Independent learning program for GPs

Unit 539 June 2017

Infectious diseases

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 Independent learning program for GPs

Independent learning program for GPs

Infectious diseases
Unit 539 June 2017

About this activity 2

Acronyms 3

Case 1 An outbreak of influenza virus 4

Case 2 Simona has genital pain 12

Case 3 David has an itchy rash 16

Case 4 Zoe has stomach cramps 21

Case 5 Mary-Joy has an ongoing cough 27

Multiple choice questions 33

The five domains of general practice

Communication skills and the patientdoctor relationship
Applied professional knowledge and skills
Population health and the context of general practice
Professional and ethical role
Organisational and legal dimensions
ABOUT THIS ACTIVITY
ABOUT THIS ACTIVITY
Mortality related to communicable disease has decreased from 13% of
all deaths in 1907 to 1.3% in 2009.1 However, infectious diseases
remain a major health concern and, usually, patients with infections
will first present to general practice. While some infectious diseases
resolve without intervention, others can be chronic and have a serious
adverse impact on an individuals daily activities.
As the speed and scale of national and international travel continue to
increase, general practitioners need to be at the forefront of
coordinated, strategic approaches to tackling pandemics.1 Genital
herpes is caused by the Herpes simplex virus (HSV), and is a common
sexually transmissible infection (STI); an estimated one in eight
Australians have the virus.2
Scabies is a highly contagious parasitic skin infection caused by
Sarcoptes scabiei. Often, treatment needs to be targeted not only at
the patient, but also at close contacts, including household members.3
Infectious gastroenteritis can be caused by bacteria, viruses or
parasites, and usually occurs when the source is ingested.4
Tuberculosis is caused by Mycobacterium tuberculosis, and most
cases are found in those from countries of high prevalence.5
LEARNING OUTCOMES
At the end of this activity, participants will be able to:
outline the role of the general practitioner in the event of a pandemic
discuss the diagnosis and management of genital herpes
describe the management of patients with scabies
summarise the assessment and management of gastroenteritis and
its complications
discuss the diagnosis and treatment of patients with tuberculosis.
AUTHORS
Bruce Bartley (Case 4) MBBS, FRCSE, FACEM, is deputy director of
the emergency department at University Hospital Geelong. He has a
surgical background and fulfils leadership and representative roles in
trauma and disaster medicine at the local, regional, state and national
levels. Dr Bartley is chairman of the Barwon Health Trauma Audit
Committee and has an ongoing leadership role in regional outreach
and support including supervision of the regional and remote specialist
training program at nearby Colac. His current priorities include
emergency health systems improvement at a local and regional level,
Aboriginal and Torres Strait Islander health, and completion of a
Masters in Public Health and Tropical Medicine.
Penny Burns (Cases 1 and 4) BMed, MPHTM, is a general practitioner
with a special interest in travel and tropical medicine. She has worked in
general practice and hospitals in Papua New Guinea and in Colombia
where gastroenteritis is a constant presentation. Dr Burns has a special
interest in public health and infectious outbreaks and has completed a
Masters of Public Health and Tropical Medicine at James Cook University.
2
check Infectious diseases
Dr Burns is also RACGP NSW&ACT Disaster Response
Representative, RACGP representative on the GP Round Table,
member of the NSW Mental Health Disaster Advisory Committee,
Chair of the Oceania Chapter of the World Association of Disaster
Emergency Medicine, member of the Immunisation Coalition, RACGP
representative on the National Immunisation Committee and chaired
the RACGP Pandemic flu kit taskforce. Dr Burns is currently
undertaking a PhD on the role GPs have to play in disasters and
pandemics at the Australian National University. She is a conjoint
senior lecturer at the University of Western Sydney.
Winnie Chen (Case 5) BMedSci, MBBS, is a general practice registrar
at Centre for Disease Control, Darwin. She is interested in medical
publishing and previously worked at the Medical Journal of Australia
as a deputy medical editor.
Alvin Chong (Case 3) MBBS, MMed, FACD, is specialist dermatologist
and senior lecturer at St Vincents Hospital Melbourne, Skin and
Cancer Foundation Inc and the University of Melbourne. He is also
principal dermatologist at Ivanhoe Dermatology Clinic, Victoria. His
special interests are in dermatology education and in the
dermatological care of immunosuppressed patients.
Rachel Davenport (Case 3) MBBS, is a research and education fellow
at the Skin and Cancer Foundation, Victoria. She is completing a
Masters of Medicine in Clinical Epidemiology. Dr Davenports research
focus is on dermatological conditions in the immunocompromised
host. Her other special interest is vulval dermatology.
Glynn Kelly (Case 1) MBBS (Hons), BSc, Cert Higher Ed, MMed,
FRACGP, is a Brisbane-based general practitioner who has a special
interest in disaster and pandemic planning, preparation and
responding particularly in the interface between primary care and
hospitals and other health services. Dr Kelly is the Chair, RACGP
Disaster Network and is the Chief Medical Officer of St John Australia.
He also has a professorial appointment with the QUT Centre for
Emergency and Disaster Management.
Vicki Krause (Case 5) MD, DTM&H, FAFPHM, is director of Northern
Territory (NT) Centre for Disease Control and the NT Head of
Tuberculosis/Leprosy Clinical and Program Services, based in
Darwin, NT and has edited the NT Disease Control Bulletin for the
past 26 years.
Catriona Ooi (Case 2) FAChSHM, MM(HIV/STDs), MBBS BSc (Med),
DipFP, DipGov, is a sexual health physician and the clinical lead at the
Western Sydney Sexual Health Service. Dr Ooi teaches is a senior
lecturer at the University of Sydney, teaching in the clinical medical
school in Westmead. She is involved in ongoing research and has
published in textbooks and peer-reviewed journals.
Kate Sandy (Case 1) MBBS, is a member of the RACGP Specific
Interests Disaster Management group. She is a graduate of the
Australian Film, Television & Radio School and has been involved in
disaster management education over the past five years. Dr Sandy
has compiled and presented disaster scenarios for GPs, practice
nurses and postgraduate students. She is currently an intern at
Nepean hospital.
check Infectious diseases ABOUT THIS ACTIVITY

Dean Zinghini (Case 4) MBBS, is a general practice registrar working REFERENCES

in Port Macquarie, New South Wales. Since completing university, he 1. Department of Health. National framework for communicable disease control.
has fulfilled both teaching and representative roles as a conjoint Canberra: DoH, 2014. Available at www.health.gov.au/internet/main/publishing.nsf/
lecturer with Western Sydney University and worked with quality Content/ohp-nat-frame-communic-disease-control.htm [Accessed 19 April 2017].
improvement on the patient care committee at Royal Prince Alfred 2. Sexual Health Australia. Genital herpes. Sydney: SHA, 2015. Available at www.
sexualhealthaustralia.com.au/genital_herpes.html [Accessed 19 April 2017].
Hospital. He has a special interest in infectious disease and 3. The Royal Childrens Hospital Melbourne. Scabies Symptoms and treatment.
paediatrics, completing his Diploma of Child Health in 2016. Parkville, Vic: RCH, 2010. Available at www.rch.org.au/kidsinfo/fact_sheets/
Scabies_symptoms_and_treatment [Accessed 19 April 2017].
4. The Royal Childrens Hospital Melbourne. Gastroenteritis. Parkville, Vic: RCH, 2015.
PEER REVIEWERS Available at www.rch.org.au/clinicalguide/guideline_index/Gastroenteritis [Accessed
19 April 2017].
Paul Griffin FRACP, FRCPA, FACTM, AFACHSM, MBBS, BSc (Hons), is 5. Department of Health. Mycobacterial infections (tuberculosis). Melbourne: DoH, 2015.
the Director of Infectious Diseases at Mater Health Services in Brisbane,
conjoint senior lecturer at the University of Queensland School of
Medicine, and affiliate senior lecturer at the Mater Research Institute. He
has fellowships in infectious diseases from The Royal Australasian
College of Physicians, and in Clinical Microbiology from The Royal
College of Pathologists of Australasia and the Australasian College of
Tropical Medicine. Concurrently, Dr Griffin maintains a joint appointment
as a scientist at QIMR Berghofer/Mater Medical Research Institute with a
primary research interest in tropical medicine particularly malaria human
challenge studies. He is the principal investigator and manager of
medical services at Qpharm Pty Ltd, a specialised contract research
organisation within QIMR Berghofer specialising in early and late phase
trials in infectious diseases where he has been the principal investigator
on in excess of 40 clinical trials predominantly in infectious diseases. As
a clinical microbiologist, Dr Griffin maintains an active interest in
diagnostic microbiology with a focus on the detection of antibiotic
resistance particularly VRE with MALDI-TOF MS.
Lawrence Tan MBBS, DCH, DRCOG, MPH, FRACGP is a part-time
general practitioner in Southwest Sydney, and senior lecturer in the
Department of General Practice, Western Sydney University. He enjoys
teaching medical students and registrars. Dr Tans research interests
are in cultural and linguistic diversity and how this affects the delivery
of primary healthcare.

ACRONYMS
ACRRM Australian College of Rural and
Remote Medicine
AFB acid-fast bacilli
AGE acute gastroenteritis
AHPPC Australian Health Protection
Principal Committee
AMI acute myocardial infarction
CMV cytomegalovirus
COCP combined oral contraceptive pill
DOTS directly observed therapy short
course
ED emergency department
EHEC enterohaemorrhagic Escherichia coli
ELISA enzyme-linked immunosorbent
assay
GBS Guillain-Barr syndrome
GORD gastro-oesophageal reflux disease
GP general practitioner
GPRT GP Round Table
HBV hepatitis B virus
HIV human immunodeficiency virus
HPV human papillomavirus
HSV Herpes simplex virus
HSV-1 Herpes simplex 1
HSV-2 Herpes simplex 2
IGRA interferon gamma release assays
LTBI latent tuberculosis infection
MCS microscopy, culture and sensitivity
MERS Middle East respiratory syndrome
MSM men who have sex with men
NAAT nucleic acid amplification test
NSAID non-steroidal anti-inflammatory drug
PCR polymerase chain reaction
PEP post-exposure prophylaxis
PHU public health unit
PPE personal protective equipment
PPI proton pump inhibitors
RACGP The Royal Australian College of
General Practitioners
STI sexually transmissible infection
TB tuberculosis
WHO World Health Organization

3
CASE 1 check Infectious diseases

CASE 1
AN OUTBREAK OF INFLUENZA VIRUS
You are working in a small urban general practice in
western Sydney with four other GPs. It is January and
you are busy managing an unusual peak in asthma
following recent local bushfires. You have yet to even
think about the next flu season.
The evening news reports an outbreak of a new strain of
influenza A virus, HzNz, in Indonesia. It is thought to
have originated in a rural poultry-farming region where
people live closely with their chickens. The outbreak has
reached the edge of the nearest city in Indonesia and is
spreading rapidly. Thousands of people have developed
an influenza-like illness and more than 100 deaths have
been recorded so far. In an attempt to slow the spread,
the Indonesian government has closed schools and
public gatherings have been cancelled.
FURTHER INFORMATION
Over the past few weeks, during the development of a pandemic
plan for your practice, using The Royal Australian College of
General Practitioners (RACGPs) Pandemic flu kit, you have kept an
eye on the news about the situation in Indonesia. Reports indicate
the HzNz virus is spreading in Indonesia, with small numbers of
cases being reported in neighbouring countries.
The practice manager draws your attention to an increase in the
number of patients who are contacting the surgery, concerned
about the overseas situation and what it means for them. An
increasing number of patients have been presenting with
symptoms they think might be the HzNz.
QUESTION 3
Is this now a pandemic? When does it become a pandemic?

QUESTION 1

Why is an overseas outbreak of relevance to individual general

practitioners (GPs) in Australia? Why is a rapidly spreading influenza A
outbreak of particular concern?

QUESTION 4

What are the pandemic stages? Which stage of a pandemic is

Australia in at this point in this scenario?

QUESTION 2

Where will you look for relevant, accurate information updates?

4
check Infectious diseases CASE 1

QUESTION 5
How would you prepare for this potential impending pandemic in your
practice in Australia (eg maintain infection prevention and control,
business continuity, and communication with staff and patients)?
been investigated in Australia over the past few weeks, all in
returning travellers from Indonesia, but not in the state where you
work. All have been negative for HzNz.
QUESTION 6

What stage have we moved into now (refer to Figure 1)?

FURTHER INFORMATION
It is now six weeks since the initial reports of the HzNz outbreak
overseas (late February). A small number of possible cases have

Figure 1. Example outline of message that might be received at this stage from the Department of Health through
the GPRT through GP organisations
Update on Department of Healths response to Influenza A HzNz

What is new:
There are currently no confirmed cases of HzNz in Australia however GPs are asked to be alert for potential presentations.
Clinical case definition:
Sudden onset of fever 38oC PLUS
Cough and/or haemoptysis PLUS
Purpuric rash OR
Somnambulism (sleepwalking)

AND

Epidemiological evidence:
Recent travel to Indonesia within two weeks of symptom onset OR Contact with a confirmed case

Specific action for GPs:

Isolate and report any probable cases immediately to the local public health unit.
Investigation with nasopharyngeal swab using full personal protective equipment is recommended in all probable cases who meet the case definition.
Antivirals (for five days) are recommended for all probable and confirmed cases if <48 hours symptoms onset.
Antiviral prophylaxis is not currently recommended.
Those thought to be at higher risk include: children, elderly, pregnant women and those with chronic disease.

What we do not know:

Case fatality and prognosis is unknown. Notifications to PHUs will help collect this information.
Work is commencing immediately on the development of a vaccine which may not be available for three to four months.

Further information: Further details and updates will be available at www.hznzhznz.com.au

5
CASE 1
FURTHER INFORMATION
Just as you are reading the information, your practice manager
rushes into your room to report that Jessica, 38 years of age and
one of your regular patients, has just returned from Bali with her
son, Josh, aged 14 years, who has been coughing since yesterday,
walked in his sleep last night, and is now feeling hot (temperature
on examination 38.5C). The practice nurse has immediately
isolated them in an empty consultation room (if there were no
empty consultation rooms available, she would have asked them to
stay in their car until you were ready to see them) and asked them
to wear masks.
QUESTION 7
What features of Joshs history are you most interested in?
FURTHER INFORMATION
You are aware that Josh and his family have no significant
comorbidities that might place them at higher risk of complications
from influenza. In view of the risk of serious infection you have also
donned a mask and proceed to see them.
QUESTION 8
What are your obligations and priorities at this stage of the pandemic?
How would you manage the consultation in this scenario?
6
check Infectious diseases
FURTHER INFORMATION
Joshs test results returns and he is positive for HzNz.
Note: Australia is now in Response Initial action stage with the
novel strain, HzNz now detected in Australia. During this stage you
are actively looking for HzNz cases and managing them as you did
Josh.
A further four to six weeks pass and there has been a significant
spread of the HzNz influenza. Despite the prompt reporting and
management of early cases by local GPs, yourself included, more
than 1000 cases have been confirmed in your state alone, and
significant spread is occurring across Australia. Updated
information comes out from Department of Health regarding case
definition and testing recommendations (Figure 2).
Figure 2. Example of a message that might be
received at the later stage of a pandemic
Update on Department of Healths response to Influenza A HzNz
Key points for GPs
1000 confirmed cases HzNz in NSW with significant spread to Vic
and Qld
Symptoms of HzNz Nearly all cases of confirmed HzNz have
presented with acute febrile lower respiratory tract illness ranging
from mild to severe pneumonia and/or ARDS and purpuric skin rash.
Somnambulism is uncommon, with less than 5 reports in Australia
Australias Pandemic Stage: Response, Targeted Action
Case definition
Sudden onset fever 38oC AND Cough/haemoptysis AND Purpuric
rash Given the significant spread of HzNz within the community
epidemiological evidence is no longer required
Testing for HzNz influenza
Routine testing for HzNz influenza is no longer required for surveillance
purposes
Management of HzNz cases
Focus on treatment and management of those at high risk of
complications (ie aged <5 years and >65 years, pregnant women and
those with chronic disease). See www.hznzhznz.com.au for details
Antiviral medications are only indicated in high risk cases
Contacts
High-risk contacts of cases should be assessed and now considered for
antiviral post-exposure prophylaxis
Practice management
Implement appropriate infection prevention and control measures
Modify practice to reduce risk of cross infection
Triaging of patients (phone and at reception desk)
Refer to RACGP resources for further information
www.racgpracgp.com.au
check Infectious diseases
QUESTION 9
How would your management priorities change now? What stage of
the pandemic are you now in?
FURTHER INFORMATION
It is 6.00 pm on a Friday afternoon and you have been working late
all week because of the surge in presentations of influenza-like
illness. You have three more patients in the waiting room:
Kerry, a war veteran aged 89 years, has been unwell with a
cough and a fever (temperature 38C), this has been associated
with a purpuric rash. Kerry is accompanied by his wife, 60 years
of age, who is well.
Gillian, 45 years of age, is an emergency department nurse who
presents with a fever (39C), cough, purpuric rash and
somnambulism.
Simon, a single parent caring for a child aged 3 years, has
presented for a check-up. He has come into contact with a
confirmed case (another parent at day care) and is anxious about
the virus with some recent media coverage of deaths due to HzNz.
QUESTION 10
How would you manage these patients, taking into consideration the
change in pandemic phase and Department of Health recommendations?
CASE 1
CASE 1 ANSWERS
ANSWER 1
GPs play a crucial role in frontline public health surveillance in
Australia.1,2 In recent years, this included monitoring for Zika and
Ebola viruses, and Middle East respiratory syndrome (MERS).
The first cases of a pandemic in Australia are most likely to present to
GPs or emergency departments (EDs). Rapid identification of these
first cases is important to maximise the efficacy of the response, and
to minimise transmission, morbidity and mortality.3
Following lessons from the 2009 influenza pandemic, GPs have been
included more specifically in the national pandemic plan.35 The
Australian Health Management Plan for Pandemic Influenza notes that:
GPs and other health providers, such as nurses, Aboriginal and Torres
Strait Islander Community Coordinated Health Organisations
(AICCHOs), pharmacists and aged care providers manage the bulk of
people with influenza within the community.3
Influenza A is a respiratory virus with the potential to cause epidemics
and pandemics with high human morbidity and mortality. History
shows highly virulent and infectious strains can spread rapidly across
the globe and kill millions before a vaccine can be produced.6 Of the
three influenza viruses that infect humans, only Influenza A has been
responsible for pandemics. Influenza B can also cause major
outbreaks and severe disease, usually in older people,6 but has never
been known to cause a pandemic. Influenza C causes a cold-like
illness in children.
Influenza A viruses are capable of changing their surface structures in
two ways, antigenic shift and drift. An antigenic drift is a subtle change
and often pre-existing immunity will still respond to these viruses, at
least to a degree. An antigenic shift is a major change in one or both
of the major surface structures such that the level of protection in the
community will be very low and prior infection of vaccination with other
strains will afford little or no protection. This is how pandemics arise.
It is the severity and infectivity of a new variant of influenza that
determines the morbidity and mortality levels. Zoonotic hosts of
Influenza A, such as birds or swine, provide a huge genetic diversity
that can combine with human influenza A virus to produce a wide
variety of strains, including highly virulent contagious strains that can
lead to high mortality.6
Increasing urbanisation and international travel mean that despite the
current Influenza A outbreak being overseas, it may soon reach
Australias shores.7 The flight time from Bali, Indonesia to Darwin is
just over 2 hours. The four pandemics of the 20th century originated
overseas.6
ANSWER 2
Unlike natural disasters, which are managed initially at a local and
then a state level, a pandemic requires early coordination at a
7
CASE 1
national level, with additional variations at state and then more
local levels as the pandemic progresses across the country.8
The Australian Health Protection Principal Committee (AHPPC)
coordinates the national approach to pandemics.9 The GP Round
Table (GPRT) is also convened during a pandemic to assist in
coordination and communication with GPs. Chaired by the Chief
Medical Officer, membership includes most GP-related
organisations in Australia, including The Royal Australian College
of General Practitioners (RACGP).
It meets regularly, and as required, to discuss and receive updates
on serious infectious outbreaks threatening Australia.10 Each
GP-member organisation then communicates this information
through its membership base. The information on outbreaks is
often standardised to include the following information:
What is known
What is not known
What GPs need to do
Where/when further information will be available.
This information will arrive in your practice, distributed by GP
organisations, including the RACGP and Australian College of
Rural and Remote Medicine (ACRRM).
The same information will be also available online on the
Department of Healths website for health professionals, with
regular updated information posts that will include case definitions
and standardised investigation and management advice. Each state
public health website will have this information, as well as more
local advice available from each local public health unit (PHU).
ANSWER 3
According to the World Health Organization (WHO), a pandemic is
the worldwide spread of a new disease.11
The most likely pandemic, an influenza pandemic, occurs when a
highly infectious novel influenza virus subtype appears as a result
of antigenic shift, infecting large numbers of people across
geographical and/or international boundaries. As no one has been
previously exposed to it, limited immunity exists.
The three characteristics of a pandemic influenza virus include an
ability to:12
infect humans
cause disease in humans
be easily transmissible between humans.
With the increase in global transport, these viruses are
increasingly more capable of spreading rapidly around the world.7
The current case is still a local outbreak, as it is contained within
one country and has not spread globally, as occurred in the 2009
influenza pandemic with H1N1 (swine flu).
8
check Infectious diseases
Pandemics are unpredictable. They can have a significant impact,
through infecting large numbers across large areas and economic and
societal, even with a low clinical severity, but the impact can be very
high for example, it is estimated that 50100 million people died from
H1N1 (Spanish flu) in 1918.13 Other pandemics from the 20th century
include H2N2 (the Asian flu in 1957), H3N2 (the Hong Kong flu in 1968)
and H1N1 (Swine flu in 2009), as shown in Figure 3.
Figure 3. Clinical severity and transmissibility of
pandemics from the 20th century3
Low Moderate High
H1N1
*H5N1 'Avian flu' 'Spanish flu'
1997ongoing H2N2 191819
Clinical severity
'Asian flu'
195758
H3N2 'Hong Kong
flu' 196869
H1N1
'Swine flu' 200910
Low Moderate High
Transmissibility
Reproduced with permission from Department of Health. Australian health
management plan for pandemic influenza. Canberra: DOH, 2014. Available at
www.health.gov.au/internet/main/publishing.nsf/Content/519F9392797E2DDCCA2
57D47001B9948/$File/AHMPPI.pdf [Accessed 22 March 2017].
ANSWER 4
The WHO encourages each country to have their own locally relevant
pandemic stages and responses. Australias stages of pandemic are
summarised in Table 1.
Australia would now be in the response standby stage of a pandemic
response.
ANSWER 5
It is important to develop and exercise a pandemic plan, and assign
roles and responsibilities before a pandemic occurs, even though
these may change on the day. There is detailed guidance on this from
the RACGPs Pandemic flu kit. There are three parts to the kit:14
Managing pandemic influenza in general practice An overview of
pandemic and GPs in pandemic.
The implementation guide Guidance on clear actions to undertake
when a pandemic is threatening.
Pandemic influenza toolkit Operational documents for use in the
practice including planning templates, triage algorithms and posters.
In summary, pandemic planning may include the following:1418
One staff member to take the lead and overall coordination.
Development of an influenza pandemic plan specific for your
check Infectious diseases
practice context following the ERPT (Emergency Response Planning
Tool) at www.racgp.org.au/your-practice/business/tools/disaster/
erpt or the Pandemic flu kit resources as mentioned above at www.
racgp.org.au/pandemicresources
Infection prevention and control
Assign a staff member to manage and focus on infection control
Plan to heighten standard precautions:
increased use of personal protective equipment (PPE), alcohol-
based hand rub dispensers, surgical masks
Use transmission-based precautions:
contact (eg gloves, gowns, distancing)
droplet (eg surgical masks or N95 masks as advised at the time,
eye protection, cough etiquette)
airborne (eg use of spacer in preference to nebuliser even though
the latter is not considered an aerosol generating procedure)
Signage regarding reasons for PPE and hand hygiene
Update seasonal vaccinations for staff and patients
No-touch waste disposal
Business continuity and clinical management
Services
Surveillance, and notification and recording of methodologies
Triaging patients by phone or at reception
Awareness of high-risk individuals
Clear clinical management for medical staff including case
definition, investigation, treatment and antivirals
Immunisation, once available
Staff
Confirm willingness and ability to work, including distance from
work if transport lines affected
Table 1. Australias pandemic stages with associated activities.3
Stage
Preparedness No novel strain detected
Response: Standby Sustained person-to-person transmission
overseas of novel strain
Response: Cases of novel strain detected in Australia but Initial information about the disease is being gathered and early cases managed.
Action Initial information about the disease is very limited
Response: Cases of novel strain detected in Australia
Action Targeted but enough information is now known to tailor
response to specific needs
Response: The threat of the disease can now be
Stand down managed as part of business as usual
Recovery
CASE 1
Re-assign jobs to offsite as possible
Back-up staff
Plan for regular practice meetings for updates during the event
Supplies
Ensuring adequate supplies
Consider supply line options
Resources
Health and education resources
Usual patients
Online services (eg scripts, referrals, e-consultations)
Cohort patients Chronic care clinics at alternate times to other
patients, afternoon flu sessions
Plan for revised patient flow through the practice
Emergency planning
Urgent patients (eg acute myocardial infarction [AMI] may not
be able to be referred on to hospitals, which may be closed or
overwhelmed with flu cases). GPs may need to continue to
manage such patients past the normal stabilisation phase of
treatment.
Communication
Establish sources for provision of information updates and monitor
Establish communication lines with stakeholders (eg pharmacist,
public health, local hospital, department of health, RACGP, AMA,
nearby practices)
Potential use of posters, newsletters, emails, practice website and
phone calls to update patients situation and changes to practice
Psychological concerns
Knowledge/education and direction to accurate information
Support for patients, staff and self during pandemic and in recovery
Activities
Develop a pandemic plan and practice the plan. Ongoing normal surveillance.
Heightened surveillance for the disease locally with readiness to respond. Checking
resources. Gaining an understanding of the disease as the information emerges.
There is an expectation of increased medical presentations.
Greater understanding of the disease and greater numbers may be infected.
Clinical severity, transmissibility, epidemiology and antiviral resistance will inform
management strategy. Management may target those most at risk.
Move back to business as usual and revise plans for future pandemics.
Work with affected communities and individuals to resume health and wellbeing
9
CASE 1
ANSWER 6
We are still in response standby because there are positive cases
overseas, but it has not been detected in Australia.
If it is discovered that any patient has tested positive for HzNz,
Australia will move into Response Initial action stage.
The Department of Health, your state and local PHUs, as well as GP
organisations will all be providing you with regular, consistent information.
One of these updates, sent through from the GPRT via the RACGP,
includes a clinical case definition and what is currently known (Figure 1).
ANSWER 7
At this initial stage, with the flu season beginning (late March) and
increasing numbers of patients presenting with influenza-like illness,
the epidemiological evidence of recent travel to Indonesia or contact
with a known case is crucial. Josh fits the case definition for both:
clinical evidence; PLUS
epidemiological evidence.
As Josh is a regular patient, you are aware of any existing
comorbidities that might place him or his family at high risk. You will
also want to know about any high-risk contacts, as suggested in
Figure 1. Those at higher risk may not be well known at this early
stage and will vary according to the particular virus. Thus it may
change as a greater understanding of the virus develops.
ANSWER 8
At this early stage of this pandemic the aim is to:
contain or slow the spread of the pandemic in Australia through:
prompt identification and PHU notification of early cases
consistent management as per directives
infection control
collect viral samples (if directed), which are crucial for further
understanding and investigation of the virus and development of
vaccine
maintain business continuity.
Infection control is paramount During the consultation, at the
reception and in the waiting room particularly because of the limited
information available about the severity of the disease. Early in a
pandemic, it can be difficult to assess case fatality and identify those
most at risk. Jessica and Josh would need to be instructed on
infection control and it would be a good time to strengthen your
practice and staff infection control measures.
Early contact with the local PHU will be required in this scenario to
notify them immediately of a potential case of HzNz, if uncertain of any
of the management aspects of this case, and to facilitate expedited
testing as well as commence contact tracing.
10
check Infectious diseases
Discussion with the PHU in regard to management of potentially
exposed staff or patients will also be needed with appropriate follow-
up. Advice will be needed on the use of post-exposure prophylaxis
(PEP). The practice may also need to consider some messaging to
patients via waiting room signs or on their webpage.
At this stage, following the Department of Healths directives (Figure 3)
and advice from the local PHU you would want to:
undertake a nasopharyngeal swab from Josh, using full PPE
commence antiviral medication for five days19 before waiting for the
results
ask Jessica to keep Josh isolated at home until the results of the
throat swabs are returned
follow-up as relevant as advised by the PHU and depending on the
course of Joshs illness.
Note: In some pandemics, the directive may be to not swab in general
practice because of the high risk from infection. This will vary
according to the particular pandemic.
The important message is that what you do may be different in each
pandemic according to guidance from DOH and public health units as
the response to a pandemic is a national response with local variation
that is adjusted as an understanding emerges of the novel virus
including the transmissibility of the virus, the clinical severity of the
disease and identification of those most at risk.
ANSWER 9
Australia will now have moved into Response Targeted action
stage, with enough information on the disease to target the response.
Epidemiological information is no longer relevant to the case definition
as it is presumed that most presentations of influenza-like illness are
now HzNz. The current priority is to identify those who are at greater
risk of complications from HzNz, and manage those groups to reduce
morbidity and mortality as per the provided recommendations. Those
identified at greatest risk in the last communication from the
Department of Health (Figure 1) include those aged <5 years and >65
years, pregnant women, and those with chronic disease.
ANSWER 10
Kerry has clinical evidence of HzNz and is a high-risk patient because
of his age. He should be treated with antivirals, given education on
infection control, and followed-up to review his progress.
Gillian has clinical evidence of HzNz and is a low-risk patient, but risks
exposure to high-risk people (eg at work). Voluntary home isolation
until she has been without fever for more than 24 hours should be
advised.
Simon has no clinical evidence of HzNz. He can be reassured and
educated regarding the HzNz virus, and advised regarding antiviral
use in post-exposure prophylaxis, given that he has a small child at
home. If he were to develop symptoms, good personal hygiene and
check Infectious diseases
cough etiquette would be recommended and the child could be
offered PEP, as the child is high risk for complications.
When seeing these patients, it is important to remember the
importance of infection control measures, including individual
measures, organisational and environmental measures and
personal protective equipment. These individual measures include
hand hygiene and cough etiquette; organisational and
environmental measures include practice modification and patient
placement and segregation; and correct use of personal protective
equipment. These help to prevent the transmission from those
potentially infected patients to those who are not infected.20
Note: Guidelines will vary from pandemic to pandemic but the stages
of response and principles of management during these will be
consistent.
CONCLUSION
Over the next week, influenza-like illness presentations have
decreased significantly. There is talk in the media of availability of a
HzNz vaccine soon. Australia moves to Response Standby stage
and you return to normal business.
According to Professor Anne Kelso from the WHO, There will one day
be another pandemic but we dont know when or from where or what
it will look like'.21
RESOURCES FOR DOCTORS
The RACGPs Pandemic flu kit, www.racgp.org.au/
pandemicresources)
RACGPs Managing pandemic influenza in general practice,
www.racgp.org.au/your-practice/guidelines/flukit
RACGPs Implementation guide, www.racgp.org.au/download/
Documents/Guidelines/Flukit/implementation-guide.pdf
RACGPs Pandemic influenza toolkit, www.racgp.org.au/
download/Documents/Guidelines/Flukit/pandemic-influenza-
toolkit.doc
Australian Health Management Plan for Pandemic Influenza, www.
health.gov.au/internet/main/publishing.nsf/Content/ohp-ahmppi.htm
Influenza Specialist Group guidelines for clinicians, http://isg.org.au
State pandemic plans are available from state health websites:
New South Wales health influenza pandemic plan, www1.
health.nsw.gov.au/pds/ActivePDSDocuments/PD2016_016.pdf
Queensland Health pandemic influenza plan, www.health.qld.
gov.au/__data/assets/pdf_file/0030/444684/influenza-
pandemic-plan.pdf
Victorias Pandemic influenza plans, www2.health.vic.gov.au/
emergencies/emergency-type/infectious-diseases/pandemic-
influenza
Tasmanian health action plan for pandemic influenza 2016,
CASE 1
www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/215063/
THAPPI_2016.pdf
South Australias Pandemic influenza plan, www.sahealth.sa.
gov.au/wps/wcm/
ACKNOWLEDGEMENT
The authors would like to thank and acknowledge Michelle Gonsalvez
from The Royal Australian College of General Practitioners (RACGP) for
her substantial contribution to this case study.
REFERENCES
1. Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. Influenza pandemic
2009/A/H1N1 management policies in primary care: A comparative analysis of three
countries. Aust Health Rev 2013;37(3):29199.
2. Simonsen K, Steinar H, Sandvik H, Rortviet G. Capacity and adaptations of general
practice during an influenza pandemic. PLoS One 2013;8(7).
3. Department of Health. Australian health management plan for pandemic influenza.
Canberra: DOH, 2014.
4. Collignon PJ. Swine flu Lessons learnt in Australia. Med J Aust
2010;192(7):36465.
5. Department of Health. Review of Australias health sector response to pandemic
(H1N1) 2009: Lessons identified. Canberra: DOH, 2011.
6. Cunha BA. Influenza: Historical aspects of epidemics and pandemics. Infect Dis Clin
North Am 2004;18(1):14155.
7. World Health Organization. WHO checklist for influenza pandemic preparedness
planning. Geneva: WHO, 2005.
8. Australian Emergency Management Institute. Australian emergency management
arrangements Handbook 9. 2nd edn. Barton, ACT: Attorney-Generals Department,
2014.
9. Department of Health. Australian Health Protection Principal Committee. Canberra:
DOH, 2016. [Available from: www.directory.gov.au/directory?ea0_
lfz99_120.&&9ad55aad-bbd8-40d4-8826-afa786b147cb [Accessed 22 March
2017].
10. Department of Health and Ageing. General Practice Roundtable (GPRT) Meeting.
Canberra: Department of Health and Ageing, 2013.
11. World Health Organization. What is a pandemic? Geneva: WHO, 2010. Available at
www.who.int/csr/disease/swineflu/frequently_asked_questions/pandemic/en
[Accessed 22 March 2017].
12. World Health Organization. WHO pandemic phase descriptions and main actions by
phase. Geneva: WHO, 2016. Available at www.who.int/influenza/resources/
documents/pandemic_phase_descriptions_and_actions.pdf [Accessed 22 March
2017].
13. Johnson N, Mueller J. Updating the accounts: Global mortality of the 1918-1920
Spanish influenza pandemic. Bull Hist Med 2002;76:10515.
14. The Royal Australian College of General Practitioners. Pandemic flu kit. East
Melbourne, Vic: RACGP, 2014.
15. The Royal Australian College of General Practitioners. Implementation guide. East
Melbourne, Vic: RACGP, 2014.
16. Collins N, Litt J, Winzenberg T, et al. Plan your pandemic A guide for GPs. Aust
Fam Physician 2008;37(10):79499.
17. Collins N, Litt J, Moore M, et al. General practice: Professional preparation for a
pandemic. Med J Aust 2006;185(10 Suppl):S6669.
18. Anderson J. A GP work plan for pandemic flu. Aust Fam Physician 2007;36(4):25759.
19. Influenza Specialist Group. Influenza in children. Melbourne: Influenza Specialist
Group, 2015 [updated 31 August 2015. Available at http://isg.org.au/index.php/
clinical-information/influenza-and-children [Accessed 22 March 2017].
20. Brockie J. Insight Pandemic. In: SBS, editor. Insight. Sydney: SBS, 2014.
21. The Royal Australian College of General Practitioners. 6.3 Infection prevention and
control Managing pandemic influenza in general practice. East Melbourne, Vic:
RACGP, 2014. Available at www.racgp.org.au/your-practice/guidelines/flukit/6-
preparedness/63-infection-prevention-and-control [Accessed 22 March 2017].
11
CASE 2 check Infectious diseases

CASE 2
SIMONA HAS GENITAL PAIN
Simona is 21 years of age and works in a sandwich
shop in urban Australia. She has felt unwell for about
the past four days, experiencing headaches, fevers and
myalgia, and has not been able work. She reports
severe pain down there over the past two days. The
pain is worse with urination and she feels
uncomfortable when sitting or walking. Simona has
been generally well and has no significant medical
history. She takes the combined oral contraceptive pill
(COCP), but no other medications. Simona has been
seeing someone, Dean, for three months. They always
use condoms for vaginal sex. They have not had oral
sex. Prior to her relationship with Dean, Simona last
had vaginal sex six months ago with her ex-boyfriend.
that she may have caught something from Pete, a man she met at a
Christmas party nearly two weeks ago. She states that after a few
drinks, they had oral sex. She is worried that Dean will find out.
Examination reveals inguinal lymphadenopathy. There is bilateral
vulval ucleration around the labial minorum, and clusters of small
circular lesions with clean bases and surrounding erythema at the
urethra. More peripherally, there are several small clusters of
circular blisters, which are filled with colourless fluid. The
surrounding area is erythematous.
QUESTION 2
What is your provisional diagnoses? What tests do you need to confirm
the diagnosis?

QUESTION 1

What further information do you need from Simona?

QUESTION 3

What treatment do you offer?

FURTHER INFORMATION
Simona has no abdominal pain or any increase in urinary
frequency. She has not noticed any abnormal bleeding, vaginal
discharge or smell. The last time she had vaginal sex was 10 days
ago with Dean. There was no dyspareunia. Her last period was two
weeks ago and she has not missed any of her COCPs. Simona had
a urine test for chlamydia at the end of her last relationship, six
FURTHER INFORMATION
months ago, but has not been tested for other sexually
transmissible infections (STIs) or blood-borne viruses. She has You take genital swabs for PCR testing for Herpes simplex virus
completed the human papillomavirus (HPV) vaccination course, but (HSV)-1, HSV-2, gonorrhoea and chlamydia. You also order serology
cannot recall having hepatitis B vaccinations. Simona has never testing for HIV, HBV and syphilis. PCR testing is positive for HSV-1
had cold sores. She has not travelled recently, used any new skin infection. The STI screen and all other testing were unremarkable.
care products, or taken any new medication. She denies history of Serology was negative for HIV and syphilis, and she is hepatitis B
genital trauma. non-immune. Simona presents a week later for the results. She is
angry with Pete, whom she assumes was the source of the
Simona has not had these symptoms previously and is worried about
infection. She is also worried about Dean and their relationship.
human immunodeficiency virus (HIV) infection. Her main concern is

12
check Infectious diseases CASE 2

QUESTION 4 QUESTION 6

What advice can you give Simona? What should you do now?

QUESTION 5 FURTHER INFORMATION

What advice should you give Simona about contact tracing (partner
notification)?
Simona feels well despite new lesions appearing, so the treatment
is extended to 10 days. Hepatitis B vaccinations also commenced
today.
Simona is worried she will not be able to have children. She has
also read that herpes can cause cancer and increase HIV risk.

QUESTION 7

What advice do you give Simona?

FURTHER INFORMATION
Simona returns the following week. She reports that some of the
genital lesions are almost healed, but although she feels well, she
has noticed new ones appearing. She has been doing her own
online research and has a few questions.

13
CASE 2
CASE 2 ANSWERS
ANSWER 1
You should obtain a full medical history, including a detailed sexual history,
vaccinations, and previous sexually transmissible infections. Consider the 5
Ps: partners, practices, protection from STIs, past history of STIs and
prevention of pregnancy.1
ANSWER 2
The most likely diagnosis is genital herpes. As Simona has not experienced
this before, it is an initial episode of either Herpes simplex 1 (HSV-1) or
Herpes simplex 2 (HSV-2) infection, which may be non-primary (ie with
prior exposure to the other type) or a primary infection (first infection with
HSV-1 or HSV-2 with no pre-existing antibodies to either). Previous HSV-1
or HSV-2 exposure cannot be ruled out, despite the lack of previous
symptoms (eg orolabial cold sores or genital lesions), as most infections
are subclinical or unrecognised and remain undiagnosed. Both HSV-1 and
HSV-2 can infect the genital area, transmitted via genital to genital and
mouth to genital contact. The clinical presentation of genital HSV-1 and
HSV-2 is similar and indistinguishable. Although genital infections are
historically associated with HSV-2, the majority of new genital infections in
Australia are caused by HSV-1.2
Testing is required to confirm the diagnosis and rule out differential
diagnoses. Differential diagnoses for genital ulceration include infectious
causes (eg primary syphilis) and non-infectious (eg Behcets syndrome,
fixed drug eruptions) and tests conducted according to risk and history.
An HSV nucleic acid amplification test (NAAT), for example, HSV PCR, is a
direct detection swab test that confirms HSV type and is required for
diagnosis, management, counselling and discussion of prognosis. HSV
NAAT is widely available and has superseded viral culture because of its
superior sensitivity. For best results, samples are taken by swabbing the
base of an ulcer or de-roofing a vesicle.
Direct detection swabs are both site-specific and symptom-specific, unlike
HSV serology, which offers limited value in many settings and therefore
recommended only in particular circumstances. A second ulcer swab may
be collected for syphilis NAAT (PCR) testing to exclude primary syphilis,
which may be considered in at-risk groups; for example, men who have
sex with men (MSM) or Aboriginal and Torres Strait Islander peoples.
Simona reported dysuria, so a mid-stream urine microscopy, culture and
sensitivity (MCS) test may exclude a urinary tract infection; however, it is
likely that dysuria is secondary to genital ulceration associated with HSV
infection. Testing for other STIs should be done. A speculum examination
may not be appropriate given the severity of Simonas symptoms;
however, to test for Neisseria gonorrhoea and Chlamydia trachomatis, a
self-collected vaginal swab or first-void urine sample can be taken for
NAAT.3 As Simona is concerned about HIV infection, collect serology for
HIV, syphilis and hepatitis B virus (HBV); vaccinating for HBV is advisable if
Simona is not immune. A urinary pregnancy test can be considered if there
is a pregnancy risk.
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check Infectious diseases
ANSWER 3
Simona's presentation is consistent with genital herpes. She is shocked
and distressed. Counselling and information are important, despite
unconfirmed diagnosis. The volume of information given at this time will be
dependent on Simonas response and needs. It may be appropriate to
cover issues after confirmation of the diagnosis.
Patients are advised to take simple analgesics if required. Topical
anaesthetic gels may be helpful for some, particularly for patients with
painful urination. Saline baths can assist in lesion healing. Secondary
infection is uncommon, and local antiseptics are unnecessary. Avoid
genital applications of powders, creams and use of soap.3
All patients should be offered oral antiviral treatment while awaiting test
results.3
Convenient authority prescription streamline codes for treatment of genital
herpes states microbiological confirmation of diagnosis is desirable but
need not delay treatment.4
There is little evidence that topical antiviral medication reduces symptoms
and dual therapy of topical and oral antivirals is of no added benefit. Timely
treatment can reduce the duration and severity of symptoms, and all
antiviral agents are effective.5,6 There is limited research comparing five
days of treatment with longer courses in initial episodes, but treatment
could be extended if new lesions appear, complications occur or the
patient is systemically unwell. There are three antiviral agents available for
treatment and evidence suggests that valacyclovir, famcyclovir and
acyclovir are therapeutically equivalent. Dosing, pill burden and cost vary,
and will determine the regimen. For a first episode genital herpes, consider
either acyclovir 400 mg orally, eight-hourly for five days, famciclovir 250
mg orally, eight-hourly for five days or valacyclovir 500 mg orally,
12-hourly for five days. Up to 10 days of treatment may be needed for
severe disease.7
Complications are rare and some, such as urinary retention and aseptic
meningitis, may require hospitalisation. Other complications, such as
secondary infection of lesions and autoinoculation, may be managed in the
community.
ANSWER 4
After confirming the diagnosis, normalisation and reassurance may assist
with reducing distress and stigma. Australian studies report nearly 80% of
Australian adults are HSV-1 seropositive, and 12% HSV-2 seropositive.8
As only 20% of those infected experience classical symptoms (ie recurrent
blisters), most infections remain undiagnosed and can be transmitted
unwittingly.9 Most people with a symptomatic first episode of genital HSV-2
will experience recurrences (about four per year); however, recurrences
are less frequent after an initial episode of genital HSV-1 infection (about
one per year).10,11 Disease activity and viral shedding are greatest in the
first 612 months after infection; however, Simona can be reassured that,
over time, any future recurrences will be less severe, self-limiting and less
frequent, and that treatment is available to manage her infection.1214
Although it is likely that this is a new infection and timing suggests that it
might have been transmitted during oral sex with Pete, it is impossible to
identify the source. Simona had two sexual partners within the HSV-
check Infectious diseases
incubation period, which generally ranges from two days to two weeks:
oral sex with Pete two weeks ago and vaginal sex with Dean 10 days ago.
Condoms reduce transmission risk, but they are not 100% effective, as
transmission is via skin-to-skin contact, so either Pete or Dean could be
the source of a new infection. Furthermore, only about one-third of those
infected will experience a symptomatic response at the time of acquisition,
suggesting that this is possibly the first presentation of an established
infection. This is unlikely given the severity of Simonas presentation.
Onward transmission is often a concern. Simona should be advised to
avoid autoinoculation during this initial infection and abstain from sexual
contact until the diagnosis is confirmed.
Autoinoculation is uncommon, however, more likely to occur during a
primary infection, prior to the development of circulating antibodies.7,15
Simple measures such as hand washing after toileting can avoid this.
Following this initial episode, reassure Simona with regard to the low risk
of autoinoculation and fomite spread.
This risk of onward transmission is greatest during a symptomatic episode
and contact during this time should be avoided. Transmission may occur at
other times as a result of asymptomatic viral shedding; however, this can
be minimised with use of suppressive antiviral medication. Use of male
condoms can also reduce infection risk.
Ongoing treatment options also need to be addressed. Many patients with
recurrent genital HSV infection experience only mild, infrequent symptoms
and do not require medication. Management options range from supportive
care alone to episodic and suppressive therapy. Treatment should be
tailored to suit the individual and may change over time. Suppressive
treatment has the added advantage of suppressing asymptomatic viral
shedding and therefore reducing onward transmission risk. Episodic
treatment is cheaper and does not require daily adherence. Short-course
regimens (one to three days) provide added convenience.
ANSWER 5
Disclosure is challenging for many people, and tricky in this case, given
that the source cannot be determined. Genital herpes is not a notifiable
condition and contact tracing is not recommended. It would be prudent,
however, to raise and document the issue of disclosure, and discuss the
advantages of informing current sexual partners, such as decreasing
onward transmission risk.
ANSWER 6
You could extend the duration of treatment to 10 days.7 It is also advisable
for Simona to be vaccinated against hepatitis B.
ANSWER 7
Reassure Simona that the future risk of neonatal herpes is <1% for
women with prenatal histories of recurrent herpes. It is also advisable for
Simona to be vaccinated against hepatitis B.16,17 Acyclovir has been used
safely for many years at all stages of pregnancy and breastfeeding.18,19
Limited data and clinical experience indicate valacyclovir, a prodrug of
acyclovir, and famciclovir also have a low risk in pregnancy. HSV is not
associated with cancer.
CASE 2
Both HSV-1 and HSV-2 increase the risk of HIV acquisition twothreefold
in men and women.20 Simona is in a low-risk group for HIV and should be
reassured accordingly.
CONCLUSION
Herpes is a common, chronic, preventable infection, which is largely
undiagnosed in the Australian context. Diagnosis can be associated with
significant psychosocial morbidity yet infection can be managed effectively
with available treatment options and prevention methods. Management
should be tailored to the individual and reviewed in response to patient
needs.
REFERENCES
1. Centers for Disease Control and Prevention. A guide to taking a sexual history.
Atlanta: CDC, 2005. Available at www.cdc.gov/std/treatment/sexualhistory.pdf
[Accessed 19 April 2017].
2. Tran T, Druce JD, Catton MC, Kelly H, Birch CJ. Changing epidemiology of genital herpes
simplex virus infection in Melbourne, Australia, between 1980 and 2003. Sex Transm
Infect 2004;80(4):27779.
3. Australasian Sexual Health Association. Australian STI management guidelines for use in
primary care. Melbourne: ASHA, 2016. Available at http://www.sti.guidelines.org.au
[Accessed 19 April 2017].
4. Department of Health. Pharmaceutical Benefits Scheme. Canberra: DoH, 2017. Available
at www.pbs.gov.au/browse/streamlined-authority [Accessed 19 April 2017].
5. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes
simplex virus infections with acyclovir: Results of topical, intravenous and oral therapy. J
Antimicrob Chemother 1983;12:7988.
6. Fife KH, Barbarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of
first-episode genital herpes infection. Results of an international, multicenter, double-
blind, randomized clinical trial. The Valaciclovir International Herpes Simplex Virus Study
Group. SexTransm Dis 1997;24:48186.
7. Patel R, Green J, Clarke E, et al. 2014 UK national guideline for the management of
anogenital herpes. Int J STDs & AIDS 2015;26(11):76376.
8. Cunningham AL, Taylor R, Taylor J, Marks C, Shaw J, Mindel A. Prevalence of infection
with herpes simplex virus types 1 and 2 in Australia: A nationwide population based
survey. Sex Transm Infect 2006;82(2):16468.
9. Corey L, Simmons A. The medical importance of genital herpes simplex virus infection.
International Herpes Management Forum, 1997.
10. Lafferty WE, Coombs RW, Benedetti J, Critchlow C, Corey L. Recurrences after oral and
genital herpes simplex virus infection: Influence of anatomic site and viral type. N Engl J
Med 1987;316:144449.
11. Engelberg R, Carrell D, Krantz E, Corey L, Wald A. Natural history of genital herpes simplex
virus type 1 infection. Sex Transm Dis 2003;30:17477.
12. Wald A, Zeh J, Selke S, Ashley RL, Corey L. Virologic characteristics of subclinical and
symptomatic genital herpes infections. N Engl J Med 1995;333:77075.
13. Benedetti JK, Zeh J, Corey L. Clinical reactivation of genital herpes simplex virus infection
decreases in frequency over time. Ann Intern Med 1999;131:1420.
14. Wald A, Zeh J, Selke S, Warren T, Ashley R, Corey L. Genital shedding of herpes simplex
virus among men. J Infect Dis 2002;186(Suppl 1):S3439.
15. Fatahzadeh M. Human herpes simplex virus infections: Epidemiology, pathogenesis,
symptomatology, diagnosis, and management. J Am Acad Dermatol 2007;57(5):73763.
16. Brown ZA, Wald A, Morrow RA, et al. Effect of serologic status and cesarean delivery
on transmission rates of herpes simplex virus from mother to infant. JAMA
2003;289:20309.
17. Brown ZA, Benedetti J, Ashley R, et al. Neonatal herpes simplex virus infection in
relation to asymptomatic maternal infection at the time of labor. N Engl J Med
1991;324:124752.
18. Andrews EB, Vankaskas CB, Cordero JF, Schoeller K, Hampp RN. Acyclovir in
pregnancy registry: Six years experience. Obstet Gynecol 1992;79:113.
19. Brown ZA, Baker DA. Acyclovir therapy during pregnancy. Obstet Gynecol
1989;73:52631.
20. Wald A, Link K. Risk of human immunodeficiency virus infection in herpes simplex virus
type 2-seropositive persons: A meta-analysis. J Infect Dis 2002;185:4552.
15
CASE 3 check Infectious diseases

tried topical corticosteroids to no avail. Davids wife and children

CASE 3 have had similar symptoms over the past two weeks.
On examination, David has a widespread erythematous papular
DAVID HAS AN ITCHY RASH eruption. On the flexor aspects of his wrists, interdigital spaces of
David, 40 years of age, presents to you with a six-week his hands and genital area, there are also scaly, excoriated papules
history of a widespread, intensely itchy rash. He has no (Figure 1).
significant past medical history and does not take any
On closer inspection using a dermatoscope, a linear burrow is
regular medications.
evident on Davids right wrist (Figure 2).

QUESTION 1 Figure 2. Dermatoscopic view of Davids right wrist,

showing burrows
What further information should you obtain from David? What
physical examination would you perform?

FURTHER INFORMATION
David tells you he is very itchy. The heat makes the itch more
severe, and it is particularly bad after a hot shower. The itch is
most pronounced at night and is affecting Davids sleep. He has

Figure 1. Erythematous lesions

A B C

A. Widespread erythematous papules on trunk that are visibly itchy; B Scaly, erythematous papules on flexural aspect of wrist. C Excoriated erythematous papules and nodules on
penis.

16
check Infectious diseases CASE 3

QUESTION 2 FURTHER INFORMATION

What is the most likely diagnosis? What pathognomonic finding would A scabies mite is detected by light microscope on a skin scraping
you expect to see on physical examination? taken from the flexural aspect of Davids wrist (Figure 3).

QUESTION 5

How would you manage Davids scabies? What treatment options are
available?

QUESTION 3

What are the differential diagnoses?

FURTHER INFORMATION
David was prescribed 5% permethrin cream, which he applied to
his entire body before going to bed and leaving it overnight. He
repeated this process one week later. His family also underwent
the same treatment. He was reviewed one week after his second
application of permethrin. The itch had improved significantly, but
he was still itchy.

QUESTION 6

What are the possible reasons for Davids persistent symptoms,

despite treatment?

QUESTION 4

What diagnostic tests are useful in determining the diagnosis?

17
CASE 3
CASE 3 ANSWERS
ANSWER 1
History-taking should determine the following:
Where did the itch start?
What makes the itch worse?
Is Davids sleep disturbed?
Is there any itching in the genital areas?
Did the rash coincide with an illness or change in diet, ingestion of
over-the-counter products, change in work or leisure activities,
recent overseas travel?
Is there anyone in Davids family or close contacts with similar
symptoms?
Does David have a personal or family history of atopy?
What treatments has David tried?
The entire skin surface should be inspected.1,2 In particular, the
interdigital spaces, wrists and ankles should be closely scrutinised. If
Davids genitals are itchy, then this area also needs to be examined. If
scabies is suspected, gloves are a necessity. It is important to examine
the skin in a well-lit room and with the aid of magnification, ideally
using a dermatoscope.2
Assess the distribution and morphology of the rash.3 Attention should
be paid to the number, colour, size and symmetry of lesions.1,3 In
particular, look for burrows scaly, squiggly lines often found on diagnosis of scabies is often overlooked.7 An important practice point
the wrists, sides of fingers and genitalia.
ANSWER 2
In Davids case, scabies is the most likely diagnosis.
The possibility of scabies should be considered in patients who
present with the following symptoms and signs:
Widespread and intense pruritus that spares the head and neck
(except in infants and young children).
Itching that tends to be worse at night or following a hot bath or
shower.4
Cutaneous lesions that are symmetrical and involve interdigital
webbing of the hands, flexural aspect of the wrists, axillae, posterior
auricular area, waist, ankles, feet, buttocks and genitalia, and on
the breasts of women.4
Pruritus in close contacts; other household members with similar
symptoms.4
Initially, scabies can be asymptomatic. In the early stages of the
infestation, the itch can be localised to the areas preferred by the
18
check Infectious diseases
scabies mite, which are the cooler parts of the body, such as the
hands, wrists, ankles, genitalia and breasts. After a few weeks, the
body develops an allergic response to the mite, and the intense,
generalised pruritus starts. Patients often describe the itch as the
worst itch they have ever experienced.
The rash is characterised by pruritic erythematous papules that
become excoriated. Vesicles, especially acrally in infants, indurated
nodules, eczematous dermatitis and secondary bacterial infection are
also common.
The pathognomonic sign is the scabies burrow (Figure 2), representing
the tunnel that a female mite excavates while laying eggs.4 On
inspection, the burrow is a greyish white, wavy, thread-like structure
that is 110 mm in length.4 Using dermatoscopy, a characteristic jet
with contrail or hang-glider appearance may be seen and
corresponds to the mite5 (refer to Answer 4). In many instances,
however, burrows may be absent or difficult to find clinically. In the
immunocompetent individuals, there may only be 1015 mites on a
patient at any one time.
Crusted scabies, formerly known as Norwegian scabies, is a
hyperinfestation of millions of mites.6 Clinically, there is marked
hyperkeratosis with an acral distribution.4 However, any part of the
body can become involved and, in some cases, may resemble
psoriasis.6 Crusted scabies occurs in immunocompromised hosts and
those with decreased sensation or inability to scratch, such as patients
with neurological disease and the elderly.4 This highly contagious form
of scabies can be a problem in institutional settings, such as aged
care facilities.
It is important to remember that the degree of reaction is variable.7
Clinical signs may be subtle, or even absent, and this means a
is to consider scabies in every patient presenting with intense pruritus,
especially if there is a familial account of similar symptoms.8
ANSWER 3
In humans, the signs and symptoms of scabies infestations can mimic
a broad range of skin diseases.6 Almost all pruritic dermatoses must
be considered as differential diagnoses.6 The clinical picture is
frequently masked by secondary infection and eczematous changes
or, in cases of less impressive scabies (referred to as scabies
incognito8), by topical corticosteroids. The list of differential diagnoses
is long and includes the following:
atopic, allergic contact and nummular dermatitis
arthropod bites
folliculitis/impetigo
tinea corporis
papular urticaria
prurigo nodularis
infantile acropustulosis
check Infectious diseases CASE 3

dermatitis herpetiformis
Figure 3. Light microscopic appearance of a scabies mite
pityriasis rosea
drug eruptions
viral exanthema.

As mentioned previously, crusted scabies can resemble psoriasis.9

ANSWER 4
In practice, a presumptive diagnosis is often made on the basis of the
history and examination of the patient, as well as on the history of
close contacts.10 A clinical diagnosis of scabies can be made on the
detection of a burrow at a usual predilection site.6 It can be difficult to
visualise a burrow, however, as they are often obscured by eczema or
impetigo.6 Dermatoscopy can be very useful in the detection of
burrows (Figure 2). Alternatively, the burrow ink test can be used to
delineate the lesions.
A more definitive diagnosis requires the microscopic identification of mites,
eggs or faecal pellets.10 At present, light microscopic examination of
scales obtained by skin scrapings is the gold standard for diagnosis.11,12
Skin scrapings should be taken from the end of a burrow or from a
non-excoriated papule if possible.8 The entire burrow, or the end of Few tests are sufficiently sensitive or specific, making an accurate
the burrow with the black dot can be obtained by scraping the skin diagnosis of scabies difficult.15 Research into more sophisticated
with a size 15 blade.10 The material that has been scraped off is then diagnostic techniques, such as polymerase chain reaction (PCR)
carefully transferred to a slide8,10 A drop of mineral oil can be applied antigen detection, intradermal skin test, and enzyme-linked
to the material before covering with a coverslip and examining under a immunosorbent assay (ELISA) antibody detection are in progress.
light microscope, if available at your practice.8,10,11
ANSWER 5
Potassium hydroxide can be used as well in the preparation of the
sample, but it may dissolve the mite and its products.8,10 Because Management of Davids scabies involves the following principles:
those with classical scabies harbour only 1015 mites, multiple
1. Treatment of the index case with anti-scabies treatment First-
superficial skin scrapings can be taken in order to increase the
line treatment here would be topical 5% permethrin cream,
likelihood of finding a mite.10 Visualisation of a mite or parts thereof,
applied from the neck down to cover the whole body, including
eggs and faecal material of the mites would confirm the diagnosis.
genitalia and interdigital spaces, then left on overnight and
While this technique provides excellent specificity, some skill and
washed off in the morning.
experience are needed, and failure to demonstrate the mite does not
rule out scabies.10 2. Treatment of the whole household with 5% permethrin cream at
the same time to prevent cross-infestation.
Studies show that dermatoscopy-guided skin scrapings can help
identify mites, and the authors of this case study believe this approach 3. In the morning, all bedclothes and pyjamas need to be hot-
should be applicable in the primary care setting13 (Figure 3). washed and tumble dried to kill mites. Non-washable items can
be stored in a hermetically sealed bag for one week.
Skin biopsies may only show non-specific findings of arthropod bites,
although, rarely, biopsy may include a scabies mite or mite products, 4. The index case and any symptomatic family members will need
such as eggs and faecal material. to repeat the 5% permethrin cream treatment in one week from
initial application.
The adhesive tape test is another diagnostic technique and involves the
use of transparent tape (eg packing tape), which is firmly applied to a Careful identification followed by appropriate and thorough
lesion and then pulled off rapidly.11,14 The tape is subsequently applied treatment of patients, as well as their close physical contacts,
to a glass slide and examined under magnification. The rationale is that remain the cornerstone of scabies management.6 As scabies does
mites contained within the upper layers of the epidermis (ie the layers not always present with symptoms and clinical signs, all live-in
loosened by repetitive skin scratching) and those temporarily migrating family members and other close physical contacts should be
on the skin, should stick to the adhesive tape.11 This test is treated simultaneously, even in the absence of symptoms and
advantageous as it does not require specialised equipment. signs.6

19
CASE 3
A range of agents, most of them topical, have been used to treat
scabies (Table 1).16 Topical preparations should be applied to the
entire body from the neck down, paying particular attention to the
interdigital spaces, intergluteal cleft, umbilicus and subungual areas
(apply under the fingernails using a soft brush).4 In order to maximise
exposure of the mite to the active drug, topical agents should be left
on the skin for at least eight hours before washing.16 It is thus most
practical to advise your patients to apply the solution in the evening
and leave it overnight.4,16 To eradicate any newly hatched mites, a
second application should be administered one to two weeks after the
first application.4,16
It should be noted that in certain populations, scabies can also occur
above the neck. This is most common in central and northern
Australia, and in infants and the elderly.17 In such individuals, topical
formulations should also be applied to the face and hair, with care
taken to avoid the eyes and mucous membranes.7
The risk of re-infestation via fomite transmission, although rare, can
be minimised by laundering clothing, bed linens and towels at the time
of treatment.4 Non-washable items can be stored in a hermetically
sealed bag for one week.4
Treatment of crusted scabies requires special consideration and we
recommend specialist referral to a dermatologist or an infectious
diseases physician. In general, treatment involves combination therapy
with repeated doses of ivermectin, frequent application of a topical
scabicide and keratolytics.
ANSWER 6
Re-infestation needs to be excluded. David needs to be closely examined
for scabies burrows. If none are found, the likelihood is post-scabetic
itch. This is because mites and mite products can still cause a significant
allergic response in the skin until they are shed.
Post-scabies itch can be expected to persist for up to four weeks after
the end of successful scabicide therapy.10 This can be treated with
twice-daily administration of a medium-to-potent topical corticosteroid
cream (eg mometasone furoate 1 mg/g cream) and emollient. When
symptoms persist beyond four weeks, treatment failure secondary to
poor compliance, resistance or re-infestation should be considered, as
well as diagnoses of nonscabetic origin.10
SCABIES IN AUSTRALIA
Scabies is endemic in many Aboriginal communities within
Australia.17,18 A review of clinic attendance by Aboriginal children of
remote northern Australia found that 69% of infants presented with
scabies in the first year of life.17 Scabies is associated with significant
morbidity.17 Secondary streptococcal infection can predispose children
to rheumatic heart disease and post-streptococcal glomerulonephritis,
which, worldwide, have the highest incidence in Australian Aboriginal
and Torres Strait Islander peoples.17 Mass drug administration
programs using topical permethrin to eradicate scabies and, more
recently, oral ivermectin, have been implemented with varying degrees
of success.2,18,19
20
check Infectious diseases
REFERENCES
1. Oakley A. Scabies. Hamilton, NZ: DermNet New Zealand, 2015. Available
at www.dermnetnz.org/topics/scabies [Accessed 22 March 2017].
2. Wong LC, Amega B, Barker R, et al. Factors supporting sustainability of a
community-based scabies control program. Australas J Dermatol 2002;43(4):274
77.
3. Wolff KJ, Johnson R, Saavedra A. Fitzpatricks colour atlas and synopsis of clinical
dermatology. 7th edn. New York: McGraw-Hill Medical, 2013.
4. Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 2012. London, Elsevier Health
Sciences, 2012.
5. Micali G, Lacarrubba F, Massimino D, Schwartz RA. Dermatoscopy: Alternative uses
in daily clinical practice. J Am Acad Dermatol 2011;64(6):113546.
6. Heukelbach J, Feldmeier H. Scabies. Lancet 2006;367(9524):176774.
7. Expert Group for Dermatology. Dermatology: Insects and mites: Scabies. In: eTG
complete [Internet]. Melbourne: Therapeutic Guidelines Ltd, 2015. Available at
https://tgldcdp.tg.org.au/viewTopic?topicfile=insects-mites#toc_d1e47 [Accessed 9
February 2017].
8. Hengge UR, Currie BK, Jager G, Lupi O, Schwartz RA. Scabies: A ubiquitous
neglected skin disease. Lancet Infect Dis 2006;6(12):76979.
9. Gach JE, Heagerty A. Crusted scabies looking like psoriasis. Lancet
2000;356(9230):650.
10. Chosidow O. Clinical practices Scabies. N Engl J Med 2006;354(16):171827.
11. Walter B, Heukelbach J, Fengler G, Worth C, Hengge U, Feldmeier H. Comparison of
dermoscopy, skin scraping, and the adhesive tape test for the diagnosis of scabies in
a resource-poor setting. Arch Dermatol 2011;147(4):46873.
12. Argenziano G, Fabbrocini G, Delfino M. Epiluminescence microscopy. A new
approach to in vivo detection of Sarcoptes scabiei. Arch Dermatol 1997;133(6):751
53.
13. Albrecht J, Bigby M. Testing a test: Critical appraisal of tests for diagnosing scabies.
Arch Dermatol 2011;147(4):49497.
14. Katsumata K. Simple method of detecting sarcoptes scabiei var hominis mites
among bedridden elderly patients suffering from severe scabies infestation using an
adhesive-tape. Intern Med 2006;45(14):85759.
15. Mounsey KE, McCarthy JS, Walton SF. Scratching the itch: new tools to advance
understanding of scabies. Trends Parasitol 2013;29(1):3542.
16. Currie BJ, McCarthy JS. Permethrin and ivermectin for scabies. N Engl J Med
2010;362(8):71725.
17. Kearns TM, Speare R, Cheng AC, et al. Impact of an ivermectin mass drug
administration on scabies prevalence in a remote Australian aboriginal community.
PLoS Negl Trop Dis 2015;9(10):e0004151.
18. Kearns T, Clucas D, Connors C, Currie BJ, Carapetis JR, Andrews RM. Clinic
attendances during the first 12 months of life for Aboriginal children in five remote
communities of northern Australia. PLoS One 2013;8(3):e58231.
19. Carapetis JR, Connors C, Yarmirr D, Krause V, Currie BJ. Success of a scabies
control program in an Australian Aboriginal community. Pediatric Infect Dis J
1997;16(5):49499.
check Infectious diseases CASE 4

QUESTION 2
CASE 4
What is the most likely diagnosis? What are the differential diagnoses?
ZOE HAS STOMACH CRAMPS What are the high risk diagnoses you need to consider?

Zoe, 26 years of age, is a teacher at the local high

school. She is your first patient for the day and presents
with a two-day history of frequent loose stools;
uncomfortable, crampy central abdominal pain; dull
headache; and feeling hot and cold. Apart from her
current symptoms, Zoe has no personal or family history
of significance. She is worried about passing it on to her
students, who are about to do their final exam.

QUESTION 1

How would you approach this consultation? What specific features of

the history and examination are you most interested in?
QUESTION 3

What investigations, if any, would you consider? What is your rationale

for this choice?

FURTHER INFORMATION
Zoe is fit and healthy. She has not been travelling or in contact with
anyone else with similar symptoms, Oh, except for Sally, my
neighbour, who had abdo cramps last week, but I think that was
her periods. Sally has not been travelling. For the past 24 hours,
Zoe has had frequent small loose stools with a small amount of
blood and mucous. She has no significant medical history and
takes no medications. On examination, you note that Zoe looks
well, but uncomfortable, and is haemodynamically stable. She feels
slightly thirsty. She has mild, generalised abdominal tenderness but
no signs of peritonism and no abnormal masses.
FURTHER INFORMATION
You assess Zoe as being mildly dehydrated and prescribe oral
rehydration solution, 23 L, to be taken in small volumes frequently
over 24 hours. You advise her to eat if she feels hungry, and that
returning to her normal diet as soon as possible will help her
recovery,1,2 but that she should be careful with foods containing high
levels of fat or simple sugars. Large amounts of the latter, especially
soft drinks, sports drinks, cordials and fruit juice may increase the
osmotic load.2
You ask Zoe to stay home from work and return for review once the
results are available. You advise that she will not be able to return
to work until at least 48 hours after her stools return to normal.3
To prevent spread Zoe should be advised to follow simple hygiene
precautions, most importantly regular handwashing.4,5

21
CASE 4
QUESTION 4
What is your management strategy while you await the results of the
stool sample?
FURTHER INFORMATION
Your next patient, Zoes aunt, Anne, aged 75 years, comes to see
you. She has weakness in both of her legs and has had increasing
difficulty walking upstairs over the past three days. Anne feels a
severe, deep ache in her legs when moving them, especially at
night. She also notes pins and needles in her hands and feet. On
specific questioning, Anne tells you that she has not seen Zoe for
weeks and it was nice to catch up in the waiting room. She also
mentions that she had loose stools and mild fever about two to
three weeks ago, which have since resolved.
QUESTION 5
What is the most likely diagnosis in view of the associated
gastroenteritis in the preceding weeks?
FURTHER INFORMATION
You consult a specialist for advice about Annes condition. The
specialist organises for Anne to be admitted to hospital for a lumbar
puncture, electromyography investigations and therapy.6
22
check Infectious diseases
QUESTION 6
What are the serious complications associated with the more prevalent
gastrointestinal infections in Australia?
FURTHER INFORMATION
You see three other patients with symptoms similar to Zoes symptoms.
You are now concerned about whether these episodes of diarrhoea are
linked and whether you need to contact the local public health unit (PHU).
You phone your local PHU and report your suspicion on the now four to
five possibly linked cases of gastroenteritis, with one of the cases
working in an educational institution.
The PHU trace your initial contacts and find many more people in town
with similar symptoms. They investigate both cases, and local water
and food sources in an attempt to identify the source. The other general
practice in town has now also reported several cases.
Zoes stool result returns positive for Campylobacter. You are now
seeing many more people with the same symptoms, and those without
symptoms but who are worried about getting it. You have had to
increase your hours to manage the extra load.
The evening news reports on large numbers of work absences due to
gastro sickness. One of the local primary schools has closed because
of the high number of staff affected. The stores in town have all sold
out of bottled water.
QUESTION 7
What are the requirements, if any, for notification of Campylobacter infection?
check Infectious diseases
QUESTION 8
What are the key components of the emergency health response to such an
outbreak?
CASE 4 ANSWERS
ANSWER 1
Diarrhoea is one of the top 30 presentations to Australian general practice,
with abdominal pain, diarrhoea and vomiting accounting for 2.7% of primary
reasons for presentations.7 There were more than 1.2 million hospitalisations
for acute gastroenteritis (AGE) in the nine years between 2001 and 2010.8
Diarrhoea has a reported prevalence of 6.4% in Australian communities, with
one in five seeking medical care. Children under five years of age have the
highest prevalence.9
The introduction of rotavirus vaccine in the National Immunisation Program
Schedule in 2007 has resulted in a considerable decrease in rotavirus and all-
cause gastroenteritis notifications, and hospital presentations in children
younger than 5 years, with a 71% reduction in hospitalisation rates for
rotavirus gastroenteritis after three years of the program.7,8,10 It also appears
to have had a broader effect with a reduction in hospitalisations in the 519
years age group as well.8
In Zoes case, the acute onset of abdominal pain, diarrhoea and fever could
be minor and self-limiting, but could also point to serious and potentially fatal
causes.
A thorough history and examination are essential to establish:1113
hydration status
clinical severity
associated comorbidities and potential effect of gastroenteritis
medications and potential effect of gastroenteritis
epidemiological evaluation
probability diagnosis and
selection of appropriate candidates for faecal studies.
CASE 4
Universal infection-control precautions are needed throughout the consultation
and within the practice to avoid spread of any communicable disease.
This includes community contacts and risk of spread within the
community. Zoe works in a school, so is in a higher risk occupation for
communicable disease spread. Certain diarrhoeagenic enteric pathogens are
notifiable, varying by state and territory (refer to Resources for doctors).
General practitioners (GPs) have a crucial role in surveillance and early
detection of infectious outbreaks and emerging infectious disease in their
local communities.
Clinical history should explore the patients presenting problem, with a focus
on the context in which it occurred. Questions should be asked to elicit
information about:
fluid intake and output, including:
vomiting, urine output and urine colour
stool characteristics onset, frequency, type, volume, presence of
blood (note: diarrhoea of the small bowel is typically watery, large
volume, associated with abdominal cramping, bloating and gas.14,15
Large bowel diarrhoea is associated with frequent regular small volume
bowel movements that may be painful with fever, and bloody or
mucous stools)14
past medical history, including vaccinations and potential sources of
Salmonella infections (eg questionable food consumed, travel, unwell
contacts, animal exposure and occupation involving exposure to sources of
infection
medications
antibiotics are associated with Clostridium difficile infection
proton pump inhibitors (PPI) increase the risk of infectious diarrhoea
immunosuppressants increase the risk of cytomegalovirus (CMV) and
parasitic infections14
absorption of some medications may be reduced (eg combined oral
contraceptive pill)
medications more likely to cause adverse effects in the presence of
dehydration include non-steroidal anti-inflammatory drugs (NSAIDs),
angiotensin converting enzyme inhibitors (ACEIs), angiotensin II
receptor blockers, diuretics, digoxin, warfarin, metformin, lithium
comorbidities
pregnancy (risk of listeriosis increases 20-fold)14
epidemiological evidence including food history, travel, unwell contacts,
similar recent presentations.11,14
Clinical examination may be entirely normal, but should include general
appearance, vital signs (eg heart rate, respiratory rate, blood pressure,
temperature), fluid status, body weight, and abdominal signs, including
masses, distension, tenderness, signs of peritonism, bowel sounds.11,16
Rectal examinations can assist in clarifying features of the stool including
blood and mucous.16
Assessing hydration status of a patient is the key to appropriate rehydration
strategies. Signs of severe dehydration include altered level of consciousness,
23
CASE 4 check Infectious diseases

intense thirst, dry mucus membranes, marked loss of skin turgor, In Zoes case, as there was blood in the stools, and as she is a school
haemodynamic instability, decreased/no urine output and increased urine teacher with a high risk of spreading any infectious disease to others, early
osmolality with ketones.13 In elderly patients, these signs and symptoms may diagnosis and management would be beneficial. It would be useful to perform
be absent, and dehydration may present atypically with increasing confusion, a stool culture and a faecal multiplex polymerase chain reaction (PCR).12,20
chest pain or falls.13
The PCR provides rapid results within 24 hours and increased sensitivity. It
currently detects the more common pathogens (ie Salmonella,
ANSWER 2 Campylobacter, Shigella, Yersinia enterocolitica, Aeromonas, Giardia,
The combination of fevers, cramping abdominal pain and bloody diarrhoea is Entamoeba histolytica, Dientamoeba, Blastocystis and Cryptosporidium).
suggestive of bacterial enteritis. In Australia and worldwide, diarrhoea is most However, molecular methods (PCR) may also detect asymptomatic infection
commonly caused by viral pathogens. In returned travellers, up to 90% of or non-viable organisms16 and have increased detection rates of rarely
diarrhoea is caused by bacteria.13,16 Zoe presents with mild dysentery. Visible pathogenic organisms such as Blastocystis hominis and Dientamoeba fragilis.
blood in the stool in febrile patients generally indicates infection due to
invasive pathogens such as Shigella, Salmonella and Campylobacter.11 Table 1. Causative pathogens and clinical features18,20,21
The main infectious differentials (for fever and bloody or mucoid stools) Pathogen Incubation period Clinical features
besides Salmonella, Shigella and Campylobacter include parasites
Salmonella Usually 1236 hours Headache, fever, abdominal
(Entamoeba histolytica), cytotoxic infection (C. difficile) or enterohaemorrhagic
with range 672 cramps, diarrhoea (+/ blood
Escherichia coli (EHEC) infection and, rarely, enteric viruses (CMV or hours or mucus), nausea
adenovirus).14 Other differentials include initial presentations of chronic
conditions, such as inflammatory bowel disease (ulcerative colitis, Crohns Shigella Usually one to three Fever, vomiting, abdominal
disease),14,16 or diarrhoea with haemorrhoids or periods.17 The rapidity of days, or up to seven cramps, diarrhoea (+/ blood
onset of severe abdominal pain means that ruling out an abdominal condition days or mucous)
requiring surgery, including ischaemic colitis, is essential.16 Campylobacter Usually two to five Fever, nausea, abdominal
In a patient with suspected gastroenteritis, clinical features may suggest the days, range of 110 cramps and diarrhoea (+/
days blood or mucous). Vomiting is
causative pathogen (Table 1). uncommon
Note: for acute diarrhoea, maintaining and correcting intravascular Shiga toxin Three to four days, Diarrhoea (+/ blood) and
fluid volume takes precedence over identifying a causative agent.11 For producing range of 210 days abdominal cramps. Little or no
most patients, such as Zoe, who do not have severe illness or high-risk Escherichia coli fever or vomiting
comorbidities, it is reasonable to make a clinical diagnosis and continue (STEC) 0157
expectant management.14
Yersinia Four to seven days Fever, abdominal pain and
cramps, diarrhoea (often blood
ANSWER 3 in kids), arthralgia in 50%
adults
Stool culture may be indicated if identification of potential bacterial pathogens
would alter management or suggest possible complications.16,18 In Australia, Clostridium Risk factors: recent Watery diarrhoea (+/ blood),
in 2011, less than one in five people presenting with diarrhoea were asked to difficile antibiotic use, long fever, anorexia, nausea,
submit a stool sample.19 Indications for stool culture include: hospital stay, elderly, abdominal pain
immunosuppression.
profuse watery diarrhoea with signs of dehydration
Entamoeba Days to weeks Often asymptomatic, or severe
frequent small volume stools with blood or mucus histolytica abdominal cramps, diarrhoea
(+/ blood or mucous), mild
bloody diarrhoea fever
temperature 38C
Such results need to be carefully interpreted in the clinical context to avoid
severe abdominal pain
unnecessary antimicrobial treatment. It should not be used in the absence
recent antibiotic use or hospitalisation13 of symptoms.22,23 Furthermore, PCR will not report on antimicrobial
sensitivities so subsequent stool culture is still needed to provide
older age (>70 years) or immunocompromised patient
susceptibility testing and for public health reasons.2
comorbidities that may be exacerbated by hypovolaemia
Collection of stool samples early in the illness is preferable as the number
symptoms persisting for more than a week
of pathogens in stool samples decreases with time. The specimen should
public health concerns (eg healthcare workers, food handlers, teachers, be stored in a sterile container and refrigerated to prevent overgrowth of
childcare workers or at the beginning of a pandemic).13,16,20 non-pathogenic organisms, and processed as soon as possible (within a

24
check Infectious diseases
day or two of collection).13 Submission of a second sample increases the
detection rate to 99% of bacterial agents but is rarely required if PCR
testing has also been requested.24
Bacterial pathogens are generally excreted continuously, and so, a
negative culture is usually not false.14 Stool culture results are usually
reported within three days and provide microbial sensitivity.25 Common
viruses can be detected using highly sensitive and specific enzyme
immunoassay.25 More specific requests for the cause of bloody diarrhoea
in travellers could be considered for the detection of cysts, ova and
parasites with a possibility of E. histolytic or EHEC, as well as direct
testing for Shiga toxin and faecal lactoferrin.14,16
Routine laboratory tests are generally not required and would not be
indicated for Zoe.3,25 If the patient is significantly dehydrated, serum
electrolytes, urea and creatinine may be indicated as a screen for renal
dysfunction.14
ANSWER 4
Management of patients with acute diarrhoea begins with fluid repletion and
nutrition maintenance. The high incidence of viral and self-limiting
gastroenteritis in Australia does not support empirical antibiotic treatment for
uncomplicated illness1214 particularly with current concern about
antimicrobial resistance with inappropriate use of antibiotics.22 In a case
such as Zoes, where there is a mild presentation of bloody diarrhoea,
waiting for the results of the stool testing is justifiable.22 The purpose of
antibiotic therapy is to decrease duration, severity, excretion and spread of
infection, or to prevent serious complications.13 In cases of severe bloody
diarrhoea, the use of empirical antibiotic therapy, such as azythromycin 500
mg once daily for three days, or an oral fluoroquinolone, such as norfloxacin
400 mg twice daily for three to five days, would be appropriate.
Fluoroquinolone resistance is increasing, especially in Campylobacter.12,14
Antimotility antidiarrhoeal agents such as loperamide have been shown to
reduce diarrhoea in randomised controlled trials, but should be avoided in
children and the elderly because of potential adverse effects,10 such as toxic
magacolon. In a case with bloody diarrhoea, these would not be
recommended unless antibiotics were also being taken, as they may prolong
the illness or increase its severity.4,5,7 Anti-emetics may be considered in
adults to reduce the severity of nausea and vomiting.6
Dietary aims in gastroenteritis are to return to as normal a diet as soon as
possible after rehydration.2 Although transient lactase deficiency is common
following gastroenteritis, a meta-analysis of clinical trials has indicated that a
lactose free diet is rarely necessary.1
ANSWER 5
Anne might have developed Guillain-Barr syndrome (GBS). Reactive
arthritis and GBS are complications of Campylobacter gastroenteritis. The
peak incidence is in men aged 6575 years and women 7585 years.26
The chance of developing GBS in the two months following symptomatic
Campylobacter enteritis is <2/10,000 with a higher risk with Campylobacter
jejuni.27
GBS is a group of immunologically mediated polyneuropathies. The most
common form can present with weakness of the lower limbs with associated
CASE 4
paraesthesia and pain that progresses proximally.28 About two-thirds of
patients with GBS report respiratory or gastrointestinal symptoms in the
preceding three weeks, and 5089% experience nociceptive and/or
neuropathic pain with movement in the affected muscles that is worse at
night.6 Campylobacter jejuni is the most commonly recognised precipitant of
GBS and may trigger around 30% of all cases. Those subtypes with a slower
recovery and a higher residual disability risk are more likely to be preceded
by gastrointestinal symptoms.6 Although this is an uncommon condition,
early diagnosis can improve outcomes.6 Most people recover spontaneously,
but given the unpredictable and potentially life-threatening and disabling
nature of GBS, it is advisable to discuss Annes condition with a specialist.
ANSWER 6
Most commonly, gastroenteritis can cause volume depletion and electrolyte
disturbance (eg hypernatraemia, hyponatraemia, hypokalemia).29 Other
potential outcomes include acute renal failure (from severe volume
depletion) and sepsis.29 Other specific complications of bacterial enteritis
include reactive arthritis, cardiac complications (eg pericarditis, myocarditis)
and haemolytic uremic syndrome (from Shiga toxin-producing E. coli).4,16
ANSWER 7
In Victoria where you are working, gastroenteritis caused by Campylobacter
is a notifiable disease.30,31
Note: There is variation between states in notification requirements and so it
is worth checking locally. In Victoria Campylobacter infection is a group B
condition so requires completion of the Group B form to the Department of
Health and Human Services within five days. At time of publication
Campylobacter infection is not notifiable in NSW but this is likely to change
in the near future to align with other states. In 201216, an estimated
>18,000 cases of Campylobacter infections were reported annually across
Australia.30 This number is likely to be an underestimation and the actual
number of cases is steadily increasing.31,32
ANSWER 8
GP surveillance role
GPs have a crucial role to play in early identification of infectious outbreaks
and emerging infectious disease, including those related to bioterrorism.17
GPs are spread through rural and urban communities and, with emergency
departments (EDs), are the frontline health contact with these communities.
A heightened awareness is required to differentiate an isolated presentation
from the start of a larger outbreak.
GPED interface
High-quality collaboration and communication between EDs and GPs are
vital in such public health events. Real-time communication and information
sharing between emergency health providers is required to ensure home-
based care or hospital-based care is provided appropriately. Strong linkages
and functional systems for business as usual for patients moving between
primary care and emergency departments will maximise the chances of
having the best possible health response for a community during infectious
disease outbreaks.
25
CASE 4
CONCLUSION
By the end of your first week, an alert comes through from the PHU, warning
about the large number of patients presenting with gastroenteritis due to
Campylobacter and the suspicion that it is linked to the towns water supply,
which today tested positive for Campylobacter. The Mayor announced that
the water is now being treated with chlorine, which should eradicate any
Campylobacter, but residents have been advised to boil all water until the
final test results are available. Water tankers have been stationed throughout
the town.
The news that evening reports that there have been hundreds of
presentations of gastroenteritis, including 22 requiring admission to hospital.
All schools in the town have now closed as more than 50% of staff and
children are absent with gastroenteritis.
[This scenario has been loosely based on an actual outbreak.]
RESOURCES FOR PATIENTS
GBS CIDP Foundation International provides explanations about GBS,
www.gbs-cidp.org
GBS CIDP State based Groups exist in Australia including:
Queensland: www.gbsqld.com
New South Wales: www.gbs-cidp-nsw.org.au
Victoria: www.ingroup.org.au
Tasmania: www.connectingup.org
RESOURCES FOR DOCTORS
Notifiable diseases by jurisdictions:
Tasmania: www.dhhs.tas.gov.au/__data/assets/pdf_
file/0003/53319/Guidelines_for_Notifying_Diseases_and_Food_
Contaminants_FINAL_ISSUED.pdf
Victoria: www2.health.vic.gov.au/public-health/infectious-diseases/
notify-condition-now
Western Australia: ww2.health.wa.gov.au/Articles/N_R/Notification-
of-infectious-diseases-and-related-conditions
New South Wales: www.health.nsw.gov.au/Infectious/Pages/
notification.aspx
Queensland: www.health.qld.gov.au/clinical-practice/guidelines-
procedures/diseases-infection/notifiable-conditions/list
Australian Capital Territory: http://health.act.gov.au/sites/
default/files/Reporting_of_notifiable_conditions_code_of_
practice_and_form_0.pdf
Northern Territory: https://health.nt.gov.au/professionals/centre-for-
disease-control/cdc-programs-and-units/notifiable-diseases
National disease notification, www.health.gov.au/internet/main/
publishing.nsf/Content/cda-surveil-nndss-casedefs-distype.htm
26
check Infectious diseases
REFERENCES
1. Murphy M. Guidelines for managing acute gastroenteritis based on a systematic review of
published research. Arch Dis Child 1998;79:27984.
2. ETG_Complete. Supportive management of acute gastroenteritis. Melbourne: Therapeutic
Guidelines Ltd, 2016.
3. Kelly A, Cheong E. How to treat: Paediatric gastroenteritis. Sydney: Australian Doctor, 2007.
4. Juckett G. BMJ best practice Campylobacter infection. London: BMJ Best Practice, 2015.
5. Ejemot RI, Ehiri JE, Meremikwu MM, et al. Hand washing for preventing diarrhoea. Cochrane
Database Syst Rev 2008;1:CD004265.
6. Walling AD, Dickson G. Guillain-Barre syndrome. Am Fam Physician 2013;87(3):19197.
7. Britt H, Miller G, Henderson J, et al. General practice activity in Australia 201415. Sydney:
Sydney University Press, 2015.
8. Dey A, Wang H, Menzies R, Macartney K. Changes in hospitalisations for acute
gastroenteritis in Australia after the national rotavirus vaccination program. Med J Aust
2012;197(8):45357.
9. Scallan E, Majowicz SE, Hall G, et al. Prevalence of diarrhoea in the community in Australia,
Canada, Ireland, and the United States. Int J Epidemiol 2005;34(2):45460.
10. Australian Technical Advisory Group on Immunisation. Part 4: Vaccine preventable diseases.
In: Department of Health. The Australian immunisation handbook. 10th edn. Canberra: DoH,
2017.
11. World Gastroenterology Organisation. World Gastroenterology Organisation Global Guidelines
Acute diarrhea in adults and children: a global perspective. Milwaukee, WI: World
Gastroenterology Organisation, 2012.
12. Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: Diagnosis, treatment, and
prevention of acute diarrheal infections in adults. Am J Gastroenterol 2016;111(5):60222.
13. Acute gastroenteritis [Internet]. Therapeutic Guidelines Ltd, 2016. Available at www.tg.org.
au [Accessed 28 March 2017].
14. Wanke C, Calderwood SB, Bloom A. Approach to the adult with acute diarrhea in resource-
rich settings. Alphen aan den Rijn, Netherlands: UpToDate, 2016.
15. Wanke C. Small intestinal infections. Current opinion in gastroenterology 1994;10(1):5965.
16. Pawlowski S. BMJ best practice assessment of acute diarrhoea. London: BMJ Publishing
Group Ltd, 2016.
17. Dalton T. How to treat: Foodborne illness. Sydney: Australian Doctor, 2005.
18. NSW Health. Foodborne-illness outbreak control guideline. Sydney: NSW Health, 2015.
Available at www.health.nsw.gov.au/Infectious/controlguideline/Pages/foodborne-illness.
aspx [Accessed 28 March 2017].
19. Australian Institute of Health and Welfare. Australian burden of disease study: Impact and
causes of illness and death in Australia 2011. Canberra: AIHW, 2016.
20. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of
infectious diarrhea. Clin Infect Dis 2001;32(3):33151.
21. SA Health. Infectious diseases. Adelaide: SA Health, 2017. Available at www.sahealth.sa.
gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/Health+topics/Health+condi
tions+prevention+and+treatment/Infectious+diseases [Accessed 28 March 2017].
22. Spelman D, Jenny AW, Burgner DP. Australasian Society for Infectious Diseases: Low value
interventions. Med J Aust 2017;206:28283.
23. Jones CA, David JS, Looke DF. Death from an untreatable infection may signal the start of
the post-antibiotic era. Med J Aust 2017;206:29293.
24. Valenstein P, Pfaller M, Yungbluth M. The use and abuse of routine stool microbiology: A
College of American Pathologists Q-probes study of 601 institutions. Arch Pathol Lab Med
1996;120(2):20611.
25. Hewison CJ, Heath CH, Ingram PR. Stool culture. Aust Fam Physician 2012;41(10):77579.
26. Hughes RA, Charlton J, Latinovic R, Gulliford MC. No association between immunization and
Guillain-Barre syndrome in the United Kingdom, 1992 to 2000. Arch Intern Med
2006;166(12):130114.
27. TAM CC, Rodrigues LC, Petersen I, Islam A, Hayward A, OBrien SJ. Incidence of Guillain-
Barre syndrome among patients with Campylobacter infection: A general practice research
database study. J Infect Dis 2006;194:9597.
28. Vriesendorp F. Guillain-Barre syndrome in adults: Clinical features and diagnosis. Alphen
aan den Rijn, Netherlands: UpToDate, 2016.
29. Brown K. BMJ best practice viral gastroenteritis. London: BMJ Best Practice, 2016.
30. Communicable Diseases Network Australia. National Communicable Diseases Surveillance
Report Fortnight 25, 2016. Summary notes for selected diseases 3 to 16 December
2016. Canberra: Department of Health, 2016.
31. National Notifiable Diseases Surveillance System. Canberra: Department of Health Australian
Government; 2017.
32. Humphries RM, Linscott AJ. Laboratory diagnosis of bacterial gastroenteritis. Clin Microbiol
Rev 2015;28(1):331. connect/6701668047c17b259896da
check Infectious diseases CASE 5

QUESTION 3
CASE 5
What are your differential diagnoses?
MARY-JOY HAS AN ONGOING COUGH
Mary-Joy, 23 years of age, is from the Philippines. She
presents to your clinic with a five-week history of
cough. She has not had any shortness of breath, fevers
or night sweats. Mary-Joy notes that she has lost 3 kg
over the past two months but believes this is because
of stresses at work. You note on her past history that
Mary-Joy had a positive Mantoux test (19 mm) when
she first came to Australia as a nursing student. She
was clinically well and had a normal chest X-ray, but
was diagnosed with latent tuberculosis infection (LTBI).
At the time, she was preoccupied with moving house
and did not attend any further follow-up to address her
LTBI status.

QUESTION 1
What is your first priority in managing this presentation?
FURTHER INFORMATION
Mary-Joy tells you that she was born in the Philippines and moved
to Australia two years ago. She has not travelled elsewhere,
currently works in a non-clinical role, and is not aware of any
known TB contacts. As an infant, she received the BCG vaccination
against TB.
She is otherwise well and is a non-smoker. On examination, she is
afebrile and observations are within normal limits. Her weight is 52
kg (55 kg, two months ago). Mary-Joy has no evidence of
respiratory distress. Her chest is clear and there is no palpable
lymphadenopathy.

QUESTION 4

How efficacious is the BCG vaccination against TB disease?

QUESTION 2

What information should you obtain on history? What physical

examination would you perform?

27
CASE 5 check Infectious diseases

QUESTION 5 QUESTION 7

What are risk factors for progression of LTBI to active TB? How would you interpret Mary-Joys chest X-ray?

FURTHER INFORMATION
QUESTION 6 Given the findings on the chest X-ray, you refer Mary-Joy to a TB
If you suspect that a patient has active pulmonary TB, what clinic. Although the sputum sample is negative for AFB, the TB unit
investigations are appropriate? requests polymerase chain reaction (PCR) testing as there is high
clinical and radiological suspicion of TB in Mary-Joys case. The PCR
results are positive for M. tuberculosis and indicate no rifampicin
resistance. Sputum cultures subsequently confirm M. tuberculosis.

QUESTION 8

How would you manage Mary-Joy? What is the treatment for pulmonary TB?

FURTHER INFORMATION
You collect a sputum sample from Mary-Joy, order a chest X-ray
(Figure 1) and refer her to a TB clinic.

Figure 1. Mary-Joys chest X-ray

QUESTION 9

What are potential side effects of Mary-Joys TB medications?

28
check Infectious diseases
FURTHER INFORMATION
Mary-Joy is seen daily by TB nurses for DOTS. She has a monthly
medical review at the TB clinic to review clinical progress, adjust
medications if required, and identify any new issues.
At three months she has no cough and has gained weight back to
baseline. She is tolerating her medications and experiences no side
effects. Mary-Joy had no changes to her baseline visual acuity or
colour-vision testing (Ishihara test). A repeat chest X-ray shows
minor residual left upper lobe findings.
On contact tracing, Mary-Joys three housemates, who are well,
are identified as at-risk contacts and referred for screening. Mary-
Joy is encouraged to talk with her family, who are in the
Philippines, to be aware of the signs and symptoms of TB, and to
consider being screened for LTBI.
QUESTION 10
What is the purpose of contact tracing? What investigations are used?
CASE 5
CASE 5 ANSWERS
ANSWER 1
Tuberculosis (TB) is spread via airborne droplets. If active pulmonary
disease is suspected, infection control measures are a priority at the
clinic to reduce transmission to other patients and healthcare
providers. Depending on local policies, this may include moving
patients away from crowded areas, asking the patient to wear a
surgical mask, including when being transferred (eg to radiology), and
for the general practitioner (GP) to wear a N95 mask.
ANSWER 2
Given Mary-Joys prolonged cough and history of known LTBI on
previous Mantoux tuberculin skin test and assessment, active
pulmonary TB is an important consideration. In a young person with
prolonged cough and weight loss, questions to assess for the
presence of TB include:1
history of known TB contacts (eg family, friends, occupational, others)
country of birth, travel history and age of arrival in Australia
characterising symptoms of cough, sputum production,
haemoptysis and pleuritic chest pain
constitutional symptoms of fevers, night sweats, weight loss and
lethargy.
Other information to elicit, to establish differential diagnoses include:
symptoms of wheeze, shortness of breath, rhinitis, sore throat, reflux
past medical and family history, including history of atopy
medications, known allergies and immunisations
social history, including smoking status, occupation and home
situation (eg children).
A full physical examination should be conducted. Specifically, this
would need to include examining vital signs, weight, respiratory
system and presence of lymphadenopathy.
ANSWER 3
In addition to active pulmonary TB, differential diagnoses for chronic
cough in Mary-Joys demographic are reactive airway diseases,
pertussis, atypical pneumonia, post-infectious cough, postnasal drip
and gastro-oesophageal reflux disease (GORD). Less common
differentials include fungal infections, non-TB mycobacterial infection,
non-acute presentation of melioidosis (in northern Australia),
bronchiectasis, pulmonary abscess and malignancy.1
TB is caused by Mycobacterium tuberculosis and spread via airborne
droplets. In most cases, infection (LTBI) is contained by the immune
system, without progression to active disease. One-third of the
worlds population is estimated to have LTBI. Approximately 10% of
29
CASE 5
infected individuals develop active disease in their lifetime. Active TB
can be pulmonary or, less commonly, extra-pulmonary, which can
include involvement of the lymph nodes, pleura, genitourinary tract,
bones and joints.2
Globally, the incidence of TB is highest across south-east Asia and
sub-Saharan Africa (Figure 2). TB remains one of the top 10
leading causes of death worldwide. The World Health
Organizations (WHOs) African Region has the case fatality ratio
(>20%), reflecting poor outcomes in the absence of timely TB
diagnosis, limited access to high-quality treatment, and regions of
high multidrug resistance.2
In Australia, high-risk populations for TB infection include:3
recent migrants and returned travellers from high-incidence
countries
contacts of active TB cases
Aboriginal and Torres Strait Islander peoples in certain areas of the
Northern Territory, Queensland and coastal New South Wales.
TB notification rates are much higher in people born overseas (19.5
per 100,000) than in those born in Australia (4.5 per 100,000);
common countries of birth for TB cases in Australia include India,
Vietnam, Philippines, China and Nepal.3
Figure 2. WHO estimated TB incidence rates, 2015
Reproduced with permission from the World Health Organization. Global tuberculosis report 2016. Geneva: WHO, 2016.
30
check Infectious diseases
ANSWER 4
The BCG vaccine is used mainly to protect against severe
disseminated disease in young children (miliary and meningeal TB).
There is variable protection against adult pulmonary disease (080%).
It is not effective once a person is infected with M. tuberculosis.4
ANSWER 5
Risk factors for progression to active TB include:5
recent initial infection (within five years)
aged under five years and the elderly
comorbidities affecting immune function (eg untreated human
immunodeficiency virus [HIV] infection, end-stage renal disease,
head and neck cancers, and haematological malignancies)
other pulmonary comorbidities and smoking
medications such as tumour necrosis factor alpha (TNF-)
inhibitors, glucocorticoids, immune modulators used in organ
transplantation and immune-compromising chemotherapy agents.
ANSWER 6
A flowchart showing the pathway for investigations when considering a
diagnosis of TB is shown in Figure 3.6
check Infectious diseases CASE 5

lymphadenopathy and there are minor changes within the right upper
Figure 3. Investigations when considering a diagnosis zone. These findings favour active TB.
of TB
Poorly defined consolidation favouring upper lobes (unilateral or
bilateral) is the most common chest X-ray finding for adult pulmonary
Consider TB TB. Other radiographic features may include volume loss, cavitation,
pleural effusion and hilar lymphadenopathy.8
Symptoms Note that in pulmonary TB, clinical symptoms, examination signs and
chest X-ray findings are variable. For patients with a chest X-ray
similar to Mary-Joys, there are often minimal symptoms on history
Latent Active
and a normal physical examination.

TST IGRA Chest X-ray and ANSWER 8

3 x sputum samples
More difficult Not if <2 The GP has an important role in considering TB as a diagnosis in high-
to interpret if years of risk patients and initiating prompt referral to TB services. Nationally,
previous age Microscopy TB is notifiable by clinicians and laboratories.
BCG vaccine
And TB treatment is usually supervised by the local TB service to provide
If TST or IGRA Culture Molecular directly observed therapy short course (DOTS). Mary-Joy is started on
consider
positive exclude assay standard short-course therapy of isoniazid, rifampicin, pyrazinamide
active TB AND and ethambutol. Pyridoxine (vitamin B6) is given to guard against
follow up peripheral neuropathy from isoniazid use.9 Ethambutol should be
Drug susceptibility
testing ceased when susceptibility testing verifies fully susceptible TB.9
Pyrazinamide is ceased after completing two months of treatment as
its benefit is only during the initial phase of treatment.9 Mary-Joy
Liaise with experts about approriate treatment should receive four further months of isoniazid and rifampicin (ie six
months total).
Reproduced with permission from The Royal Australian College of General Practitioners
from: Coulter C. Tuberculosis testing. Aust Fam Physician 2012;41(7):48992. She should also be given information on the importance of adhering to
the current combination of treatment medications for the full six
Initial investigations include a chest X-ray and three sputum samples, months to achieve cure and prevent selection of drug-resistant TB.
preferably early morning collections, for acid-fast bacilli (AFB) culture
and susceptibilities, in addition to standard microscopy, culture and ANSWER 9
sensitivity testing (MCS).3
Potential side effects of TB medications include:1,9
Sputum samples need to be collected in a well-ventilated place, away
from other people, and not in restroom facilities. For highly suspected Hepatitis, jaundice, nausea or vomiting (pyrazinamide, rifampicin,
clinical presentations of active TB, a spot sputum should be collected isoniazid)
and referral made to a hospital with respiratory isolation. In these Orange or red urine is expected from rifampicin
cases, patients should be kept in respiratory isolation (typically in a
hospital setting) until three sputum samples for AFB smears rule out Flu-like symptoms (rifampicin; increased risk with intermittent dosing)
active communicable TB.1,7 Tingling or numbness of hands or feet (isoniazid)
Molecular assays (PCR) for M. tuberculosis complex is a rapid Skin rash (all medications)
supplementary test that is more sensitive than AFB smear and less
sensitive than culture. PCR is routinely performed on new smear Colour vision/visual acuity impairment (ethambutol).
positive cases as it can confirm that the AFB seen are M. tuberculosis It is important for the patient and their regular GP to be aware of
complex and not non-tuberculosis mycobacteria. PCR also provides potential side effects and drug interactions. Patients should stop their
rapid information on rifampicin susceptibility to guide treatment. PCR
medication and seek review as soon as possible with the treating TB
may be requested in consultation with the TB unit and laboratory if
clinician if they experience concerning side effects.
clinical suspicion is high for active TB.3
Rifampicin is a cytochrome P450 inducer and can also reduce efficacy
ANSWER 7 of medications such as anticonvulsants, oral contraceptives and
warfarin.10 For these patients closer monitoring for drug interaction is
Mary-Joys chest X-ray shows patchy consolidation within the left required and alternative contraceptive options may need to be
upper zone. The left suprahilar region is prominent, suspicious of discussed.

31
CASE 5 check Infectious diseases

ANSWER 10 RESOURCES FOR PATIENTS

The purpose of contact tracing is to:3
identify other active TB cases: this may be the source of infection to
the index case or a contact who has progressed to active TB
screen contacts for LTBI to opportunistically offer LTBI treatment
after active TB is ruled out, to prevent progression to disease in the
future.
An algorithm for investigation of suspect active and LTBI is outlined in
Answer 4.
For asymptomatic contacts, either a Mantoux test (ie TST) or interferon
gamma release assays (IGRA) can be used. Both test for a cellular
immune response to previous mycobacterial antigen exposure. Overall,
the two tests have comparable sensitivity and specificity for diagnosing
LTBI. Refer to Table 1 for choice of test based on demographics.
Table 1. Use of Mantoux (TST) or IGRA in diagnosing
LTBI6,11
Demographics Preferred test Explanation
General Mantoux (TST) Comparable sensitivity and specificity
population OR IGRA Note: Sensitivity profiles of Mantoux
(TST) and IGRA differ and the
combination of both gives the highest
sensitivity
Children <5 Mantoux (TST) IGRA is more likely to be false
years negative in young children than adults
Previous BCG IGRA Interpretation of Mantoux (TST)
vaccination is complicated by previous BCG
vaccination
Hard to reach IGRA may be more suitable for
populations (eg patients who are unlikely to attend a
homeless) second visit for Mantoux (TST) reading
Should LTBI be confirmed, an individualised discussion will take place,
weighing up the likelihood of reactivation with the risks and benefits of
treatment. Therapeutic Guidelines recommends isoniazid for six to
nine months as first-line treatment for LTBI.9 However, LTBI treatment
guidelines differ across jurisdictions, so adherence to the relevant local
guidelines is recommended.1
CONCLUSION
While specialised TB units are primarily responsible for the
management of TB patients, GPs have an important role in the
diagnosis and ongoing care. This includes timely referral of patients to
TB services, initiating infection control, being aware of and monitoring
for side effects and drug interactions, managing comorbidities (eg poor
nutrition, smoking cessation), and providing ongoing support in the
patients social setting to complete curative treatment.12
NSW Healths TB fact sheets (including multicultural resources),
www.health.nsw.gov.au/Infectious/tuberculosis/Pages/tuberculosis-
factsheets.aspx
RESOURCES FOR DOCTORS
Therapeutic Guidelines Mycobacterium infections,9 https://
tgldcdp.tg.org.au/viewTopic?topicfile=mycobacterial-infections
CDNA National Guidelines for TB management,3 www.health.gov.
au/internet/main/publishing.nsf/Content/cdna-song-tuberculosis
Australian Family Physicians 2012 article on tuberculosis testing,6
www.racgp.org.au/afp/2012/july/tuberculosis-testing
State-based TB guidelines (eg NT),1 http://digitallibrary.health.nt.
gov.au/prodjspui/bitstream/10137/696/4/TB%20Guidelines%20
May%202016.pdf
REFERENCES
1. Centre for Disease Control. Guidelines for the control of tuberculosis in the Northern
Territory. Darwin: CDC, 2016. Available at http://hdl.handle.net/10137/696
[Accessed 27 March 2017].
2. World Health Organization. Global tuberculosis report. Geneva: WHO, 2016 Available
at www.who.int/tb/publications/global_report/en [Accessed 27 March 2017].
3. Communicable Diseases Network Australia. Tuberculosis (TB) CDNA national
guidelines for public health units Management of TB. Canberra: CDNA, 2015.
Available at www.health.gov.au/internet/main/publishing.nsf/content/cdna-song-
tuberculosis [Accessed 27 March 2017].
4. National tuberculosis Advisory Committee. The BCG vaccine: information and
recommendations for use in Australia. Communicable Disease Intelligence
2006;30(1): E110-115.
5. Getahun H, Matteelli A, Chaisson RE, et al. Latent Mycobacterium tuberculosis
infection. N Eng J Med 2015;372(22):212735.
6. Coulter C. Tuberculosis testing. Aust Fam Physician 2012;41(7):48992.
7. Chris Coulter, National Tuberculosis Advisor Committee. Infection control guidelines
for the management of patients with suspected or confirmed pulmonary tuberculosis
in healthcare settings. Communicable Diseases Intelligence 2016;40(3):E36066.
8. Burrill J, Williams CJ, Bain G, et al. Tuberculosis: A radiologic review. RadioGraphics
2007;27(5):125573.
9. Therapeutic Guidelines Limited. Mycobacterial infections [Internet]. eTG Complete.
Melbourne: eTG, 2016. Available at https://tgldcdp.tg.org.au/viewTopic?topicfile=my
cobacterial-infections [Accessed 27 March 2017].
10. Martin J, Fay M. Cytochrome P450 drug interactions: are they clinically relevant?
Aust Prescrib 2001;24(1).
11. National Tuberculosis Advisor CommitteePosition statement on interferon- release
assays in the detection of latent tuberculosis infection. Communicable Disease
Intelligence 2012; 36(1): E125-131.
12. Ralph A, Kelly P, Krause V. Whats new in TB? Aust Fam Physician 2009;38(8):578
85.

32
check Infectious diseases
ACTIVITY ID: 96529
INFECTIOUS DISEASES
This unit of check is approved for six Category 2 points
in the RACGP QI&CPD program. The expected time to
complete this activity is three hours and consists of:
reading and completing the questions for each
case study
you can do this on hard copy or by logging on to
the gplearning website, http://gplearning.racgp.
org.au
answering the following multiple choice questions
(MCQs) by logging on to the gplearning website,
http://gplearning.racgp.org.au
you must score 80% before you can mark the
activity as Complete
completing the online evaluation form.
You can only qualify for QI&CPD points by completing
the MCQs online; we cannot process hard copy
answers.
If you have any technical issues accessing this
activity online, please contact the gplearning
helpdesk on 1800 284 789.
If you are not an RACGP member and would like to
access the check program, please contact the
gplearning helpdesk on 1800 284 789 to purchase
access to the program.
CASE 1 MAISIE
Maisie is 18 years of age and presents with a one-week history of
severe itching on her hands and wrists. From your examination and
Maisies history, you consider a diagnosis of scabies.
QUESTION 1
Which of the following symptoms or signs in a patient of Maisies age
are suggestive of scabies?
A. Itching is relieved by a hot bath or shower
B. Itching localised to the hands and wrists
C. Presence of asymmetrical lesions on the palms of the hands
D. Widespread and intense pruritus that spares the head and neck
QUESTION 2
At present, a diagnosis of scabies is best made in practice via:
A. light microscopic examination of skin scrapings of burrows
MULTIPLE CHOICE QUESTIONS
MULTIPLE CHOICE QUESTIONS
B. polymerase chain reaction (PCR) for antigen detection
C. enzyme-linked immunosorbent assay (ELISA) for antibody
detection
D. intradermal skin test.
CASE 2 ROSLYN
Roslyn, 30 years of age, presents with blisters around the genital
and anal areas. About a week ago, she noticed some itchy bumps
in these areas but the itchiness has become more severe and
particularly painful when urinating. Roslyn has never had any
genital or urinary tract infections, but is worried that she may have
contracted an infection after having unprotected sex two weeks
ago with a man she met at a nightclub. Physical examination
reveals some blisters and genital ulceration. You take samples to
be tested for sexually transmissible infections (STIs). Testing
confirms Herpes simplex 2 (HSV-2) infection and you prescribe
antiviral treatment.
QUESTION 3
Which of the following is currently recommended for treatment of a
first episode of genital herpes?
A. Acyclovir 400 mg orally every eight hours for five days
B. Acyclovir 400 mg orally plus topical application every eight hours
for five days
C. Valacyclovir 500 mg once daily for five days
D. Any of the above options
QUESTION 4
What advise can you give Roslyn about HSV-2 infection?
A. Disease activity and viral shedding remain high in the first 1224
months after infection.
B. In most patients, recurrences after a symptomatic first episode are
infrequent (less than one per year).
C. Sexual contact should be avoided during a symptomatic episode;
however, transmission can occur at other times.
D. All of the above.
CASE 3 IVAN AND ERICA
Ivan, a school teacher aged 35 years, emigrated from South Africa
with his wife, Erica, 12 months ago. He comes to see you
complaining of a cough that has persisted for six weeks. He tells you
that he has also been feeling run down lately and has lost some
weight. He has no significant medical history, no allergies, is not on
any medications, and does not smoke. Ivan cannot remember if he
had a BCG vaccination, but his medical examination prior to
relocating to Australia was clear.
33
MULTIPLE CHOICE QUESTION check Infectious diseases

QUESTION 5 D. norfloxacin 400 mg twice daily for three days.

Which of the following warrants consideration of tuberculosis (TB) as
the diagnosis? CASE 5 INFLUENZA PANDEMIC

A. Ivans country of origin
B. Persistent cough
C. Weight loss
D. All of the above
FURTHER INFORMATION
Further investigations confirm that Ivan has active TB and you refer him
to a TB clinic for treatment. Erica is well and has not developed any
symptoms. She had a BCG vaccination when she was 13 years of age.
QUESTION 6
Which of the following options is correct with regards to screening
Erica for latent TB infection (LTBI)?
A. Erica should have a chest X-ray.
B. Erica should have a Mantoux test (TST) or interferon gamma
release assay (IGRA).
C. A sputum sample from Erica should be obtained for polymerase
chain reaction (PCR) testing.
D. Erica does not need to be screened as she has had a BCG vaccination.
CASE 4 REG
Reg, 58 years of age, is a chef at a local caf. He comes to see you
because he has been having headaches, abdominal cramps, nausea and
diarrhoea for the past three days. He has not noticed any blood in the
stools. He has had no appetite since the onset of his symptoms, but has
been feeling very thirsty. He has a temperature of 37.5C. Your provisional
diagnosis is gastroenteritis and you are concerned about bacterial enteritis.
QUESTION 7
As you are preparing to leave work for the day, your practice receives
an alert from the Department of Health that new strain of influenza A
virus has been identified in a rapidly spreading outbreak in California.
Over the next weeks, similar cases are reported in several other
countries and the World Health Organization (WHO) declares that a
pandemic is underway. So far the new viral strain has not been
detected in Australia.
QUESTION 9
At this stage, the response in Australia to this alert would be:
A. Preparedness
B. Respond Standby
C. Respond Initial action
D. Respond Targeted action
FURTHER INFORMATION
Three months after the initial alert, thousands of cases of the new
strain of influenza are being seen in general practices in Australia. The
pandemic stage is now in Response Targeted action.
QUESTION 10
At this stage of the pandemic, the priority in managing patients
presenting with influenza-like illness is:
A. obtaining epidemiological evidence of contact with confirmed
cases of the new strain
B. collecting viral samples for further surveillance purposes
C. identifying those at risk of complications dependent on advice from
the Department of Health and public health unit, as management
may differ in each pandemic

In Regs case you would consider ordering a stool culture to confirm D. moving back to business as usual and revising plans for the next
the diagnosis and identify the causative agent because of pandemic.

A. the duration of Regs symptoms

B. a possible public health concern
C. Regs age
D. All of the above reasons

QUESTION 8
The most appropriate management for Reg is:
A. fluid repletion with an oral rehydration solution
B. fluid repletion and nutritional maintenance with fruit juice
C. azithromycin 500 mg once daily for three days

34
GP17
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RACGP CONFERENCE en

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Sydney + 2628 October 2017 + era
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GP17: lets discuss the issues

Every week, every month and every year, you are a part of the health journey of your patients.
You are their specialist in life guiding them through each of their medical concerns. The program for
GP17 has been designed for you covering a rich and diverse range of topics relevant to you including:

+ Care of older people and their health issues

+ Children and young peoples health
+ Womens health and pregnancy
+ Travel medicine
+ Eye medicine
+ Musculoskeletal and sports medicine; as well as many more

GP17 not only provides CPD points across Categories 1 and 2 but it will also help you to fulfil some of
your evidence requirements for planning, learning and need (PLAN).

Wed love to see you there! Visit gp17.com.au to find out more or to register.

ICC Sydney
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