News in brief: Better asthma care needed for pregnant Indigenous women; ATAGI recommends COVID vax booster for patients on OCS; Health care workers can allay vax fears of parents of children with chronic lung conditions

Tuesday, 12 Oct 2021

Better asthma care needed for pregnant Indigenous women

Asthmatic, pregnant, Indigenous women are twice as likely to suffer neonatal deaths than non-Indigenous women — events that could be prevented with better respiratory care, according to an Australian study.

The retrospective study reviewed birthing outcomes in 18,802 asthmatic, pregnant women presenting to Mater Mothers’ Hospital between 1999 and 2019.

It found Indigenous women were more likely to have a pregnancy complicated by asthma (24% vs 17%) and at increased risk for neonatal deaths (mortality <28 days after birth), pre-term delivery, NICU admission and lower birth weights than non-Indigenous women (P < 0.01 for all) after adjusting for smoking status, presence of gestational diabetes or pre-eclampsia and parity, the authors wrote in The Australian and New Zealand Journal of Obstetrics and Gynaecology.

Only a quarter of Indigenous women had an asthma action plan, despite Australian National Asthma Guidelines’ recommendation that an individualised care plan be developed based on diagnosis and symptom control.

Lack of healthcare worker training, culturally appropriate asthma resources, and MBS items, along with inaccessibility to government financial incentive structures have prevented Indigenous people accessing care, the authors wrote.

Previous studies in non-Indigenous women have shown nurse-led antenatal asthma management can help reduce loss of control (relative risk [RR]: 0.67, 95% CI: 0.46–0.99), persistent uncontrolled asthma (RR: 0.48, 95% CI: 0.26–0.90) and asthma exacerbations (RR: 0.69, 95% CI: 0.33–1.42) in pregnancy.

“The key message for clinicians is that when asthma is well controlled during pregnancy, outcomes for neonates are comparable to non-asthmatic pregnancies,” they wrote.

A culturally appropriate, individualised asthma care plan based on diagnosis and symptom control, and ideally involving an Indigenous health worker, could help improve outcomes for asthmatic Indigenous patients, they concluded.

ATAGI recommends COVID booster for patients taking oral steroids

Patients using oral steroids  are now recommended by ATAGI to have a third primary dose of COVID-19 vaccine with an mRNA vaccine.

On 8 October the Australian Technical Advisory Group on Immunisation (ATAGI) recommended a booster third dose of vaccine as part of the primary course in individuals who are severely immunocompromised to address the risk of suboptimal or non-response to the standard 2 dose schedule.

The recommendation applies to all individuals aged ≥12 years with certain conditions or on therapies leading to severe immunocompromise.

These include immunosuppressive such as:

    • High dose corticosteroid treatment equivalent to >20mg/day of prednisone for ≥14 days in a month, or pulse corticosteroid therapy.
    • Multiple immunosuppressants where the cumulative effect is considered to be severely immunosuppressive.
    • Biologic and targeted therapies anticipated to reduce the immune response to COVID-19 vaccine:
      • including B cell depleting agents (e.g. anti-CD20 monoclonal antibodies, BTK inhibitors, fingolimod), anti-CD52 monoclonal antibodies (alemtuzumab), anti-complement antibodies (e.g. eculizumab), anti-thymocyte globulin (ATG) and abatacept
      • excluding agents with likely minimal effect on vaccine response such as immune checkpoint inhibitors, anti-integrins, anti-TNF-α, anti-IL1, anti-IL6, anti-IL17, anti-IL4 and anti-IL23 antibodies

ATAGI also recommends boosters for patients with solid tumours such as lung cancer if patients are having treatment including chemotherapy, radiotherapy, and/or hormonal therapy, but excluding immunotherapy with immune checkpoint inhibitors

Federal Chief Medical Officer Paul Kelly said the recommendation was to go for one of the mRNA vaccines as the booster.

“The preference is to go for a third dose of the one you had first. So if you’ve had two Pfizer, the third one would be Pfizer. No one’s had two Modernas yet, so it would be likely be Pfizer. But if Pfizer is not available or unable to be taken, Moderna would be substituted,” he said.

“In certain circumstances, there may be a need to actually use AstraZeneca, for example, with some of the side effects of the second dose of an mRNA vaccine that would not be recommended to get a third one if that was the case. So there is flexibility. But the general principle is mRNA vaccine as the third dose.

According to ATAGI, the recommended interval for the 3rd dose is two to six months after the second dose of vaccine. A minimum interval of four weeks may be considered in exceptional circumstances (e.g., anticipated intensification of immunosuppression, outbreaks). People who have had a second dose more than 6 months ago should receive a 3rd dose whenever feasible.

ATAGI also advises that antibody testing is not recommended to assess for immunity to SARS-CoV-2 following COVID-19 vaccination, including in immunocompromised individuals after a 2nd or 3rd dose, because there are no serological assays that provide a definitive correlate of immunity to SARS-CoV-2.

Health care workers can allay vax fears of parents of children with chronic lung conditions

Most parents and carers of children with chronic lung conditions (77%) are likely to get their children vaccinated against COVID-19.

An online survey of 202 parents/carers with children attending the Sydney Children’s Hospital, found that proportion increased to 94% if vaccination was recommended by the child’s paediatrician.

Additionally, 80% of parents and carers said they would vaccinate their child if recommended by their GP.

Despite their children being vulnerable to infection, parents and carers still had safety concerns about vaccination.

Lead author of the study, paediatric respiratory epidemiologist Dr Nusrat Homaira, said health care workers clearly play an important role in promoting vaccine uptake.

“Children with chronic lung conditions are a unique group as they require ongoing follow-up visits with their GPs and paediatricians for their chronic conditions. GPs and paediatricians can leverage scheduled follow-up visits to promote COVID-19 vaccines and explain the benefits and rare side effects of the vaccine.”

Read more in Health Science Reports


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