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medical link THE OFFICIAL PUBLICATION OF THE GOLD COAST MEDICAL ASSOCIATION INC.

In Review: Samoan Medical Conference "The Gold Coast Medical Association is privileged to be able to enhance the medical education efforts of our Pacific Island nation neighbours."

ISSUE 148 | DECEMBER – JANUARY 2023

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THE MEDICAL LINK •

Contents 06 A Message From the GCMA President Prof Philip Morris AM FEATURE STORY 10 In Review: Samoan Medical Conference 28-30 September, 2023 Stephen Weinstein EDITORIALS 12

Understanding Diabetic Retinopathy (DR): Prevention, Detection & Treatment Dr Richard Rawson

Radiation Therapy as a Treatment Option for Dupuytren’s Disease Prof David Christie

16 Measles – A Threat to Samoan Health: Literature Review Anu Jose 20

Psychiatric Emergencies & Suicide Prevention Prof Philip Morris AM

Radiological Management of Lower Back Pain: An Example of CT-Guided Synovial Cyst Aspiration & Fenestration Dr Kevin Leong

24 Samoa's Life Expectancy Impresses Medical Experts Talaia Mika 25 Conference Boosts Medical Association Talaia Mika

Cover Credit: pch.vector on Freepik

medicallink.com.au • 5

• THE MEDICAL LINK

A Message from the GCMA President Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

Dear GCMA colleagues,

t this time of the year it is time to reflect on the year past and look forward to the future. 2023 saw the GCMA move to second monthly Thursday evening clinical meetings. We moved to a new venue too. Bumbles Café and Restaurant at Budds Beach, Surfers Paradise is a more intimate location for our meetings. We thank the proprietor Kate Madison for her hospitality and flexibility in making this transition successful. We plan to use this facility for meetings in 2024. The restaurant section can provide seating for up to 40 members. In late January or early February 2024 we plan an exciting social function for members and their partners and we hope

to use this function as a membership drive opportunity. Our GCMA AGM will be in March as usual. I do hope we will have some enthusiastic members who will take on the key executive roles of president, vice president, secretary and treasurer at this meeting and going forward. Perhaps the highlight of 2023 was the GCMA Samoa Medical Conference in Apia, Samoa from 29-30 September at the Taumeasina Island Resort. This meeting was a collaborative effort between the GCMA, the Oceania University of Medicine, the Samoan Medical Association, the National University of Samoa, and the Samoan Ministry of Health. The conference was generously sponsored by

Griffith University and Bond University. 120 doctors and medical students attended the meeting. Speaker contributions at the conference were evenly split between Gold Coast/International and Samoan presenters. The whole meeting and the wonderful cultural exchange between delegates were deemed a great success. Accounts of the meeting and some of the topics presented are included in this edition of The Medical Link. There have been many individuals who have contributed to the GCMA activities in 2023. I would like to thank Georgia Wyllie for her work as our administrative officer. I would also like to thank my executive committee colleagues

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Wonderful Time of the Year! Thank you for supporting the Sports & Spinal Group! We look forward to continuing to work with you in 2024 and providing patients with the very best, evidence-based healthcare.

THE GCMA PRESIDENT'S REPORT •

for their sterling efforts for the GCMA this year: Prof Gordon Wright (vice-president), Dr Maria Coliat (secretary), A/ Prof John Kearney (specialist representative), Dr Graham Sivyer (GP representative), Prof Alfred Lam (academic representative), and Dr Amy Doumany (treasurer). In particular, I would like to thank our program director, Prof Stephen Weinstein (and Lis Weinstein) for their significant contribution to the Samoa conference. I very much appreciate the support I received from all these colleagues. We encourage GCMA members to write articles or advertorials for The Medical Link. Contact admin@themedicall-

ink.com.au to make a contribution. We are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA. It is very easy to do. Just go to the GCMA website (www.gcma.org.au) and click through to the ‘Become a Member’ page to join. The registration page can take credit card payments. The $150 annual membership is extremely good value. It covers monthly evening meetings where salient updates on clinical and professional matters are presented as well as a two-course meal and complimentary beverage, and the opportunity to interact with colleagues from all professional disciplines.

Finally, I would like to wish all our GCMA members, their families and their friends a Merry Christmas and a Happy Holiday Season, and a healthy and prosperous New Year! I look forward to seeing you at our next meeting. Yours sincerely, Prof Philip Morris AM President GCMA

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Advertising in The Medical Link If you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us at admin@themedicallink.com.au. Advertising of medical services in The Medical Link should comply with the same advertising guidelines released in the Medical Board of Australia Code of Conduct: Be factual and verifiable | Not include testimonials | Only make justifiable claims regarding quality and outcomes | Not raise unrealistic expectation | Not offer inducements | Not make unfair or inaccurate comparisons between your services and those of colleagues The Medical Link is designed and published by Swan Management Services. It is the advertiser’s responsibility to ensure that advertisements comply with the Trade Practices Act 1947 as amended. All advertisements are published on the condition that the advertiser indemnifies the publisher and its servants against all claims, suits, actions, loss and/ or damages as a result of anything published on the advertiser’s behalf. DISCLAIMER: The contents of articles and opinions published are not necessarily held by the publisher, editor or the Gold Coast Medical Association. No responsibility is accepted by the publisher, editor or Gold Coast Medical Association for the accuracy of information contained in any opinion, information, editorial or advertisement contained in this publication and readers should rely upon their own enquiries in making decisions touching own interest. Unless specifically stated, products and services advertised or otherwise appearing in The Medical Link are not endorsed by the publisher, editor or the Gold Coast Medical Association.

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MEDICAL EDITORIAL COMMITTEE

Philip Morris, Geoff Adsett, Stephen Withers, John Kearney, Maria Coliat

GCMA MEMBERS gcma.org.au

GCMA EXECUTIVE COMMITTEE

President Prof Philip Morris 5531 4838 Vice-President Dr Maria Coliat 5571 7233 Secretary Prof Philip Morris 5531 4838 Immediate Past President Dr Sonu Haikerwal 5564 6255 Treasurer Dr Geoff Adsett 5578 6866 Specialist Representative Prof John Kearney 5519 8319 GP Representative Dr Katrina McLean 5564 6501 Academic Representative Prof Gordon Wright 5595 4414

Keeping the Medical Community Informed The Medical Link enriches the Gold Coast medical community by uniting the voice of its doctors. Here you will find insightful stories and the latest trends in field research conducted abroad, and of course, right here on the Gold Coast. Keep informed of new health services, developments in the medical profession, and general interest items. We invite you to submit your company updates, new recruits and promotions to the following email: admin@themedicallink.com.au And if you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us admin@themedicallink.com.au.

"The Gold Coast Medical Association is privileged to be able to enhance the medical education efforts of our Pacific Island nation neighbours."

10 • Issue 148

FEATURE STORY •

In Review: Samoan Medical Conference 28-30 September, 2023 Prof Stephen Weinstein MHA, FRCPA, FRACMA, FACHSE stephenweinstein@bigpond.com

joint conference of the Gold Coast Medical Association and the Oceania University of Medicine (OUM) has recently been completed, with Prof Philip Morris and Prof Satu Viali being the respective co-convenors. The meeting was informally judged a success, based on people asking “when are you going to do it again?”. This has been the fourth medical conference the GCMA has held with a Pacific Island partner organisation, the earlier ones being in Fiji 2009 and 2015, and Vanuatu 2017. The conference was held at the Taumeasina Island Resort, one of the premier venues in Apia, the capital of independent Samoa (previously Western Samoa). This hotel is located on small island surrounded by coral reefs, and joined to the main island Upolu by a causeway. The Oceania University of Medicine is a private medical school, with Australian, American, and Samoan students. Other supporting partners were the local Samoan medical school (National University of Medicine), the Samoan Medical Association, and the Samoan Ministry of Health. GCMA members contributed heavily to the scientific program (see attached). A Samoan welcome in the plenary session, orchestrated by Prof Satu Viali, a prominent Samoa cardiologist, was a highlight, in particular the opening prayer song by medical students. Both Gold Coast Medical Schools were generous financial sponsors, with Griffith’s Prof Niru Nirathan and Bond’s Professors Peter Jones and Michelle McLean being speakers. The other significant contributors were Prof Athol Mackay, Vice Chancellor of OUM, and Ms Carmel Sang, OUM Chief Operating Officer, and MS Regina Frolova, OUM administrative officer, without

whose help the conference would not have proceeded so smoothly. After the Friday morning plenary, the meeting was split into two parallel streams. The Samoan speakers gave interesting insights into the health problems faced by the host country, including in paediatrics, psychiatry and Ob/ Gyn, as Samoa moves more from the disease pattern of a developing country toward the chronic disease profile of Western societies. Pitching the presentations at a level targeted at both medical students and practicing doctors was somewhat of a challenge, but judging by the ensuing questions and discussions, this was achieved. After the presentations on Friday, Saturday was devoted to workshops in Paediatric resuscitation, medical education, Pathology in the Pacific, and Ophthalmology. On Saturday afternoon our Samoan hosts gave us a tour of the Tupua Tamasese Meaole Hospital, the main tertiary teaching hospital of the country, at Motuotua in Apia. Samoa has much to offer the visitor, and our delegates enjoyed a traditional welcome including both kava ceremony and fire dance. While there were no conventional post conference tours, some of our people did manage to get across to Pago Pago, the capital of American Samoa, a 30-minute flight away. While sharing language and culture with independent Samoa, American Samoa has pursued a different course of development since the archipelago was partitioned in 1899. Samoa has an interesting history, becoming the first independent nation in the South Pacific in 1962 (apart from Tonga, which always retained its independent monarchy). Back in 1889, Samoa was engaged in a three-way civil war

between rival chiefs, with each side supported by Britain, Germany and the US. A great cyclone that year wrecked most of the foreign warships in Apia harbour, putting a damper on military activities. At the same time the Scottish author Robert Louis Stevenson (Tusitala – teller of stories in Samoan) was living in Apia, and was much loved by the local people (his house Vailima is a major attraction in Samoa, and his mountaintop grave can also be visited). The conflict was resolved by partition in 1899, with the larger Western islands of Upolu and Savaii going to Germany, and Tutuila, with its natural harbour of Pago Pago, becoming American Samoa, which it still is today. German Samoa was taken by a New Zealand expeditionary force in 1914, and ruled by Wellington until 1962. Also worth a visit, the island of Savaii, the other big island of Samoa, which is more rural and traditional that Upolu, where the capital Apia is located. Savaii is a two-hour ferry ride away, and has spectacular blowholes, rainforests and traditional villages. The Gold Coast Medical Association is privileged to be able to enhance the medical education efforts of our Pacific Island nation neighbours. These meetings offer an opportunity to learn about the medical circumstances of these countries, to meet local colleagues from different disciplines, to contribute to the scientific and clinical content of meeting programs, and to experience and enjoy the culture of the host country. The Samoa medical conference successfully met these objectives. We are very grateful for the wonderful hospitality, cooperation and friendship of our Samoan colleagues.

medicallink.com.au • 11

• THE MEDICAL LINK

Understanding Diabetic Retinopathy (DR): Prevention, Detection & Treatment Dr Richard Rawson MBChB, FRANZCR Ophthalmologist richard.rawson@gmail.com

iabetic Retinopathy (DR) is a serious eye condition that can lead to vision loss and blindness in individuals with diabetes. Despite significant progress in promoting regular eye checks and treatment, there are still challenges, particularly for Aboriginal and Torres Strait Islander people. However, with increased awareness and accessible healthcare, there is hope for better outcomes.

Points to Remember • • •

DR can damage the eyes before diabetes or vision problems become apparent. Up to 98% of severe vision loss can be prevented with recommended eye checks and treatment. Aboriginal and Torres Strait Islander individuals with diabetes are now more likely to receive yearly eye checks, reducing the risk of vision loss.

How Does Diabetic Retinopathy Occur? DR develops when chronic high blood sugar levels result in changes in blood flow, damaging small blood vessels in the retina. This can lead to leakage, bleeding, abnormal blood vessel growth, and even retinal detachment. It usually affects

12 • Issue 148

Diabetic Retinopathy (DR) is a serious eye condition that can lead to vision loss and blindness in individuals with diabetes. Despite significant progress in promoting regular eye checks and treatment, there are still challenges, particularly for Aboriginal and Torres Strait Islander people.

both eyes and progresses from non-proliferative to proliferative stages, with early stages often being asymptomatic.

Who Gets DR? All individuals with type 1 and type 2 diabetes are at risk, with the duration of diabetes and poorly controlled blood sugar, pressure, and cholesterol levels increasing the risk. Aboriginal and Torres Strait Islander people, being three times more likely to have diabetes, face a higher risk of developing DR.

How to Prevent Vision Loss from DR • • • •

Education on healthy habits and regular exercise. Regular eye checks at diabetes diagnosis and thereafter. Medication to control blood sugar, blood pressure, and cholesterol. Early detection and timely treatment of DR.

How to Detect DR Regular eye checks, including a medical history, vision test, and retinal examination, are crucial. NHMRC guidelines

recommend yearly eye checks for Aboriginal and Torres Strait Islander people with diabetes.

How to Treat DR • • Normal retina

•

Laser treatment (photocoagulation) is the primary form of treatment. Intravitreal injection of antiVEGF medication is a newer option. Complicated cases may require vitrectomy (eye surgery).

Delivering Eye Care for DR Primary health care plays a vital role in supporting patients: • Abnormal retina

• • •

Incorporate yearly eye checks into patient management plans. Establish patient recall systems for yearly eye checks. Refer patients to eye specialists when needed. Provide information about eye care pathways.

More Information About Eye Care

Sight threatening

tometry and Ophthalmology services, aim to make eye care more accessible, especially for those living in regional, rural, and remote areas.

The Eye Health Web Resource Primary health care services have access to an Aboriginal and Torres Strait Islanderspecific MBS item (12325) since November 1, 2016, supporting DR screening with a retinal camera.

Contact Details For more information, individuals can access resources like the Eye Health web resource or contact local healthcare providers.

Conclusion In conclusion, while progress has been made in reducing vision loss from DR, there is still work to be done. Continued support, education, and accessible healthcare are essential to ensure that all individuals, especially those at higher risk, can manage their diabetes effectively and receive timely eye care. With these measures in place, the impact of diabetic retinopathy can be significantly minimized.

Various programs, such as the Integrated Team Care Program and Outreach Op-

medicallink.com.au • 13

"Radiation therapy has been used to help treat Dupuytren's disease for many years.3 At GenesisCare, we are supporting a clinical trial which has completed recruitment called 'DEPART'."

14 • Issue 148

ADVERTORIAL

Radiation Therapy as a Treatment Option for Dupuytren’s Disease Prof David Christie MBChB, FRANZCR Radiation Oncologist, GenesisCare Southport www.genesiscare.com/au

upuytren’s disease is a condition that causes excessive scar tissue within the fibrous fascia beneath the skin of the palm of the hand.1 In the early stages this is seen as lumps or cordlike thickenings.1 Over time contraction of the scar tissue can pull the fingers towards the palm, into a permanent bent position called a ‘contracture’, which can limit function of the hand.1 Dupuytren's disease can be an inherited genetic disorder, that seems to be more common in men than women and more prevalent in older age groups (i.e. 60+).1,2 Risk factors associated with the development of Dupuytren’s disease include:1,2 • • • • • • •

The disease can have various phases where symptoms start to become noticeable, followed by later phases where disease can lead to deformity.2 Not all people experience progressive diseases, and for a large majority the disease can stabilise or even regress.2 The plantar (foot) equivalent is Ledderhose disease with which there are many similarities.2 The condition is not usually painful, but pain or discomfort can occur for some patients.2 In more advanced cases it can impact upon performance of general daily activities.2

number of potential options for treatment exist including:1,2

•

Age Hand trauma from manual labour or working with tools Excessive alcohol consumption Smoking High sugar levels Diabetes Family history

• •

needle aponeuroromy – where the contracted tissue is divided so the finger can be stretched out again surgical fasciectomy radiation therapy may be helpful in preventing the progression of early stage Dupuytren's disease, thereby reducing the need for invasive procedures

adiation therapy has been used to help treat Dupuytren's disease for many years.3 At GenesisCare, we are supporting a clinical trial which has completed recruitment called 'DEPART'. Recruitment was very successful, and the final results are awaited. The trial is aimed at assessing how effective radiation therapy is at preventing the progression or recurrence of contractures. While waiting for trial results patients can still be offered treatment in the early stages of disease to prevent progression or following surgical treatment to limit the risk of recurrence.

References 1. Ruettermann M, et al. Dtsch Arztebl Int. 2021;118(46):781-88 2. Walthill J, et al. . National Library of Medicine. StatPearls Publishing LLC [Internet]. Dupuytren Contracture. Treasure island (FL). Last Update: Feb. 2023 [Cited July 2023]. Access from: https://www.ncbi.nlm. nih.gov/books/NBK526074 (accessed November 2023). 3. Kadhum M et al. J Hand Surg Eur Vol 2017;42(7):689–692.

Dupuytren's Disease: Images of Progression

Early disease

Severe disease

medicallink.com.au • 15

Measles – A Threat to Samoan Health: Literature Review The following article is the work of a student of the Oceania University of Medicine, our partner organisation for the medical conference held in Samoa, 28-30 September, 2023. Anu Jose, MD jose.anu@outlook.com

16 • Issue 148

Abstract

easles is a significant and persistent global health concern, with Samoa being particularly impacted throughout its history. Despite substantial strides made since the introduction of the measles vaccine in the 1960s, recent events in Samoa, including a severe outbreak in 2019 and decreasing vaccination rates, underscore the fragile nature of herd immunity and the challenges posed by vaccine hesitancy. Influenced by socio-cultural beliefs, misinformation, and an unfortunate vaccination tragedy in 2018, the Samoan public's trust in immunisation programs has waned. The 2023 measles outbreak in nearby American Samoa further emphasises the regional implications of localised outbreaks. Addressing these challenges necessitates multifaceted strategies, focusing on education, transparent communication, and rebuilding public trust. Samoa's experiences provide critical lessons for global health efforts as the world endeavours to control and eventually eradicate measles.

Introduction

easles is considered as the most contagious pathogen known to humans (Ottolini 2024) and has been a focal point of global health concerns for decades. Besides COVID-19, measles is the fourth leading cause of death worldwide due to infectious diseases, following tuberculosis, HIV/AIDS, and malaria. Samoa, an island nation situated in the heart of the Pacific and renowned for its rich culture, vibrant traditions, and serene landscapes, has faced a series of health challenges. Among them, measles stands out as a notable adversary. Historically, Samoa, like many other Pacific islands, had high mortality rates due to measles since its first occurrence in the 18th century (Shanks 2016). The introduction of the measles vaccine in the 1960s marked a significant milestone in controlling the disease, substantially lowering its incidence in nations with strong immunisation initia-

tives. Yet, in spite of worldwide attempts to limit its propagation, measles remains a significant concern, especially in areas with inadequate vaccination rates. The recent resurgence of measles in various parts of the world, including Samoa, shows the struggle of health systems to control the disease. Factors such as vaccine hesitancy, driven by misinformation and socio-cultural beliefs, contribute to the vulnerabilities faced by Samoa in its battle against measles. The relationship between measles and the health of the Samoan population is intricate and multifaceted. From historical outbreaks to recent epidemics, the effects of this disease on Samoan health have been both immediate and long-lasting. This literature review aims to explore the various impacts of measles on Samoan health drawing from an array of scholarly articles. The study aims to discover the setbacks, achievements, and future challenges of Samoa’s journey in combating measles.

Clinical Overview

easles is a serious and highly infectious disease caused by a virus. Belonging to the Paramyxoviridae family and the Morbillivirus genus, the measles virus has at least 24 unique genotypes. However, it acts as a single serotype since a natural infection or proper vaccination offers extensive protection against all its types (Ottolini 2024). It is typically transmitted through direct contact and airborne. The measles virus spreads efficiently through contact with large droplets or by inhaling fine aerosolised droplets. These small droplets can linger in the air for hours even after an infected person has left the area. Contrary to other paramyxoviruses that mainly affect the respiratory epithelia, the measles virus primarily targets the immune system. Diagnosis of measles includes history and physical examination. Measles has an incubation period ranging from 7 to 21 days. The onset is marked by fever and a general feeling of discomfort (prodrome). Around 10 days post-ex-

posure, more distinct symptoms like a distinctive cough resembling "croup," nasal congestion, eye inflammation, and sensitivity to light usually manifest (Ottolini 2024). One to two days following the beginning of prodromal symptoms, a characteristic rash (Koplik spots) emerges on the inner cheek lining. These lesions are small, bluish-white specks surrounded by reddish halos (Michaels and Williams 2023). Their numbers increase before diminishing over two to three days. Around the third or fourth day, as the initial symptoms and fever intensify, another rash becomes visible. This rash starts at the hairline and, over three days, spreads downwards, eventually reaching the hands and feet. As the rash spreads, it merges in some areas but remains separate in others. Older spots might take on a rusty colour and no longer lighten under pressure. The rash starts to fade after three days, clearing up a couple of days later. Some heavily affected areas may exhibit light flaking of the skin. Swollen lymph nodes can also be observed (Michaels and Williams 2023). Complications from measles are the primary cause of death related to the disease (WHO 2023). The risks are higher for children under 5 years old and adults over 30. The most severe outcomes include pneumonia, intense diarrhoea leading to dehydration, ear infections, encephalitis, and blindness. Children with malnutrition, particularly those deficient in vitamin A, as well as those with HIV or a compromised immune system, face a higher likelihood of experiencing severe measles symptoms. There is no antiviral treatment available for the measles virus. However, supportive care involving a well-balanced diet, adequate fluid consumption, and the use of WHO-endorsed oral rehydration solution (ORS) can help reduce complications from measles. ORS replenishes fluids and vital nutrients lost through diarrhoea or vomiting. Antibiotics are effective for treating infections in the eyes, ears, and pneumonia. Administering Vitamin A supplements in two separate doses, 24 hours apart, is crucial.

medicallink.com.au • 17

• THE MEDICAL LINK

This supplement helps restore vitamin A levels in children with measles, even if they're well-nourished, reducing the risk of eye damage, blindness, and deaths related to measles (WHO 2023). Active immunisation is the primary means of prevention of measles.

Measles Vaccination

accination using the live-attenuated measles virus vaccine, typically in the form of MMR and occasionally combined with varicella as MMRV, promotes the production of long-lasting antibodies and cellular immunity. A2 vaccination approaches aim not only to shield the individual but also to guarantee that at least 89 to 94% of the community is safeguarded. This percentage is crucial to reduce the spread of measles within the community, termed "herd immunity" (Ottolini 2024). A two-dose series of live-attenuated virus vaccine – separated by at least 28 days with first dose is 97% to 99% effective in generating immunity. This initial dose is typically given between 9 to 12 months of age. However, if an infant is born during an outbreak, in a high-risk environment, or is traveling to a high-risk area, it can be administered as early as 6 months. If the vaccine is provided before the 9-month mark, a third dose becomes necessary to guarantee that two doses are administered after the maternal antibodies have waned (Ottolini 2024). Prior to the launch of the measles vaccine in 1963 and its broad adoption, significant outbreaks took place roughly every two to three years, leading to an estimated 2.6 million fatalities annually (WHO 2023). Enhanced vaccination efforts by nations, the WHO, the Measles & Rubella Partnership (previously known as the Measles & Rubella Initiative), and other global partners effectively prevented 56 million deaths from 2000 to 2021. Due to Vaccination, measles fatalities dropped from an estimated 761,000 in 2000 to 128,000 in 2021.

18 • Issue 148

Historical Outbreaks in Samoa

arious accounts of the historical measles outbreak in Samoa are recorded in the literature. Thomas (2021) indicated that in 1893, Samoa was confronted with a pervasive measles epidemic that yielded catastrophic outcomes. According to historical documentation by Davies (1894), out of Samoa's total population of 34,500, over 1,000 individuals died from measles by December 1893. However, with introduction of measles vaccination, the number of outbreaks was significantly decreased in Samoa. According to data from the WHO – Global Health Observatory (2022), the number of reported cases of measles in Samoa decreased dramatically from 1985 until 2019.

2019 Measles Outbreak in Samoa

amoa experienced a massive measles outbreak in 2019, which led to thousands of cases and numerous deaths, particularly among young children. This measles epidemic was caused by a combination of factors including a drop in child MMR vaccination rates below the 95% threshold recommended by WHO for herd immunity, the global spread of the measles virus, increased travel between affected countries, and growing vaccine hesitancy. As of 22 January 2020, the outbreak of measles in Samoa had caused 5707 reported infections and claimed 83 measlesrelated deaths since its beginning in early September 2019 (WHO 2020). 87% of the recorded deaths were children under 5 years of age. There were 1,860 measlesrelated hospitalisations, and 95% of the cases recovered and were discharged. The surge in this outbreak was driven by a sharp decline in the uptake of the measles, mumps, and rubella vaccine – dropping from more than 75% coverage for the initial dose in 2017 to roughly 40% in 2018, and under 30% for the subsequent dose. Records suggest that the height of the measles cases occurred to-

wards the end of November, with numbers diminishing afterwards. Other Pacific Island countries, including American Samoa, Fiji, Kiribati, and Tonga, also reported measles outbreaks from October to December 2019. During the outbreak, Samoa's government declared that schools would be closed across the country, banned public assemblies involving children, and instituted a compulsory vaccination drive for those who qualified. Households were required to display a red flag outside if anyone within the home belonging to the prioritised groups (specifically, individuals aged 6 months to 19 years and women aged 20–35 years) had not received the measles vaccine (Champredon, Shoukat, Singer, Galvani, and Moghadas 2020). Analysis carried out by Champredon et al. (2020) indicates that the control measures implemented by the Samoan government were instrumental in curbing the measles outbreak.

Measles Vaccinations in Samoa

he table on the opposite page shows measles vaccination coverage in Samoa since 2000. The diminishing vaccination rates in Samoa since 2013 are linked to rising apprehensions about vaccine safety, propagated by anti-vaccine factions (Champredon et al., 2020). Additionally, a vaccine tragedy on 6 July 2018, in which two infants died within minutes of receiving the MMR vaccine, further contributed to the reduction in immunization rates (Isaacs 2020). The government halted the MMR vaccination initiative following the administrative mishap in July and resumed it in November 2018. In July 2019, two nurses received 5-year prison sentences for accidentally using a curare-like muscle-blocking substance as a diluent instead of water for the lyophilized (powdered) MMR vaccine (Isaacs 2020). After the intensive measles immunization campaign from November to December 2019, the Samoan Government reported comprehensive coverage of the population (WHO 2020). However, the data

Year

Immunisation, measles (% of children ages 12-23 months)

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

Table 1: Immunisation coverage in Samoa (THE WORLD BANK 2022)

shows that the vaccination rate has been decreasing since 2019, posing a threat to the population.

2023 Measles Outbreak in American Samoa – Potential threat to Samoa

n 24 April 2023, the American Samoa Ministry of Health announced a measles outbreak, reporting 31 potential or likely cases along with one confirmed

measles case (American Samoa Government 2023). The American Samoa governor declared a public health emergency and directed all schools and childcare facilities to halt in-person instruction for a duration of three weeks. The declaration of ongoing public emergency released by American Samoa Government (2023) shows that the public emergency was in effect until June 8, 2023. As of 24 May 2023, 2 laboratory confirmed cases and more than 52 suspected cases of measles were identified during the 2023 outbreak in American Samoa. To curb the spread of measles from American Samoa, the Samoan Government has issued specific travel guidance for individuals entering Samoa from American Samoa. The directive mandates that American Samoans entering the country must have received at least one dose of a measles-containing vaccine before their arrival in Samoa (Ministry of Health 2023). However, infants under 6 months of age and pregnant mothers are exempt from this requirement.

Discussion/Conclusion

easles, despite its historical devastation, continues to remain an acute health concern for Samoa and the surrounding regions. This review has outlined both the clinical dynamics of the disease and its profound epidemiological footprint on Samoan health. Historically, Samoa has shown resilience against numerous outbreaks, however, recent data indicates that this fight is far from over. Following the 2019 measles outbreak, Thornton (2020) points to Samoa as an exemplar of what can happen in an under-immunised population. The 2019 measles outbreak in Samoa, underscored by decreasing vaccination rates and increasing vaccine hesitancy, demonstrates the fragility of herd immunity and the consequences of any lapse in vaccination efforts. The tragedy associated with the 2018 vaccination incident further complicates the public's trust in immunisation initiatives. The 2023 measles outbreak in Amer-

ican Samoa raises alarm bells for Samoa due to the close geographical and cultural ties. It serves as a stark reminder that infectious diseases, like measles, are never truly local issues but can potentially have regional implications. Factors like vaccine hesitancy, driven by misinformation and socio-cultural beliefs, are not unique to Samoa but are part of a global trend. Addressing these concerns demands multifaceted strategies that not only involve health campaigns but also socio-cultural awareness. It is essential to rebuild and sustain public trust in vaccination programs, especially when confronted with the delicate balance of achieving herd immunity. The role of misinformation in shaping vaccine perceptions cannot be ignored. As in the case of Samoa, the spread of misinformation has played a significant role in the decline of vaccination rates. Tackling misinformation requires targeted communication strategies that focus on educating the public about the safety and efficacy of vaccines. Furthermore, transparent communication about any adverse events, their causes, and resolutions is crucial in maintaining public trust. While it is encouraging to note the strides made in measles prevention, especially post the introduction of the measles vaccine in the 1960s, the recent setbacks highlight the challenges that lie ahead. Achieving a world free from the threat of measles will require sustained efforts, partnerships, and a commitment to prioritise the health and wellbeing of all, particularly the most vulnerable in society. In conclusion, the relationship between measles and the health of the Samoan population serves as a mirror to larger global health dynamics. As nations worldwide strive to achieve comprehensive measles control and eventually eradication, the experiences and lessons from Samoa offer valuable insights into the challenges and potential strategies that can guide future public health endeavours. To view the entire list of references, please visit: themedicallink.com.au/magazine/issue-148.

medicallink.com.au • 19

"...the GCMA Samoa Conference 2023 highlighted the urgent need for comprehensive reforms in the Australian mental health system and offered valuable insights for other countries facing similar challenges."

20 • Issue 148

Psychiatric Emergencies & Suicide Prevention Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

he GCMA Samoa Conference 2023 brought to the forefront crucial issues in psychiatric emergencies and suicide prevention, with a particular focus on the Australian health care system and how this might inform developments in Pacific island nations. This report aims to provide an overview of the key discussions and propose potential solutions. The Australian health care system, known for its mixed public and private model, was critically evaluated. The discussion revolved around the merits of replication by other countries, exploring aspects such as basic universal care in primary care settings and hospitals through Medicare, the role of private health insurance for non-immediate life-threatening conditions, and the potential advantages and pitfalls of fee-for-service in private practice. The tension between public and private sectors was highlighted, emphasising the delicate balance required to ensure neither sector experiences excesses, leaving room for improvement. A major concern identified at the conference was the state of the Australian mental health crisis. Despite national mental health plans and a decade of changes to public mental health services, there is a consensus that the care of mentally ill individuals is inadequate. The focus has traditionally been on public mental health services, but the issue is now extending into private practice, creating what is referred to as the 'missing middle.'

The root cause was traced back to the closure of state psychiatric hospitals, which, although in need of reform, resulted in the dispossessed long-term chronic psychotic and severely mood-disordered patients being disposed of their accommodation, clinical care and rehabilitation services. Consequences of this system failure include leading long-term patients to fill acute public hospital units. This, in turn, results in the rationing of acute beds for disturbed patients, with suicide rates peaking after non-admission of patients presenting to emergency departments because of a lack of beds or early discharge of patients due to bed pressures. The unintended consequences of new mental health acts exacerbate the problem. Inadequate, narrow focussed, and unattractive registrar training positions has led to a significant workforce shortage in psychiatry. To avoid a national psychiatric emergency, the conference proposed the provision of adequate clinical, accommodation, and rehabilitation services tailored to the needs of the chronic and severe mentally ill population. Advocacy for parallel and integrated mental health services to replace the ‘mainstream’ model was underscored, along with strategies to make psychiatry training more attractive to address workforce shortages. Shifting the focus to suicide prevention, the conference recognised it as a

collective responsibility requiring a comprehensive and compassionate approach. Strategies include raising awareness, reducing stigma, promoting mental health, identifying warning signs, and addressing risk factors such as previous attempts, substance abuse, and providing accessible care and crisis intervention. A significant emphasis was placed on removing means of suicide, akin to gun control measures. The primary importance of making sure individuals at risk do not get isolated was emphasised as an essential task for community and clinical interventions. The importance of raising awareness and knowledge at national, state, and local levels was stressed, drawing parallels with the reporting of national/state road tolls. Coronial inquiries into suicide clusters were proposed to understand and address factors beyond diagnosed mental illness, as more than 50% of suicides occur in individuals with no diagnosed mental illness. In conclusion, the GCMA Samoa Conference 2023 highlighted the urgent need for comprehensive reforms in the Australian mental health system and offered valuable insights for other countries facing similar challenges. The lessons learned underscore the importance of a balanced healthcare model, the provision of adequate services, and a holistic approach to suicide prevention.

medicallink.com.au • 21

"Lower back pain is the most common musculoskeletal complaint seen by GPs in Australia. In fact, it affects up to ONE in FOUR Australians at any time. Unfortunately, up to 40% of adults with lower back pain will develop persisting and disabling symptoms, highlighting its significant personal and societal burden within our country.."

22 • Issue 148

ADVERTORIAL

Radiological Management of Lower Back Pain: An Example of CT-Guided Synovial Cyst Aspiration & Fenestration Dr Kevin Leong MBBS (UQ), FRANZCR Radiologist at Lumus Imaging kevin.leong@lumusimaging.com.au

adiologists have a vital role in evaluating the cause of lower back pain. Firstly, imaging facilitates the exclusion of an underlying sinister aetiology. Furthermore, radiologists offer the ability to correspond the nature and location of pain with imaging findings to determine the most likely source of pain, and when conservative management has failed, propose the most appropriate CT-guided steroid injection for diagnostic and therapeutic purposes. These interventions often provide long-term relief of back pain and delay/ mitigate the need for surgical intervention. Symptomatic relief is often not permanent, but fortunately, injections can be repeated up to FOUR times a year if required. Spinal interventions for lower back pain include nerve root injection, epidural injection, facet joint injection, sacroiliac joint injection, radiofrequency ablation, and even facet joint synovial cyst aspiration, which is given as an example below. Lumbar facet joint synovial cysts are commonly seen in degenerative facet joint arthropathy and may become symptomatic when narrowing the spinal canal or compressing nerve roots. The following is a case of a 73-year-old male presenting with lumbar back pain and left lower limb radiculopathy. CT lumbosacral spine demonstrated multilevel degenerative facet joints with an associated left L4/L5 facet joint synovial cyst. This synovial cyst was in contact with the left descending L5 nerve root, appropriately accounting for our patient’s left lower limb radiculopathy. CT-guided aspiration and fenestration of the left L4/L5 facet joint synovial cyst was successfully performed. Subsequently, 1 ml (4mg) of dexamethasone and 2 ml of 0.5%bupivacaine was introduced into the adjacent epidural space.

A. Pre-procedural planning CT image shows bilateral L4/L5 degenerative facet joints with associated left L4/L5 facet joint synovial cyst containing gas. B. Intra-procedural CT image shows 22-gauge spinal needle within the left L4/L5 facet joint with contrast opacification of the facet joint (no contrast opacification of the synovial cyst at this stage). C. Intra-procedural CT image shows subsequent contrast opacification of the synovial cyst, with a second 22-gauge spinal needle approaching the synovial cyst via a translaminar approach. D. Intra-procedural CT image shows the spinal needle within the synovial cyst which was successfully aspirated and fenestrated.

Our patient described immediate symptomatic short-term relief, with persisting symptomatic relief at 1-year post-procedure. CT-guided procedures for lower back pain are safe, effective, and minimally invasive, and recommended when conservative management has failed. This example of a CT-guided synovial cyst aspiration and fenestration is one of many procedures radiology can provide to assist GPs in managing lower back pain. Again, these interventions often provide longterm relief of back pain and delay/mitigate the need for surgical intervention.

Dr Kevin Leong Dr Leong completed his Bachelor of Medicine, Bachelor of Surgery from the University of Queensland in 2013. Since graduating, he has worked at the Gold Coast University Hospital, where he completed his Radiology specialty training in 2021. He has a wide range of sub-specialty interests and further training in Radiology, particularly in breast imaging, imaging guided procedures, and pain management. Dr Leong also works at the Gold Coast University and Robina Hospitals.

medicallink.com.au • 23

• THE MEDICAL LINK

Samoa's Life Expectancy Impresses Medical Experts Talaia Mika Initially published in the Samoan Observer 30 September 2023

amoa's life expectancy, which has recorded a slight increase of 0.17 per cent since 2022, has impressed international medical specialists currently attending a conference in Samoa. Students, local and international medical experts have converged on the Taumeasina Island Resort for a two-day conference to discuss and show knowledge with peers on various medical issues. The Gold Coast Medical Association's Samoan Medical Conference opened on Friday morning and will close on Saturday. A presentation at the conference by Samoa's Acting Director General for Health, Tagaloa Robert Thomsen focused on life expectancy for the country in 2023 which he said is 77 years for women and 74 for men. However, the senior Ministry of Health (MOH) official said in his presentation that there has been a slight increase of 0.17 per cent since 2022. In an interview with the Samoa Observer on Friday, Pule Dr. Viali Lameko, a Clinical Associate Professor and Public Health Consultant at Tupua Tamasese

24 • Issue 148

Mea'ole Teaching Hospital stressed that having overseas specialists in Samoa benefits Samoa in various ways. He added that they were impressed with Samoa's life expectancy during a presentation on Friday morning on the first day of the two-day conference. "Most of them, this is their first time in Samoa, they've heard of Samoa and rugby but they've never been to Samoa and just this morning, some of them shared that they are so amazed and happy about how Samoa looks as a country and also for them to learn about the health profile of Samoa," said Dr. Lameko. "They were so amazed about the health profile of Samoa, life expectancy, health indicators and all those things so it's a win-win for everyone participating in this conference. "The whole idea not only from a local clinician like myself, but also as an academic locally, is to bring the conference here rather than one or two doctors going overseas to one conference. "It's better to bring all the doctors over here and also nurses if they want to join and learn from the more than 30

specialists from overseas who are actually from different colleges in Australasia who are here to present on different subjects. "That's the whole idea behind this which is why I was heavily involved in this because I like the idea of bringing them here rather than us going there one by one." Dr. Lameko added that the conference is also good exposure for Samoa's local doctors and medical students on how to organise medical conferences while acknowledging the calibre of people presenting. "Speaking in front of people is a different story altogether and so all of that I believe the benefit of the conference to us altogether and also at the same time is also our colleagues overseas to experience Samoa," he said. This week's two-day conference took a whole year of organising between the Oceania University of Medicine, Gold Coast Medical Association, Samoa's Ministry of Health, Samoa Medical Association and the National University of Samoa.

Conference Boosts Medical Education Talaia Mika Initially published in the Samoan Observer 30 September 2023

edical education linked to Samoa's health system is the focus of a twoday international medical conference currently underway in Apia. The Gold Coast Medical Association's Samoan Medical Conference started on Friday morning at the Taumeasina Island Resort and targets students and medical professionals and brings together speakers with academic, research and educational backgrounds on issues considered relevant to Samoa's health system. Speakers at the two-day conference include Samoa's Minister for Health, Valasi Tafito Selesele as well as the President of the Gold Coast Medical Association, Professor Philip Morris, Oceania University of Medicine's Prof. Athol Mackay plus Pule D. Viali Lameko and Asiata Prof. Satupaitea Viali and Prof. Alan Fraser from the University Hospital of Wales, Cardiff in the United Kingdom. Samoa's Health Director General, Aiono Prof. Alec Ekeroma was also scheduled to present but it is understood that he is currently abroad. Topics to be covered during the twoday conference range from "Artificial

Intelligence in Medicine" to "Samoa's Health Profile", "Facial Surgery and Skin Cancer" and "Orthopaedic Trauma". In an interview with the Samoa Observer on Friday, Prof. Morris said this is their fourth conference where they've contributed to a local medical association in the Pacific and they are happy to be in Samoa to assist through these advanced medical talks. "Last year we came to Samoa and asked some of the doctors and people in the medical association if they're associated free of charge and with a program that will cover areas of medicine that they might be interested in," he said. "Majority of the speakers from overseas are from the Gold Coast, Queensland [and] New South Wales in Australia, one very senior speaker on machine learning from Wales in Great Britain but he's Scottish and he is keen to learn about Robert Louis museum and he has connected with a colleague to hike up to Mount Vaea. "We just like to contribute to the development of medical education and training in the South Pacific and with our

brothers and sisters in the medical profession here and we're very happy to be here. "There was nothing specific about Samoa's health situation that was of great concern, we heard earlier that there was an outbreak of measles and that was an interesting thing to contemplate. "But it was nothing specific or worrying about Samoa other than just contributing to the medical education of this area." On Saturday there will be two workshops, one on how to resuscitate children infants and babies and the other on eye disease and how to identify and treat them, which is part of the medical education of Pasifika and another on pathology, pathological tests before concluding with a visit to the Tupua Tamasese Meaole main hospital in the afternoon at Motootua. Meanwhile, Prof. Morris is a distinguished psychiatrist and the President of the Gold Coast Medical Association who holds multiple leadership positions in prestigious organizations, such as the Pacific Rim College of Psychiatrists, the Australian National Association of Prac-

medicallink.com.au • 25

• THE MEDICAL LINK

tising Psychiatrists, and the Australia and New Zealand Mental Health Association. In an interview with this newspaper, Dr. Viali shared the significance and benefit of the conference for all medical students and professionals, not only in Samoa but also in Tokelau as they are also participating to expand their knowledge as well. "It's not very often that we get international speakers in Samoa and not very often that our medical staff attend this sort of staff locally," he said. "Almost 56 of them are attending and that is to update all our knowledge on what's happening in the various areas of medicine - cardiac, obstetric, paediatric, pathology and many other areas." According to Dr. Viali, over 130 from hospitals, the private sector, doctors from the Ministry of Health, staff from the School of Medicine, and Oceania School of Medicine, and about 30 plus medical students from both schools are participating. He then shared about heart diseases and how Samoa managed to improve

... over 130 from hospitals, the private sector, doctors from the Ministry of Health, staff from the School of Medicine, and Oceania School of Medicine, and about 30 plus medical students from both schools are participating.

from this common disease in the country. "Rheumatic heart disease and rheumatic fever which is so common in Samoa and in the Pacific. I just returned from Tokelau and spent three weeks there screening and their situation is similar to Samoa. "Rheumatic heart disease comes out of rheumatic fever and our government is sending quite a lot overseas for surgery. It's getting better, but we still need to be more vigilant in making sure that we follow up with the people that have rheumatic fever and so they also talk about heart attacks, obstetric type staff and baby issues. "Me and Viali have been working with them for the last eight months trying to organise this conference. What gives motivation? Because of what great topics they'll talk about and what they bring to Samoa for us the local staff and our medical students have come to listen as well as our local doctors and doctors and directors in Tokelau are coming to listen so it's all beneficial for us."

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