I am writing to update you on the COVID-19 outbreak situation in Australia and internationally, and to outline the Commonwealth’s current and future support for the central role you are playing in our national response.
There has been a significant amount of advice and information already provided to health professionals. I recognise that the evolving nature of this outbreak has required public health advice to evolve rapidly with the emerging epidemiology. This has made it more challenging for people to keep it up to date and has led to some confusion and a perception of inconsistency of information / information gaps. We are addressing this and will enhance communication to primary care, starting with this letter and followed up by twice weekly newsletters to all GPs in Australia together with regular GP Webinars. There is the very real possibility that larger scale community outbreaks will occur across Australia, placing a significant burden on the health system, in which you play an absolutely critical frontline role.
Situation as at 8 March 2020
As you will be aware, the international situation has changed materially in the last few weeks. Cases have now been reported in over 90 countries, some with sustained widespread community transmission. Despite our success in containing the initial cases associated with travellers from China, we are now seeing the expected second wave of imported cases from a number of countries (most notably Iran). We have evidence of limited community transmission in Sydney. New imported cases are being seen every day, some from countries not previously identified as high risk. It is no longer realistic that we will be able to prevent further importation of cases, and further local outbreaks seeded from imported cases are likely.
Before I outline to you what we are doing to improve our support of the Primary Care response to COVID-19, I will share with you our current state of knowledge about COVID-19. It is clear that a great majority of people with COVID-19 infection (>80%) have mild disease, not requiring any specific health intervention. This mild disease contributes to the high transmissibility of the virus, as many people with infection will continue working and interacting with the community because their symptoms are so mild.
There is very little evidence of significant COVID-19 disease in children. Initially, it was suggested that children were less susceptible to infection, but more recent evidence supports the fact that children may be infected, in many cases without being aware of symptoms. The role children play in transmission is unknown.
The greatest concern remains the relatively small number of cases with severe pulmonary disease, some with a fatal outcome. We still don’t have certainty about the Case Fatality Rate (CFR) for COVID-19, as the estimates from some countries appear to be over-estimated by under ascertainment of mild cases. It seems reasonable to assume a CFR of around 1% in a country like Australia with a strong health system - it may even be lower. We do know that the majority of fatal outcomes have been seen in the elderly, or people with comorbidities.
Current approach to response
At present our response, under the Australian Health Sector Emergency Response Plan for COVID-19 (www.health.gov.au/Covid19-plan), is focused on early identification of cases, isolation, contact tracing and quarantine where indicated - under the supervision and direction of the public health unit in each state or territory.
If more widespread community transmission occurs, the focus will shift to early detection and home isolation of cases to prevent or delay transmission, with less emphasis on identifying contacts who are generally unlikely to be very infectious, unless they themselves also develop symptoms. We will let you know if and when such a shift in the public health response is indicated. Even in a large scale outbreak, isolation of as many cases as possible can play a critical role in flattening the epidemic curve.
Testing for COVID-19 infection is currently focused on those people with respiratory symptoms who have a relevant travel history or who have been in contact with cases. Testing has largely been done so far by public health laboratories, but I am pleased to advise that we are working on further expanding access under Medicare to private pathology laboratories for the SARS CoV2 virus (COVID-19 virus). It is important at this time that all positive results are immediately reported to the state/territory public health unit, whose contacts are provided at the end of this letter.
Reducing exposure in health care settings
It is clear that, with increasing cases of COVID-19, there will be benefit in more sophisticated strategies to prevent the co-mingling of suspect or proven cases with other patients in health care settings. We have previously advised members of the community that, if they believe that they could potentially have or be exposed to COVID-19, they should phone their GP or local health service and seek advice before attending. If followed, this practice has allowed the practice or hospital to make arrangements for isolation and testing.
As case numbers increase, there is a need for new strategies. We will shortly be announcing to the community an expansion of the COVID-19 national hotline (1800 020 080). This hotline will operate 24 hours a day, seven days a week. Expansion of the national hotline is part of our strategy to support general practices manage the flow of cases.
People who believe that they may have been exposed to or have COVID-19 will be encouraged to call the national hotline to seek advice. A standard protocol for the call centre operators will be provided. We will share call centre information and the triage protocol with you shortly, as many GP practices have asked to have the same protocol available for their reception staff to ensure consistent messaging and patient disposition.
We are also actively developing across the nation a series of COVID-19 respiratory clinics, dedicated to the assessment of suspected cases and early treatment of patients with mild symptoms. Some of these are being established by state and territory health services and we are looking at complementing these with a limited number of primary care respiratory clinics at volunteer general practices who have the appropriate infrastructure and capability. Additional infection control training and support will be provided.
The Primary Health Networks (PHNs) in collaboration with the GP Colleges and other stakeholders will be rapidly seeking interest from practices who might wish to be involved. A time limited separate funding model will be developed, cognisant of the nature and costs of this specialised practice, and appropriate personal protective equipment (PPE) will be provided to these clinics. Rural and regional areas will need special consideration and arrangements.
Some patients will continue to contact their usual general practice and want assessment and advice from that trusted source. It will clearly be helpful for clinic reception staff to have the standard triage protocol available. Practices may choose (as per the triage protocol) to refer patients to the dedicated clinics or health services, to undertake a remote telemedicine consultation (see below) or to make safe arrangements to see the patient at the clinic or in their place of residence.
Government is currently considering the time limited expansion of telemedicine MBS items to enable remote consultation of patients with suspected COVID-19 and at risk patients who will not want to be exposed to COVID-19 by attending the clinic. More details on these proposed telemedicine items will be announced very soon.
Some GPs have expressed concern about the availability of PPE, in particular surgical masks, which are the appropriate PPE for use with most patients with respiratory symptoms. A further 260,000 masks from the National Medical Stockpile were announced this weekend on top of the 750,000 already distributed to PHNs and we will work closely with PHNs to ensure appropriate supply arrangements.
We appreciate that it can be frustrating if only small numbers of masks are distributed at any one time. Masks are in very short supply worldwide and we need to conserve them at this time until our emergency procurement plan delivers a significantly enhanced stockpile in coming weeks. We recognise the need to supply GPs who are assessing potential COVID-19 patients and are focusing our efforts there.
There has been a change to messages about what PPE is required in the clinical assessment of potential COVID-19 cases. All of the evidence currently suggests that droplet spread is the main mode of transmission and that surgical masks are effective for routine care and non-aerosolising procedures (and much easier to appropriately fit than are P2 masks). Only where there is uncontrolled coughing are P2/n95 masks needed, and general practices will generally divert such patients to hospitals at this time. For your reference, the current PPE guidelines endorsed by the expert COVID-19 infection control committee is available on the Department of Health website, www.health.gov.au/Covid19-health-professionals.
In the meeting with primary care stakeholders last week, a commitment was made on a range of initiatives, many outlined above. We are very aware that additional work is needed in the residential aged care sector and for vulnerable groups, including Aboriginal and Torres Strait Islander Peoples. These have been the subject of separate planning workshops and will have their own strategies, which will be shared with you, acknowledging the roles of GPs in these areas.
We will also be undertaking a broad community education campaign on COVID-19. One of the important messages will be the value of standard hygiene messages (hand washing, cough etiquette, social distancing) in preventing transmission. I am sure that you will play a role in communicating that message to your patients along with general balanced information about this virus.
Please be on the lookout for our regular twice weekly communiques where we will be providing information about respiratory clinics, pathology testing, PPE, temporary MBS telemedicine items and the like. You will also be given details of the planned weekly webinars on COVID-19 that we will be conducting.
No-one can accurately predict how the COVID-19 outbreak will develop in Australia. Our collective response has to be flexible and collaborative.
The Australian Government has committed to provide the necessary resources to support the response in whatever form it needs to take. The critical role of primary care in this response is well understood and greatly appreciated.
Finally, can I apologise for this very long letter. We doctors hate reading long correspondence but there is a lot of information to convey. We will endeavour to keep our twice weekly newsletters on COVID-19 to one page!