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January 25, 2021
  • THE MAGAZINE OF THE NSW NURSES AND MIDWIVES’ ASSOCIATION
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Public Health

The big barriers to global vaccination: patent rights, national self-interest and the wealth gap

January 20, 2021 by Rayan Calimlim Leave a Comment

We will not be able to put the COVID-19 pandemic behind us until the world’s population is mostly immune through vaccination or previous exposure to the disease.

A truly global vaccination campaign, however, would look very different from what we are seeing now. For example, as of January 20, many more people have been immunised in Israel (with a population less than 10 million) than in Africa and Latin America combined.

Notwithstanding recent questions about the effectiveness of the initial single dose of the vaccine, there is a clear disparity in vaccine rollouts internationally.

That is a problem. As long as there are still existing reservoirs of a propagating virus it will be able to spread again to populations that either cannot or would not vaccinate. It will also be able to mutate to variants that are either more transmissible or more deadly.

Counterintuitively, an increase in transmissibility, such as has been found with the new UK variant, is worse than the same percentage increase in mortality rate. This is because increased transmissibility increases the number of cases (and hence the number of deaths) exponentially, while an increase in mortality rates increases only deaths, and only linearly.

Evolutionary pressure on the virus will inevitably favour mutations that make the disease more transmissible, or the virus itself more vaccine-resistant. It is clear, therefore, that every nation’s interest is in universal vaccination. But this is not the trajectory we are on.

Politics and profits

Fortunately, in the countries already vaccinating, the vaccine is (mostly) not allocated by wealth or power, but by prioritising those facing the highest risk. At a country level, however, national wealth is determining vaccine roll out.

Yet in the past we have managed to eradicate diseases worldwide, including small pox, a viral infection with much higher death rates than COVID-19.

There are two barriers that prevent us from rapidly pursuing a similar goal for the current pandemic:

  • big pharma is profit-driven and therefore keeps a tight lid on the intellectual property it is developing in the new vaccines
  • countries find it difficult to see beyond their national interest; not surprisingly, politicians are committed only to their own voters.

At this point, we don’t have a global system to confront either of these problems. Each vaccine’s patent is owned by its developer, and the World Health Organisation (WHO) is too weak to be the world’s Ministry of Health.

The polio vaccine model

Overcoming big pharma’s profit motive has been achieved before, however.

In 1955, Jonas Salk announced the development of a polio vaccine in the midst of a huge epidemic. The news initially met with scepticism. Even employees of his own laboratory resigned, protesting that he was moving too fast with clinical experimentation.

When a huge placebo–controlled clinical trial involving 1.6 million children proved him right, however, he declared that in order to maximise the global distribution of this lifesaving vaccine his lab would not patent it. Asked who owned the patent, he famously replied:

Well, the people I would say. There is no patent. Could you patent the sun?

In an echo of the current moment, Israel (then a new state) was also experiencing a rapidly spreading polio epidemic. Efforts to purchase vaccines from the US were unsuccessful, as not all American children were yet vaccinated. So a scientist named Natan Goldblum was sent to Salk’s laboratory to learn how to make the new vaccine.

No lawyers were involved and no contracts signed. The young Dr Goldblum spent 1956 setting up manufacturing facilities for Salk’s vaccine in Israel and by early 1957 mass vaccination was underway.

Suspend patent rights

Israel, a small and relatively poor country in the 1950s, became the third country in the world (after the US and Denmark) to produce the vaccine locally and eventually eradicate polio. It took a handful of scientists, a modest budget and, most importantly, no patenting.

Like Salk, Goldblum was aware viruses have complete disregard for political borders. He was also involved in a very successful Palestinian polio vaccination campaign in Gaza.

More recently, a highly successful international campaign in the early 2000s saw AIDS treatments distributed in poorer countries. Pharmaceutical companies that owned the patented drugs were forced to supply them at cost or for free, not at market prices set in the rich countries. This was achieved through public pressure and the willingness of governments to support the required policies.

A temporary withdrawal of the patenting rights to the successful COVID-19 vaccines, with or without compensation for the developers, seems a small price to pay for an exit strategy from this global and incredibly costly crisis.

Act local, think global

Overcoming national interest is perhaps more complicated. Clearly, countries have an interest in vaccinating their most vulnerable populations first. But at some point, well before everyone is vaccinated, it becomes more efficient for countries to start vaccinating their neighbours (the countries they are most exposed to through movements of people and trade).

Disappointingly, rich countries today behave as though they will reach 100% vaccination rates before they give away a single dose, with many having bought well in excess of what is needed for 100% coverage.

The COVAX plan to distribute vaccines in poorer countries has so far been an under-funded effort that has not yet delivered a single dose of vaccine. Even if COVAX were to be fully funded, it mostly aims to donate an insufficient number of vaccine doses to the poorest countries, rather than really bring about a universal vaccination programme.

Nevertheless, overcoming the profit-maximising interest of big pharma and the national focus of governments is not a pipe dream. The world has done it before.The Conversation

Ilan Noy, Professor and Chair in the Economics of Disasters and Climate Change, Te Herenga Waka — Victoria University of Wellington and Ami Neuberger, Clinical Assistant Professor, Technion – Israel Institute of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

How to treat sunburn pain, according to skin experts

January 20, 2021 by Rayan Calimlim Leave a Comment

So you’re one of the 21% of Australians who got sunburnt last weekend.

While we should be avoiding sunburn, it’s sometimes easier said than done in the Australian sun.

What can you do once you realise you’re turning into a temporary lobster?

First, the bad news

Once you’re sunburnt, you can’t undo the damage to your DNA and skin structures, and you can’t speed up skin healing. You can only treat the symptoms.

Sunburn is a radiation burn caused by too much exposure to ultraviolet (UV) rays, causing extensive damage to the DNA in your skin. When your skin’s DNA monitoring and repair system judges there’s too much damage to fix, it flags the cells for destruction and calls in the immune system to finish the job.

The immune cells and extra fluid squeezing into the skin cause the swelling, redness, heat and pain we know as sunburn. Blisters develop when whole sheets of cells die and lift away, and fluid fills in the space below. Later, dry peeling results when large sheets of dead cells peel off to make way for fresh ones.

However, while your skin does its thing, you can manage the symptoms and make yourself more comfortable.

Step 1: Prevent further damage and assess your burn

First, get out of the sun until the redness and pain have subsided, even if this takes several days. The full effects of a sunburn can take up to three days to develop, and further UV exposure will only compound the damage.

Next, assess whether to seek medical help. Severe cases can involve second-degree burns, which disrupt the lower layer of skin, the dermis, and stop the skin from regulating fluid loss effectively. If you have a second-degree burn across a large area of you body, complications can include electrolyte imbalances due to large amounts of fluid loss, or shock, also due to extreme fluid loss. Secondary infections are also possible since the upper layer of skin is no longer acting as a tough barrier to germs. You should definitely see a doctor if you:

  • have large areas of blistered skin, especially on the face
  • have severe swelling
  • can’t manage the pain with over-the-counter painkillers
  • experience fevers, chills, nausea, dizziness or confusion.

Blistered sunburn in children needs immediate attention from your GP.

Step 2: Ease the suffering

As with a thermal burn, water is your friend. Drink plenty to correct any dehydration from being in the sun too long and replenish the fluid being drawn into your skin. Cool baths, showers or damp cloths ease the sensation of heat and can be used as often as you like throughout the day. Avoid putting ice on a sunburn, as this can make matters worse by causing intense vasoconstriction, where blood vessels narrow sharply and cut off local blood supply to already damaged skin.

Moisturising lotions can also help soothe by keeping moisture in, but avoid skin-numbing creams unless prescribed by your doctor. Any water-based moisturiser should do, including aloe vera gel.

Despite its popularity as a home remedy, there’s surprisingly little research on aloe vera for sunburn specifically. There’s promising data for its use in wound healing, but many studies investigated aloe extracts taken orally, rather than gel on the skin. In any case, a commercial aloe vera gel won’t do you any harm if you find it soothing. However, gel straight from the plant in your garden comes with a risk of soil-borne infections in skin that’s already damaged (warning: gruesome pictures in that link).

Over-the-counter painkillers like ibuprofen or paracetamol can take the sting out of your sunburn and help you rest more comfortably. If your skin is very itchy, try an antihistamine. US guidelines also often suggest low-dose (0.5-1%) hydrocortisone cream; there’s not much evidence for its effectiveness, but it also won’t hurt you to try it for a few days.

If you have blisters, try not to pop them as that exposes the damaged skin underneath to infection; cover them up with a wound dressing if you’re tempted.

While none of these remedies will fix the damage in the way antibiotics fix an infection, they will make you more comfortable while your skin gets on with healing itself.

Step 3: Make a plan

While you’re stuck inside, pinpoint how you got burnt and how you might prevent it next time. Most sunburn happens when you did not expect to be outdoors for long, or when you thought sunburn was unlikely because the weather was cool, windy or cloudy. UV radiation is still present in these conditions, but you don’t have the benefit of feeling hot to remind you to get out of the sun.

Here are a few familiar scenarios:

  • got burnt when you unexpectedly had to park 10 minutes’ walk away? Apply sunscreen as part of your daily routine whenever the UV index will be 3 or over. This will protect you from these sneaky sunburns and also from sub-sunburn levels of UV damage. Don’t worry — there’s no evidence wearing sunscreen every day will make you vitamin D deficient or cause a toxic build-up of chemicals in your body
  • arrived at the cricket and realised you left your hat or sunscreen at home? Many venues offer free sunscreen, so ask at the check-in or the health and safety officer
  • coming in from the beach, garden or bike ride just a bit too late? Sunscreen won’t protect you all day, so make sun-protective clothes part of your regular attire — a rashie, long-sleeved shirt, or UV-protective armguards and leggings
  • got to the park BBQ when all the shady spots were taken? Arrange your next outing to avoid the most UV-intense middle of the day. The SunSmart app or Bureau of Meteorology weather report will tell you the UV forecast and when you need sun protection
  • forgot to reapply sunscreen? Set an alarm on your phone next time to remind you.

The more you practise this kind of thinking, the easier it will become.The Conversation

A screenshot of the SunSmart app showing the UV forecast for Brisbane and recommending sun protection between 7:30am and 3:20pm.
The SunSmart app will tell you when you need to use sun protection based on your location.
SunSmart app

Katie Lee, Research assistant, The University of Queensland and Monika Janda, Professor in Behavioural Science, The University of Queensland

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Personal Protective Equipment (PPE)

December 21, 2020 by Avelia Gandarasa Leave a Comment

The NSW Nurses and Midwives’ Association is providing support and advice to any members seeking information regarding the novel coronavirus (COVID-19).

Join the NSWNMA to ensure you’re covered at work.

The Commonwealth Department of Health website contains detailed guidance for health sector workers and is updated regularly.

Escalation to moderate risk

Given the current context of local transmission, NSW Health is advising Local Health Districts (LHDs) and Specialty Health Networks (SHNs) to escalate to a moderate risk level (Amber). This requires all health workers wear a surgical mask if they are within 1.5m of patients. Patients are also required to wear a mask, where possible.

The new advice on mask use is underpinned by expert risk assessments. The recommendations are detailed in the COVID-19 Infection Prevention and Control Response and Escalation Framework and this poster.

Access Frequently Asked Questions (FAQs) about the escalation to Amber Alert here.

Your rights

If you are providing care for patients who have or are suspected to have COVID-19 or are working in a high-risk clinical area, your employer must provide you with appropriate PPE to ensure you can do your job safely. Such as:

  • You are to wear prescribed PPE as instructed (your employer needs to ensure you are trained in how to use PPE safely).
  • Do not undertake tasks requiring PPE if the PPE is not available for use. Any such tasks are not to proceed until required PPE is readily available.
  • If you are concerned for your safety, you must raise your concerns immediately with your manager.

Where staff are performing tasks requiring P2/N95 mask use under the CEC guidelines and where the employee has fit checked the available P2/N95 mask sizes and these sizes are not a correct fit, then the employee is to be temporarily redirected to work which does not require the use of a P2/N95 mask until suitable masks with correct fit become available.

CEC guidelines around Respiratory Protection in Healthcare also state:

In NSW, LHDs/SHNs are required to implement respirator fit testing in their facilities for health workers (HWs) performing respiratory Aerosol Generating Procedures (AGPs) on patients with COVID-19 or providing clinical services to patients on airborne precautions in high risk areas.

What PPE do I need?

Refer to CEC guidance to determine the correct use of PPE in your area:

  • Special Precautions for COVID-19 Designated Zones (added 28/4/2020)
  • Infection Prevention and Control COVID-19 Personal Protective Equipment (added 28/4/2020)
  • Quick Guide to PPE for the Emergency Department (05/01/20)
  • Application of PPE in Response to COVID-19 Pandemic (added 05/01/2021)
  • Principles of fit checking: how to don and fit check P2 and N95 masks (updated 19/3/2020)

Fit testing program

The NSW Government and Clinical Excellence Commission (CEC) have recognised the need for clearer and consistent fit testing thanks to ongoing campaigning from unions. A fit testing program is now recognised as an addition to current infection prevention and control education and guidance on the adequate use of PPE.

Further details to ensure the safety of NSW Health workers at all times and during the COVID-19 crisis, can be found here.

When do I need to wear PPE?

Guidance on from the Clinical Excellence Commission directs nurses working in high-risk areas to wear PPE (previously it was only when working with confirmed or suspected cases).

Health workers caring for patients in high-risk clinical areas (see list below) should comply with contact and droplet precautions for all close contacts (gown, surgical mask, eye protection and gloves). When performing aerosol generating procedures, comply with contact, droplet and airborne precautions.

High-risk clinical areas include:

  • Intensive Care Units (ICU)
  • Emergency Departments (ED)
  • COVID-19 Wards
  • Acute Respiratory Assessment Clinics

A dedicated floor plan in Emergency Departments should be established that clearly designates areas assigned for suspected or confirmed COVID-19 patients. If possible, consider rostering of staff to support the separation of areas and resourceful use of PPEs. For staff working directly in the area of suspected or confirmed cases of COVID-19, PPE should be worn accordingly.

National guidelines

The Australian Government has also published recommendations for the use of PPE when caring for people with possible COVID-19 infection.

  • Using Personal Protective Equipment (PPE) during hospital care
  • Using PPE during non-inpatient care

Report PPE concerns

If you have concerns that your employer is not providing you with the necessary PPE (or is making it very difficult to access) and/or is not training people in its safe use, then you should:

  1. Put in an incident report at your workplace
    AND
  2. Escalate your concerns to your manager in writing and ask for an urgent response

If your concerns are not being taken seriously, we can assist to ensure appropriate measures are in place. Contact us here. You can also contact SafeWork NSW on 13 10 50.

Further information for public health nurses and midwives

Further information for private health nurses and midwives

Further information for aged care nurses

 

Blacktown Hospital fails to fix maternity crisis

December 18, 2020 by Cameron Ritchie Leave a Comment

UPDATE: Since publishing, Blacktown Hospital has finally started advertising for the 15 FTE midwifery vacancies.

Frustrated by Blacktown Hospital management’s delays in following through on its commitments, the NSW Nurses and Midwives’ Association filed a dispute with the NSW Industrial Relations Commission last night.

The NSWNMA has been seeking genuine consultation to address the crisis in the maternity ward and for management to advertise the additional 15 full-time equivalent midwifery roles as they committed to do.

NSW Health Minister, Brad Hazzard, took steps to address the crisis by launching a thorough review in November. But in a meeting last week, Blacktown Hospital management could not provide a report to NSWNMA midwife representatives about the review and are acting as if the midwifery and obstetric issues are unrelated.

NSWNMA General Secretary, Brett Holmes, said Blacktown Hospital management is failing in its duty of care to staff and the community.

“The NSWNMA wants to participate in meaningful consultation to resolve the crisis,” Mr Holmes said. “But if Blacktown Hospital management won’t carry out its promise of more staff, the unreasonable workloads continue as does the threat to safe patient care.

“When Western Sydney LHD offered to add 15 extra midwives to the roster, we welcomed the move as a step in the right direction. Despite our concerns it will not be enough to address the very high workloads our members currently face.

“The LHD committed to advertising the roles in the week beginning November 30. It’s almost Christmas and still they have not placed an ad for the additional positions.

“Now we are hearing of delays to promised reviews, positions not being backfilled, and excessive overtime.

“Our members at Blacktown Hospital know how critical this situation is and their actions have proved that.

“In order to protect patient safety and in fear that their professional registrations are at risk, nurses and midwives have taken all reasonable steps possible.

“It’s time the Minister intervened again to ensure that this crisis is dealt with and resolved quickly. It shouldn’t be up to midwives to go to the courts to hold their management to account.

“Nurses and midwives at Blacktown deserve better and the Blacktown community deserves better.”

COVID in the air that we breathe

December 2, 2020 by Rayan Calimlim Leave a Comment

COVID-19’s airborne transmission poses a challenge to hospital infection control, says an Australian biosecurity expert.

Studies that show the SARS-CoV-2 virus can travel as far as 4.8 metres are challenging the 1.5-metre rule for physical distancing, according to Professor Raina MacIntyre, the Head of the Kirby Institute’s biosecurity program.

Professor MacIntyre spoke to Association members at a safe work webinar last month.

She says one study showed a viable virus 16 hours after aerosolisation. Another found the virus could be detected “everywhere – on the floor, the bedrails, on locker handles, the cardiac table, electric switch, the chair, the toilet seat and flush, and the air exhaust vent” in a hospital setting.

Large droplets emitted by infected patients travel much further than conventionally thought, Professor MacIntyre said. While the WHO has defined “large droplets”, which are assumed to fall close to the patient, as anything greater than five microns, Professor MacIntyre argues that droplets up to a hundred microns can potentially be airborne.

“Droplets that are less than a hundred microns will stay in the air and can be inhaled. But there’s this belief in hospital infection control that only … smaller airborne particles [travel a] great distance. The notion that one or two metres is a safe distance is therefore an ‘arbitrary rule’,” she said.

The initial response to the virus from the WHO was to focus on its spread by droplets and direct contact, Professor MacIntyre said.

“But the WHO response wasn’t based on any evidence; it was only based on an assumption.”

One recent study has found that some of the earliest studies that did not detect viable virus in the air were using air sampling methods that appeared to kill the virus. A more recent study “used a different kind of air sampler and found a viable virus in the air samples up to 4.6 metres in the absence of aerosol generating procedures”.

Speaking transmits more than coughing

Known outbreaks of coronavirus have also clearly demonstrated airborne transmission. In one case somebody was infected after passing by the open door of a patient room multiple times. Other infections have occurred on buses and restaurants, despite people having no close contact with the infected.

“Other outbreaks include a choir where people rehearsed indoors for two and a half hours with physical distancing and [yet] 86 per cent of them got infected.”

In an outbreak documented in China, the virus travelled well beyond the five people first infected on the 15th floor of a building.

“There was a vacant apartment on the 16th floor and the bathroom of that apartment was covered in virus … which means it became aerosolised through the sewage pipes and then deposited. People on the 25th and 27th floors also got infected,” Professor MacIntyre said.

“The transmission of SARS-CoV-2 really is about the air we breathe,” Professor MacIntyre said.

While we may think of coughing and sneezing as two key sources of virus transmission, in absolute terms far greater amounts of virus are emitted when people are speaking, singing or shouting, she says.

“The total amount of aerosol that’s generated is probably far greater from speaking and breathing because those things happen constantly. Whereas sneezing and coughing happen very occasionally.”

Aerosols accumulate in closed settings

The virus can build up in the air of an infected patient’s room.

“Essentially, one minute of loud speaking can produce thousands of droplets per second. And at least a thousand virus-containing droplet nuclei could remain airborne for more than eight minutes. Opening a window will disperse the aerosols, but unfortunately, many health facil-ities don’t have windows that can be opened.”

Professor MacIntyre cited one study that investigated the effect of HEPA air purifier filters in classrooms. Without air purifiers, the concentration of the airborne virus will increase in a closed room, whereas if you add an air purifier it decreases substantially.

Professor MacIntyre said: “I think we need to shift our mindset from transmission being a one hit event where somebody sneezes and this ballistic droplet comes and lands on your eye or in your nose, to [understanding] a more cumulative exposure.

“In a closed setting, where there’s no good ventilation, the aerosols are just going to keep accumulating like cigarette smoke, but you can’t see it. The longer you’re in that closed space, the greater your risk, and that risk 
is there just from patient’s breathing or speaking.”

Ordinary air conditioning recirculates the air rather than bringing in fresh air. An effective air conditioning system in the presence of SARS-CoV-2 needs to replace and purify the air, she said.

Because the virus is shed in faeces, toilets are another huge risk. When toilets are flushed’ you “get massive upward aerosolisation of virus particles”.

Since many hospital toilets do not have lids, there is the “potential for 40 to 60 per cent of the particles to rise above the toilet seat lid, leading to widespread contamination in bathrooms. Once aerosolised, this material can be deposited on surfaces and then re-aerosolised by human activity, like shaking out the bedsheets.”

Professor MacIntyre urged hospital staff to lobby for lids on all toilets.

Regional nurses have their say

December 2, 2020 by Rayan Calimlim Leave a Comment

Nurses in country NSW will tell city-based decision makers how their local health services can be improved.

The NSWNMA will help members in rural and regional NSW tell a parliamentary inquiry about their local health services.

The inquiry will investigate the condition of rural and regional healthcare, including barriers to services, staffing challenges, capital expenditure, planning systems and the gap in health outcomes depending on postcode across NSW.

The NSWNMA will make a submission to the inquiry and has asked members to provide their experiences and views.

“Tell us about the challenges you and your colleagues face. Your stories will help inform our submission,” said a union flyer distributed to members.

“Are there enough staff? Do you have access to quality health services? What are the wait times like? Do services accommodate for indigenous or culturally and linguistically diverse communities? Is enough money being spent improving access to health services?”

Problems facing non-metropolitan nurses can include shortages of both GPs and nursing staff, replacement of local GPs with remote video calls, no security services and police off duty late at night.

NSWNMA General Secretary, Brett Holmes, urged the Berejiklian government to fast-track the allocation of extra nurses and midwives across the state.

“The government must prioritise the roll-out of additional nurses and midwives it promised, instead of waiting until weeks out from the next state election in 2023,” he said.

“Our regional communities have faced ongoing battles with drought, severe water shortages, catastrophic bushfires and now further economic downturn thanks to COVID-19. They deserve access to the best health care possible, regardless of where they choose to live

“For years, we’ve been calling for increased nurse-to-patient ratios across all public hospitals in NSW to improve safety and promote better patient outcomes, but the government continues to refuse to commit to mandatory minimum staffing.”

Across NSW, thriving hospitals that were the largest employers in rural towns have lost vital services such as maternity and operating theatres.

While obesity, Type 2 diabetes and suicide are on the increase, diabetes services no longer exist at many sites, and community and mental health services have been scaled back.

Labor’s Shadow Minister for Health, Ryan Park, told Channel Nine’s 60 Minutes he wants all sides of politics to join forces to fix rural healthcare.

“We’ve got a system that is really, really sick when it’s beyond the major cities,” Park said.

“This is Australia in 2020; we should pride ourselves on having universal access to healthcare. At the moment, a postcode is determining the level of access to healthcare you get and that’s simply not right.”

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