age receive at least one antibiotic a year,’ he said.
Prescribing rates for respiratory-related illnesses were higher than expected, with antimicrobials rarely required to treat these illnesses, found the report.
‘Respiratory illnesses are often viral in origin and don’t require antibiotics,’ added Dr Chia.
Pharmacists can help to contribute to antimicrobial stewardship by educating patients, parents and carers about appropriate use of antimicrobials, leveraging awareness events such as World Antimicrobial Awareness Week, held from 18–24 November every year, with this year’s theme being Educate. Advocate. Act now.
‘For example, if an antibiotic was prescribed for a child for an independent infection, making sure [parents] are aware that they need to adhere to the prescription,’ he said.
This includes discussing duration of use, in accordance with PSA’s cautionary advisory label for antibiotics, where pharmacists should specify the number of days the antibiotics is required for, as advised by the prescriber
‘Instead of using the words ‘until all finished’, we should specify how many days the antibiotic is required for,’ said Dr Chia.
‘Because a lot of doctors are still prescribing, “amoxicillin three times per day”, for example, so we need to explain whether the treatment is for 5 or 7 days, depending on the indication.’
Furthermore, Dr Chia said pharmacists should also promote symptom management.
‘Viruses are often self-limiting, so we can provide pain relief and hydration [treatment], he said.
‘And when we come across prescriptions where therapeutics are not optimised, we should collaborate closely with prescribers and always double check whether the dose is prescribed in accordance with Therapeutic Guidelines.’
