July 6, 2022

Public Health

Monkeypox is not a global emergency for now, says WHO. 3 things we need to know next about how it’s mutating and spreading

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The World Health Organization (WHO) has decided not to declare monkeypox a public health emergency of international concern. This may change in the future.

However, WHO Director-General Tedros Adhanom Ghebreyesus said he was “deeply concerned” about the evolving threat of monkeypox, which he said had reached more than 50 countries.

There have been more than 4,100 confirmed cases globally, including at least 13 in Australia.

The WHO also acknowledged there were many unknowns about the outbreak.

Here are three things we know about monkeypox and three things we want to find out.

3 things we know

1. Monkeypox is caused by a virus

Monkeypox is a large DNA virus belonging to the orthopoxvirus family. Unlike the related smallpox virus, variola, which only affected humans, monkeypox virus is found in rodents and other animals in parts of Africa.

We know of two clades (virus groupings), and it is the less severe of the two currently circulating outside Africa.

Orthopoxviruses are stable viruses that do not mutate much. Multiple mutations, however, have been described in the virus causing the current outbreak.

In the United States, at least two separate strains have been circulating, suggesting multiple introductions into the country.

2. You can be infected for more than a week and not know

It takes an average 8.5 days from infection to showing symptoms, such as enlarged lymph nodes, fever and a rash, which usually looks like fluid-filled blisters that erupt. People are infectious while they have the rash, and are usually infectious for about two weeks.

Children are most severely affected and have a higher risk of dying from the disease. Historically, in the endemic countries of Africa, almost all deaths have been in children.

The European epidemic is mostly in adult males, so this, together with better access to care, may explain the low rate of deaths in these countries.

3. We have vaccines and treatments

Vaccines work. Past vaccination against smallpox provides 85% protection against monkeypox. Smallpox was declared eradicated in 1980, so most mass vaccination programs ceased in the 1970s.

Australia never had mass smallpox vaccination. However, an estimated 10% of Australians have been vaccinated in the past, mostly migrants.

Vaccines protect for many years but immunity wanes. So declining population-level protection is likely responsible for the resurgence of monkeypox seen since 2017 in Nigeria, one of seven endemic hot spots in Africa.

Mass vaccination is not recommended. But vaccines can be given to contacts of confirmed cases (known as post-exposure prophylaxis) and people at high risk of contracting the virus, such as some lab or health workers (pre-exposure prophylaxis).

There are also treatments, such as vaccinia immune globulin and antivirals. These were developed against smallpox.

3 things we want to find out

1. How much do these new mutations matter?

The virus causing the current outbreak has several mutations compared with versions of the virus circulating in Africa. However, we don’t know if these mutations affect clinical disease and how the virus spreads.

The monkeypox virus has a very large genome, so is more complex to study than smaller RNA viruses, such as influenza and SARS-CoV-2 (the virus that causes COVID).

Experts wonder if the mutations have made it more contagious or changed the clinical pattern to be more like a sexually transmitted infection. A study from Portugal shows the mutations likely make the virus more transmissible.

2. How is it spread? Is that changing?

Monkeypox has not been described as a sexually transmitted infection in the past. However, the current transmission pattern is unusual. There seems to be a very short incubation period (of 24 hours) following sexual contact in some, but not all, cases.

It is a respiratory virus, so aerosol transmission is possible. But historically most transmission has been from animal to human. When there was transmission between humans, this usually involved close contacts.

The rapid growth of the epidemic in non-endemic countries in 2022, however, has been all due to spread between humans. There may be many more cases than officially reported.

We do not know why the pattern has changed, whether it is sexually transmitted or simply transmitted due to intimate contact in specific and globally connected social networks, or whether the virus has become more contagious.

The virus is found in the skin rash, mouth and semen, but this does not prove it is sexually transmitted.

3. How far will it spread? Does COVID make a difference?

Will this spread more widely in the community? Does the COVID pandemic increase the risk? Possibly, yes.

We must also not drop the ball on surveillance in the wider community or stigmatise the LGBTQI community.

Due to waning immunity from the smallpox vaccine globally and the spread of monkeypox to many countries already, we may see the epidemic spreading more widely.

If it does so and starts infecting large numbers of children, we could see more deaths because children get more severe infection.

So we should monitor globally for clusters of fever and rash, and misdiagnosis as chickenpox, hand foot and mouth disease, herpes simplex or other diseases with a rash.

Another factor is COVID. As people recover from COVID, their immune system is impaired. So people who have had COVID may be more susceptible to other infections.

We see the same with measles infection. This weakens the immune system and increases the risk of other infections for two to three years afterwards.

If the epidemic becomes established in countries outside the endemic areas, it may infect animals and create new endemic zones in the world.

It is important we do everything possible to stop this epidemic.The Conversation

C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW Sydney

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

Burnt out nurses and midwives deflated by no staffing ratios

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​​​​​​Thousands of public sector nurses and midwives have been left wondering when the NSW government will genuinely address the serious workloads and staffing crisis impacting the state’s health system.

Off the back of two statewide strikes this year, members of the NSW Nurses and Midwives’ Association (NSWNMA) called for urgent investment into the health workforce and an introduction of shift by shift ratios to deliver safe patient care.

NSWNMA Acting General Secretary, Shaye Candish, said today’s pre-budget workforce announcement was a welcome start, but lacked details on how many nurses and midwives would actually be recruited, when it would be rolled out, or where they would go once recruited.

“At a time when our health system is under unprecedented demand, any injection of new nurses and midwives into the system is welcome, but we’ve got very little specifics and there’s no mention of nurse-to-patient ratios, which is what our members are desperately seeking,” said Ms Candish.

“We need shift by shift ratios in NSW to deliver safe staffing and improve the working conditions of those who have endured so much while keeping our communities safe.

“It took two statewide strikes for this government to acknowledge they needed to act, but today’s announcement has raised more questions and left thousands of health professionals in the dark.

“Given growing cost of living pressures, the government’s one-off $3,000 ‘thank you’ payment will be welcomed by our members, but it won’t help with their cost of living in two months or another two years’ time.

“There’s also no clarity if casual nursing staff or those on temporary contracts will receive this payment, many of whom worked beyond fulltime hours in this pandemic to help their workplaces and communities. It would be deplorable if these hardworking nurses and midwives were arbitrarily excluded.”

NSWNMA Acting Assistant General Secretary, Michael Whaites, said confirmation the government’s draconian wages policy would rise from 2.5 to 3 per cent this year was a slap in the face for public sector workers.

“No one can argue that nurses and midwives are not deserving of fair and equitable remuneration for the working conditions they are continuing to persevere through,” said Mr Whaites.

“The government’s new 3 per cent wages cap is a slap in face and doesn’t even come close to the current inflation rate, which will leave nurses and midwives’ real wages going backwards.

“We sought a modest pay rise of 4.75 per cent, given the wage freeze our members suffered in 2020. They will be insulted by the 3 per cent offer and hints of a further 0.5 per cent next year if they promise to work even harder.

“NSW needs a government willing to be transparent and accountable. Today’s announcements achieve neither of these things and further highlight how out of touch they are with issues facing our state’s health workforce.”

The NSWNMA has confirmed it will meet with the Ministry of Health this week and will seek further meetings with the Health Minister to explain the government’s plan.

Maintaining the momentum

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Our two strikes in the Public Health System in February and March have made the NSW Government take notice.

The NSW Government has started to shift beyond its previous intransigent position in its talks with the Association over award conditions in the public health system.

Health Minister Brad Hazzard and Minister for Finance and Industrial Relations Damien Tudehope, have agreed that there will be further discussions with the NSWNMA about “staffing and pay”.

Michael Whaites, NSWNMA Director, Strategy and Transformation, says this shows some movement from the government in response to our actions.

“In previous years, the Ministry of Health has rejected our claims for safer staffing without any negotiations, but our two strikes have clearly forced the NSW Government to reconsider its position,” he said.

Michael said the NSWNMA has continued to strongly push its ratios claim and has sought details about the NSW Government’s plan to fix the nursing and midwifery crisis.

“They have been reluctant to talk about actual numbers but they say they are responding to what they call ‘our very informative discussions on staffing’. But there is still no recognition from them about the need for shift-by-shift ratios,” he said.

“While talks continue, we still need to maintain pressure and build support at workplaces for what comes next.”

NSWNMA members working in rural MPS facilities have also met with the newly appointed Regional Health Minister, Bronnie Taylor, who promised them she would focus her attention on workforce issues.

The government said there will be announcements about pay and staffing in the state budget on 21 June.

Michael said the NSWNMA is well advanced in planning the next steps in the campaign.

“We held a highly successful training day on 16 May for member leaders in the public health system. It was clear on the day that there is still a lot of anger about the crisis in our public health system and the lack of action by the government to fix the problems.

“There is a high level of engagement from our member leaders and a strong commitment to make our ratios campaign successful. There is a determination to keep taking action until we win.”

We need to convince politicians about ratios

NSWNMA General Secretary Brett Holmes said implementing shift-by-shift ratios in NSW is ultimately a decision for politicians and together with the NSW Government, we need to convince more politicians over the importance of ratios.

“Both the NSW Government and NSW Labor need to understand the cost of not investing in the nursing and midwifery workforce will be felt by local communities for decades,” he said.

“There are politicians who have listened and are supportive of our claim but we need to take more action to convince all MPs – regardless of which political party they belong to – of the importance of ratios in solving the staffing crisis in our public health facilities.”

Get ready:  What you can do next

The upcoming state budget on 21 June will give us a clearer indication of the NSW Government’s plan for the public health system. In the meantime, the voices of nurses and midwives can make a big difference. You can do this by:

  • making an appointment to see your state MP; tell them what your working day is like, how shift-by-shift ratios will help, and ask for their support
  • getting in touch with other nurses and midwives and letting them know we need help to build the next statewide action
  • considering whether your branch should hold an own-time action about a local issue between now and the state budget on 21 June
  • preparing now for a large meeting on Tuesday, 28 June at 2pm at Sydney Town Hall and online to decide our response to the state budget announcements.

Preparing the next steps

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PHS member leaders shared campaign experiences and planned the way forward at a recent NSWNMA training day.

Training builds skills, lifts spirits

Melissa Mansell, president of the NSWNMA branch at Liverpool Hospital, was recovering from a fractured rib as a result of a workplace assault, when she got the chance to attend union leadership training.

“I felt deflated after the assault. I wasn’t sure I wanted to stay the course and continue to be active in the branch,” she said.

“However, I felt reinvigorated after the training course. It gave me a positive outlook that we can win staffing ratios and other improvements, because a lot of nurses are really willing to fight for a better deal.

“The training was really useful. I learned new leadership and communication skills and met some great people.

“I realised I wasn’t alone and that the dire conditions affecting nurses are state-wide across the public health service. We have to change the government’s approach in order to get better staffing and pay.

“During the training sessions I was already messaging my other branch officials to say, ‘You guys need to do this too. You need to enrol in the next course.’”

Melissa said she learned networking and communication skills that would help her to channel members’ negative feelings about their working conditions into positive action.

“I want to help turn anger into hope and actions that will contribute to the NSWNMA campaign for ratios and a decent pay rise.”

She agrees there is ample reason for negativity.

“We have lost four senior triage level nurses in my emergency department just this month. They left because of pressure resulting from our chronic understaffing.

“I need to do something to help turn the situation around. I’m one of the people working there so it directly affects me. I’ll end up with no senior nurse on the floor, which is extremely dangerous and worries me a lot.

“However, we sometimes get lost in complaining and forget that we have the power to influence change.

“Nurses often say things like, ‘I’m sick of this, there are so many people in the waiting room and we’re short-staffed again.’

“I can ask them what they want to do about it, explain that we’ve been campaigning for ratios, and invite them to join us.”

Melissa said the training had shown her that “We can fight this together. Seeing other nurses with the same passion, the same drive, gives me great hope that we will win this if we can multiply our numbers.

“My goal is to make the Liverpool branch a bigger and stronger presence in the next phase of the campaign.”

Melissa said the training course has led to more frequent communication among branch officials in South-West Sydney Local Health District.

“It’s important to have ongoing social connection, so we’ve arranged monthly gatherings at a local hotel for branch members from around the district,” she said.

Course inspires community approach

Media training at the NSWNMA leadership course inspired Wagga Base Hospital branch officials Natalie Ellis and Karen Hart to write to their local newspaper, The Daily Advertiser, seeking community support for the ratios and pay campaign.

Their letter took issue with false claims about the hospital by local Nationals MP Wes Fang, and informed readers that Murrumbidgee Local Health District had more than 300 nurse vacancies – “a critical shortage now impacting services on a daily basis.”

The letter explained the need for staffing ratios and asked the public to support nurses by raising the issue with local politicians.

The editor published their letter as a prominent opinion piece, exempt from the usual word limit for readers’ letters.

Karen said the “excellent” NSWNMA course included “fast track media training” that “clarified what we can and can’t do and say and the best way to word things. It gave us reassurance that as branch members we can speak up in the media on issues like staffing and pay, as long as we remain professional.”

She said the course was a rare opportunity to network with members from other branches in person following a long period of COVID-related isolation and online meetings.

“During the training sessions we heard many good ideas from different branches that have been pursuing the public health campaign in their own ways.

“At Wagga we have had good engagement from our members, but we really want to get the community behind us.

“We have decided to do a flyer drop and get the community involved in our next action. We want the public to participate and share their experiences of the public health system.”

Gaining confidence from media coaching

Grace Langlands, delegate and president of the NSWNMA Orange Health Service branch, said media interviews were an important focus of the recent NSWNMA leadership training course.

“We had the opportunity to get mic’d up, stand in front of a screen and learn to be comfortable with answering media questions,” Grace said.

“It gave me more confidence in dealing with the media and also the reassurance that as union members and union reps we are entitled to speak to the media.

“Doing so doesn’t breach our workplace code of conduct because we’re not talking on behalf of the hospital or NSW Health.”

Grace said the course was “very useful – I learned new skills and refreshed previous training in a very collaborative and supportive environment.”

The course included a session on lobbying politicians.

“We covered issues such as how to book appointments with an MP and plot out a meeting, the need to take your own notes, and how to put a persuasive case by giving them examples they can relate to,” Grace said.

“Mapping skills” were also on the course agenda.

“Mapping involves identifying where union members are located within the hospital, how involved they are in union activity, and whether they may be interested in getting further involved,” she said.

“It’s a useful technique for branch officials to encourage members to get more active with a view to taking on leadership roles at the workplace level.”

Grace said building union strength in the workplace is vital to the success of the ratios and pay campaign.

“When the union is visible, active and supported at the local level, members will be more inclined to engage in state-wide campaigns.

“And when the big actions like the recent strikes are strongly supported, that will encourage more interest in and support for union activity at the branch level.”

She said member involvement in the Orange branch “dropped a bit at the start of COVID because people couldn’t pay fees and were just so overwhelmed.

“We’ve managed to turn that around in the last six months with the strikes. We’ve seen a lot more nurses getting involved, having conversations, and asking what they can do to help.

“At times some people may not understand that it’s going to take more than one or two strikes to get this done; it’s multiple actions that will bring about change.”

Grace said the strikes have shown Orange branch members that “the union is a united front. It’s not just Orange or Sydney that’s fighting for change – the whole state wants ratios and is willing to fight for it.

“When the Industrial Relations Commission ordered us not to strike, it was heart-warming to see the long list of branches that voted yes to striking – and others that supported the strike but were unable to take action because their staffing numbers were already dangerously low.

“I led the chants on our march up and down the main street of Orange. Hearing everyone band together and start chanting gave me goosebumps – I was so proud to see our branch making a noise and being heard for the benefit of our community.

“Members in Orange can feel that something is happening, that we’re going in the right direction.”

Progress, but much more to do

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International Nurses Day and International Day of the Midwife are always days of celebration. But this year, they were also days to make a statement.

 At a rally outside the John Hunter Hospital on the  International Day of the Midwife, Jessica Plater, a midwife and an RN, said Australian maternity wards were shockingly out of step with the theme for this year’s IDM: “100 years of progress”.

“Why does it feel that today … we have made minimal to no progress at all?” Jessica told the crowd of midwives and their supporters at the lunchtime rally on 5 May.

“Why are we still fighting for our right to fair pay, ratios and to make our babies count? At any given time, a midwife can have anywhere between four to eight women in their care and that does not include their babies!

“When you start to include our babies, our patient load can then be anywhere from eight to 16 patients,” said Jessica, who has been a midwife for five years.

“How is this fair on our midwives and how is this fair on our women and the care they receive?

“International Day of the Midwife is meant to be a celebration of our wonderful and rewarding profession, but instead of celebrating, we are here today, exhausted and burnt out, to fight for our right for fair pay, ratios and to make our babies count.”

Chronic understaffing means midwives are doing more shifts to fill the gaps. And the poor pay for midwives in NSW compared to other states exacerbates the issue.

It’s not uncommon for NSW midwives to move to other states because of better pay, Jessica told The Lamp.

Prince of Wales  

The issue of ratios was also front and centre at a rally outside the Prince of Wales Hospital in Randwick on International Nurses Day on 12 May.

Kath Power, a Clinical NUM1 in the Emergency Department, told The Lamp: “We’re unable to provide safe patient care at present with our current ratios.”

Nurse-to-patient ratios are currently one to five in the department’s short stay area, and two to three in the resuscitation area.

Kath said the union wants “a ratio of one nurse to every three in the Emergency Department, one to four in the short stay area and general wards, and one to one in the resuscitation area”.

“Nurses’ workloads are high, we are understaffed, staff morale is at its lowest and sadly, nurses are leaving. It’s disappointing that NSW is lagging behind Victoria and Queensland on this issue.”

Improved wages for nurses in aged care facilities is another key issue, she added, as is having registered nurses in aged care facilities around the clock. This would stem the frequent transfer of aged care residents to emergency departments at night, Kath explained.

The rally, on the corner of Barker and Avoca streets, was held in the pouring rain, but it attracted support from Matt Thistlewaite, the federal member for Kingsford Smith, and representatives from the Greens party.

“A lot of people were beeping their horns in support,” Kath said.

“We’ve had ratios on our agenda for years and it is not progressing. So we will do anything we can to bring it to the awareness of the general public.”

Short-staffed and ‘a culture of fear’ in rural health

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It’s official – health services outside the state’s biggest cities are chronically underfunded and critically short of staff who are ruled by “a culture of fear”.

A NSW parliamentary inquiry has delivered a damning indictment of regional, rural and remote health services and NSW Health.The inquiry found that people outside Sydney, Newcastle and Wollongong face “significantly poorer health outcomes, greater incidence of chronic disease and greater premature deaths” as a result of chronic underfunding and critical staff shortages.

After 15 public hearings and more than 700 submissions, the inquiry’s final report called for a review of funding needs and gaps in services.

“There has been a historic failure by various NSW and Australian governments to attract, support and retain health professionals, especially doctors and nurses in rural, regional and remote areas,” it said.

The inquiry reserved its harshest language for NSW Health’s treatment of staff.

It found there is “a culture of fear operating within NSW Health in relation to employees speaking out and raising concerns and issues about patient safety, staff welfare and inadequate resources.”

It said NSW Health and rural and regional Local Health Districts (LHDs) “lack transparency and accountability” while LHD boards and management show “a lack of communication and genuine consultation” with the communities they supposedly serve.

Inquiry chairman Greg Donnelly, a Labor MP, said staff were “pushed to breaking point” by “unsustainable working hours, poorly coordinated recruitment and retention strategies, inadequate remuneration, lack of resources, threats to physical safety and a culture of fear”.

“On the issue of nurses and midwives, the evidence has shown a disconnect between the reality of the daily challenges faced by them working in rural, regional and remote areas, and NSW Health’s perception of the situation,” Donnelly added.

“In order to expand and develop the workforce, the committee has recommended that NSW Health expedite its review of the nursing and midwifery workforce with a view to urgently increasing nurse and midwifery staffing numbers based on local need across rural, regional and remote NSW.”

The NSW Opposition pledged to act on the inquiry’s recommendations “from day one” if elected in 2023.

However, both Liberal and Labor MPs – accounting for five of the seven committee members – refused to back Greens and Animal Justice Party MPs in calling for mandated nurse-to-patient ratios in regional and rural hospitals.

A spokesman for Labor leader Chris Minns told the Sydney Morning Herald the Opposition would not allow other parties to dictate its election policies and there were no up-to-date costings for increased staffing.

NSW Health Minister Brad Hazzard declined to comment on the report to the Herald.

However, the new Minister for Regional Health Bronnie Taylor said: “We need to be able to look at (workforce issues) in a courageous way and a different way. I certainly don’t want to keep doing the same thing because then you can only expect the same outcomes.”

The NSWNMA called on the government to immediately adopt the committee’s recommendations.

Acting General Secretary Shaye Candish said that while the union welcomed the committee’s recom-mendation for a workforce review, “the urgent implementation of safe staffing ratios is paramount and would help to address these issues.”

Shaye said services would remain at risk until the government adopted safe staffing ratios.

“The NSWNMA will continue to fight for safe shift-by-shift ratios regard-less of which party is in government,” she said.

“The goodwill of nurses and midwives to continue working under-staffed and keep the doors of their rural and regional hospitals open must stop being exploited. It’s not safe for our members; it’s not safe for our communities.

“Nursing and midwifery under-staffing in rural and regional health must change. The poor skills mix issues must change. The lack of enough clinical nurse and midwifery educators to provide supervision and mentoring must change.”

‘On the issue of nurses and midwives, the evidence has shown a disconnect between the reality of the daily challenges faced by them and NSW Health’s perception of the situation.’ – Committee Chairman Greg Donnelly MP

What the RRR inquiry recommended

The parliamentary inquiry made a number of recommendations specific to nursing and midwifery in rural, regional and remote parts of the state. It called on NSW Health to:

Work with the federal government to establish a 10-year plan, to improve health outcomes and address staff shortages including GPs, nurses and midwives, nurse practitioners, mental health nurses, psychologists, psychiatrists, counsellors, social workers, paramedics, allied health practitioners and rural generalists.

Expedite its review of the nursing and midwifery workforce with a view to urgently increasing staffing numbers based on local need.

“Widely implement” the nurse practitioner model of care by funding the recruitment and training of additional NPs, particularly in facilities without 24/7 doctor coverage, or that use virtual medical coverage.

Employ a geriatric nurse in all peer group C hospitals in addition to peer group B hospitals. Where a geriatric nurse is not employed, NSW Health should give staff members annual training in geriatric care.

“Formalise and remunerate” on-call arrangements for nurses and midwives across all rural and regional public health facilities “in accordance with industrial awards”.

Implement professional, financial and career enhancement incentives for nurses and midwives who work in rural and remote locations.

Commit to a model of care “under which virtual care technology is used to supplement, rather than replace, face-to-face services.”