Chapter 9: Prevention in general practice

Prevention may be defined as the means of promoting and maintaining health or averting illness.

It is concerned with removal or reduction of risks; early diagnosis; early treatment; limitation of complications, including those of iatrogenic origin; and maximum adaptation to disability.

The promotion of health concerns helping well people to learn healthy behaviours and to accept responsibility for their own well-being.

A preventive attitude implies that the doctor understands and can utilise the preventive potential in each primary care consultation by an ‘opportunistic approach’. In addition to the traditional management of both presenting and continuing problems, the doctor takes the opportunity to modify the patient's health-seeking behaviour, to provide education about the illness, and to promote health by relating the patient's present condition to previous unhealthy behaviour.

A general reference for prevention is the RACGP red book—Guidelines for preventive activities in general practice (9th edition). www.racgp.org.au/your-practice/guidelines/redbook.

Primary prevention

Primary prevention includes action taken to avert the occurrence of disease. As a result there is no disease. Primary preventive strategies include:

1. education to bring about changes in lifestyle factors known to be associated with diseases (e.g. smoking cessation, healthy balanced diets, reduction in alcohol intake, exercise)

2. sterilisation of surgical instruments and other medical equipment

3. eradication, as with vector control of mosquitoes to prevent malaria

4. immunisation against infective diseases

5. sanitation, keeping our water supplies clean and disposing efficiently of sewage and industrial wastes

6. legislation to ensure that some of these primary preventive measures are carried out

Secondary prevention

Secondary prevention includes actions taken to stop or delay the progression of disease.

The term is usually applied to measures for the detection of disease at its earliest stage, i.e. in the presymptomatic phase, so that treatment can be started before irreversible pathology is present. The early recognition of hypertension through routine testing (screening) of patients allows treatment during the presymptomatic phase of the illness process. Screening for cervical cancer allows the treatment of cervical dysplasia, a premalignant condition. Other examples include mammography and endoscopy for polyps of the large bowel.

Tertiary prevention

Tertiary prevention includes the management of established disease so as to minimise disability.

The term is usually applied to the rehabilitation process necessary to restore the patient to the best level of adaptation possible when there has been damage of an irreversible nature. A patient who has suffered a stroke because of hypertension may be restored to a useful lifestyle with appropriate rehabilitation.

Relationship between types of prevention

It can be seen that there is a clearer demarcation between primary and secondary prevention than between secondary and tertiary prevention, although the latter term is particularly useful in dealing with the elderly and the handicapped. Conceptually, curative medicine falls within the definitions of secondary and tertiary prevention while public health measures are mainly concerned with primary prevention. Prevention is really wider than medical practice but because of the success of public health practices in the past, more attention is now being focused on prevention by doctors (see FIG. 9.1).²

As GPs our role in prevention is twofold.

1. First, we can recognise the preventable factors that are involved in an illness process and determine appropriate interventions.

2. Second, we can act to implement the preventive measure. In cases where the responsibility rests with the individual or the community, doctors can support prevention through education, applying political pressure or working with community agencies.

What is preventable?

The first step in the implementation of prevention is to define which specific diseases can be prevented and to what extent, given certain restraints such as human resources, technology and the cost to the community. All diseases have a potential preventability but it may be unrealistic to try to achieve this.

Diseases that can be prevented can be grouped according to their aetiology. They fall into the following broad categories:

• genetic disorders

• conditions occurring during pregnancy and the puerperium

• developmental disorders

• accidents

• infections

• addictions

• behavioural disorders

• occupational disorders

• premature vascular disease

• neoplasms

• handicap in the disabled

• certain ‘other’ diseases (e.g. diverticular disease)

Mortality is the only reliable index by which the outcome of preventive activities can be judged. Conditions can be ranked in importance as causes of premature death according to the ‘years of potential life lost before 78 years [of age]’ as follows:¹

This gives quite a different perspective to prevention and explains why the efforts of public health authorities and practising doctors do not always coincide.

The interventions available to us in medical practice are as follows:

1. educational—health promotion, health education and illness education

2. screening

3. surveillance

4. interventional care—immunisation, behaviour modification and drug prophylaxis

5. rehabilitation

Primary prevention par excellence can be practised in general practice under the opportunities provided by the following clinical circumstances:

• antenatal care

• postnatal care

• advising people travelling overseas

• visits by infants with their parents

• times of crisis or potential crisis

• pregnancy planning

The Royal College of General Practitioners (UK) has identified the seven most important opportunities for prevention as:

1. family planning

2. antenatal care

3. immunisation

4. fostering the bonds between mother and child

5. discouragement of smoking

6. detection and management of raised blood pressure

7. helping the bereaved

An understanding of the mortality and morbidity patterns in the modern human being is essential to the planning of preventive programs. The great infectious diseases of the past, such as tuberculosis, syphilis, smallpox, influenza, diphtheria and streptococcal infections, have been largely contained but other diseases have become prominent as life expectancy increases. The great modern diseases are atherosclerosis (hardening of the arteries), malignant disease (cancer), HIV infection and iatrogenesis (doctor-induced illness). The two most common causes of death in Australia are cancer and cardiovascular disease, each accounting for approximately 29% of all deaths.³

By comparison, the ten leading causes of death in the world are (in order) ischaemic heart disease, stroke, lower respiratory tract infection, COPD, diarrhoeal disease, HIV/AIDS, cancer, diabetes mellitus, road injury and prematurity (WHO: Fact sheet 310; July 2013).

These diseases and the common causes of mortality (see TABLE 9.1) act as a focus for our energies in addressing preventive programs.

It is worth focusing on the changes in disease indices during the past generation in order to evaluate the effect of preventive and health promotion programs during this period (see TABLE 9.2).³ The messages are to harness and promote with renewed vigour those strategies that are working, such as prevention of death from coronary artery disease and motor vehicle accidents, and to re-evaluate those important areas, such as Aboriginal mortality, HIV infection, cancer, suicide and asthma, which are bad news!

The World Health Organization (WHO) defines good health as ‘a state of dynamic harmony between the body, mind and spirit of a person and the social and cultural influences which make up his or her environment’.

A considerable amount of epidemiological information has emerged to support what GPs have known for a long time—that a commonsense, healthy lifestyle not only promotes good health but also reduces the risk of the main causes of mortality and morbidity in this country, including cardiovascular disease and cancer.

The common theme for virtually all disease is to follow the nutrition and lifestyle guidelines presented in CHAPTER 10.

Behaviour modification

Lifestyle habits that have developed over many years can be very difficult to change even when the individual is well motivated to change. A variety of instructional, motivational and behavioural techniques can be used to initiate a lifestyle change program; GPs should be aware of these and use the resources of a multidisciplinary team to give support to motivated people who as a rule find behaviour modification difficult.

Risk factors for vascular disease (atherosclerosis) are:

• hypertension

• smoking

• high cholesterol

• diabetes

• obesity

• sedentary lifestyle

• stress

• alcohol excess

• poor diet

• family history

The guidelines for good health given in CHAPTER 10, if followed, will help prevent the development of cardiovascular and cerebrovascular disease.

It is worth noting that the death rate from coronary heart disease is about 70% higher for smokers than for non-smokers and for very heavy smokers the risk is almost 200% higher. It has been shown that the incidence of heart disease falls in those who have ceased smoking.

GPs can estimate the absolute 5-year risks of cardiovascular events in their patients by referring to the New Zealand Guidelines Group Cardiovascular Risk Charts (www.nzgg.org.nz); see CHAPTER 85.

The parameters used are:

• gender and age

• smoking status

• diabetes status

• blood pressure

• total cholesterol/HDL ratio

Primary prevention of cancer is an important objective and there is a need to focus on this vital factor as much as on secondary prevention.

Updated important facts about cancer in Australia^* (current and immediate future)

• It continues to be more common in men than women overall; in 2017 more than half (54%) of all diagnosed cases were expected to be in men.

• Breast cancer (in women) is expected to be the most common type of cancer diagnosed, followed by colorectal cancer and prostate cancer.^*

• The death rate from all cancers has fallen from 209 deaths per 100 000 people in 1982 to an estimated 161 per 100 000.

• Survival rates from all cancers have improved substantially, with five-year survival increasing from 48% in 1984–1988 to 68% in 2009–2013.

• Survival varied by cancer type, with the largest survival improvements seen in prostate cancer, non-Hodgkin lymphoma, kidney cancer and multiple myeloma.

• Pancreatic cancer and lung cancer showed only small improvements, while bladder cancer and cancer of the larynx actually had lower survival rates.

• Lung cancer is likely to be the leading cause of cancer death, followed by bowel cancer, prostate cancer, breast cancer in women and pancreatic cancer.

That environmental factors are involved in the aetiology of colorectal cancer and other cancers is indicated by wide variations in incidence between different countries.

Suspicion falls on diet and there is epidemiological evidence implicating diets high in animal fats and low in insoluble fibre, fruits and vegetables, and also high alcohol consumption. It is noted that there are higher incidence rates in people migrating from low-to high-risk countries, such as Japanese to Hawaii⁵ and Greeks and Italians to Australia.⁵

Studies in the US indicate that at least 35% of all cancer deaths are related to diet. Obese individuals have an increased risk of colon, breast and uterine cancers. High-fat diets are a risk factor for prostate, breast and colon cancers. Salt-cured, smoked and nitrate-cured foods increase the risk of upper GIT cancers. Foods rich in vitamin A and folate (dark green and deep yellow vegetables and fruits) and vitamin C and cruciferous vegetables (cabbage, Brussels sprouts, broccoli and cauliflower) are all considered to have protective effects for various cancers.^6,7 Phytochemicals (plant chemicals) exist in these foods and in other vegetables and fruit that have a cancer-protective effect.⁸

Overall, diet, smoking, alcohol and occupational exposures (5%) appear to account for over 73% of all cancer mortality.⁷

Doll and Peto⁹ considered that environmental factors were responsible for 80–90% of cancers and estimated that diet was a major factor in the cause of cancer in 40% of men and 60% of women.

The role of immunity in cancer

The development of a number of cancers appears to be related to a depression of the individual's immune system, particularly in relation to cellular immunity, in a similar way (albeit on a different scale) to the effect of HIV infection. Studies have shown that the immune system is adversely influenced by:¹⁰

• stress, especially bereavement

• depression

• ageing

• drugs

• pollutants

• cigarette smoke

• inappropriate diet

• alcohol

• radiation

On the other hand, a protective effect on the immune system may be provided by:

• food antioxidants (see TABLE 10.1 in CHAPTER 10)

• tranquillity

• meditation

In some instances malignancies appear to undergo unpredictable remissions with patients following an optimal diet, taking antioxidants, changing their lifestyle and practising meditation. However, an Australian study indicated that the enthusiasm for the value of antioxidants may be unjustified.¹¹

Diet certainly appears to be a most important factor in the primary prevention of disease. If immune deficient diseases can respond in such a way, imagine what a powerful primary preventive force such a lifestyle represents for all disease.

The death rate and morbidity rate for asthma and other respiratory diseases is unacceptable and much of it can be prevented.¹² A report on the cost of asthma claimed that there is evidence that a significant proportion of diagnosed asthmatics are currently receiving treatment that does not provide the best possible control of the disease.¹²

Prevention means being better informed and treating such an ‘irritable’ disease as bronchial asthma aggressively. It means focusing on better assessment and monitoring (e.g. home use of the mini peak flow meter), better delivery of medication to the airways (e.g. use of spacers attached to inhalers and/or use of pumps and nebulisers) and appropriate management of the cause (inflammation of the bronchial tree) by the use of inhaled corticosteroids or sodium cromoglycate as the first-line treatment for significant asthma. An appropriate strategy is to follow the six-step asthma management plan (see TABLE 9.3) of the National Asthma Campaign.

The protective effect for asthma and COPD of vitamin C, fish oils, a low-salt diet and other natural antioxidants is highlighted by Sridhar.¹³

Since 86% of the population visit a GP at some stage of the year,³ and these people visit about five times each year (on average), GPs are in an ideal position to develop strategies for a periodic health examination. An emphasis should be placed on the history in addition to the physical examination and related basic investigations.

As for any smooth-running quality professional program, it is important to be organised with prepared practice staff, checklists and record systems. The Royal Australian College of General Practitioners (RACGP) has developed a College Record System, which has several leaflets covering all approaches to the patient ‘check-up’.¹⁴

The following guidelines for the periodic health examination are adapted from those recommended by the Preventive and Community Medicine Committee of the RACGP.¹⁴ This represents appropriate screening at the front line of primary health care.

Aims of screening

In practice, screening is not only to detect disease in asymptomatic people at its earliest stage, but also to find individuals at risk or those with established disease who are not receiving adequate care. There are three levels at which screening practice can be applied in general practice:

1. ‘well’ individuals with risk factors that predispose to disease (e.g. obesity, uncomplicated essential hypertension, hyperlipidaemia)

2. asymptomatic individuals with signs of early disease or illness (e.g. developmental dysplasia of the hip, ectopic testis, glaucoma, bacteriuria of pregnancy, carcinoma in situ of cervix)

3. symptomatic individuals whose irreversible abnormalities are unreported but the effects can be controlled or assisted (e.g. visual defects, deafness, mental handicap)

An appropriate history will allow the recognition of certain risk factors that may foreshadow future disease. Though established patients will have a previously acquired database, their history should be reviewed and updated. It is recommended that the following items be included in history taking in the appropriate age groups.

Family history. In particular, cardiovascular disease, some cancers (breast, bowel, melanoma with dysplastic naevi), diabetes, asthma, genetic disorders and bowel disease will alert the doctor to specific risk factors (and psychological factors) for these patients.

Suicide and accidents. Consider the risk factors predisposing to suicide and accidents, which are the major preventable causes of death in children and young adults.

Substance abuse. Tobacco and alcohol are the major causes of preventable death in adults, although other drugs contribute to a lesser extent. Counselling by GPs, about smoking in particular, has been shown to be effective.

Exercise and nutrition. These factors have a role to play in preventing cardiovascular disease and to a lesser extent in blood pressure control, cancer, diabetes and constipation. They have an even greater role to play in improving general well-being and preventing morbidity.

Occupational health hazards. Consider these in working adults, as occupational health hazards can significantly contribute to morbidity and mortality (e.g. exposure to toxic substances, unsafe work practices). Specific examples include:

• coal miners—pneumoconiosis

• gold, copper and tin miners—silicosis

• asbestos workers and builders—asbestosis, mesothelioma

• veterinarians, farmers, abattoir workers—zoonoses

• aniline dye workers—bladder cancer

• health care providers—hepatitis B

Physical functioning, home conditions and social supports. Consider these in elderly people, as physical function and social supports are of crucial importance in determining whether they can care for themselves—intervention can prevent accidents and death.

Sexuality/contraception. Sexually transmitted infections are all preventable, as are unwanted pregnancies. Opportunities should be sought to ask young people, in particular, about their sexuality, and to counsel them. The question ‘Do you have any concerns about sex?’ is very useful in this context.

Osteoporosis. Osteoporosis affects nearly a third of all postmenopausal women, most of whom suffer osteoporotic fractures. Fractures of the femoral neck have a particularly poor prognosis, with up to a third of these women dying within 6 months, and many more requiring continuing nursing home care. Bone loss accelerates at the time of the menopause, and can be reduced by hormone replacement therapy.

Women at risk of osteoporosis are short, slim, Caucasian; they drink coffee and alcohol, smoke, eat a high-protein and high-salt diet, and don't exercise.

Masquerades in general practice. It is worth considering the ‘masquerades’ (see CHAPTER 17, TABLES 17.4 and 17.5), which may present as undifferentiated illness, as a means of following the important medical principle of early detection of disease: engendering a certain awareness.

Primary masquerades to consider are:

• depression

• diabetes mellitus

• drug problems

• anaemia

• thyroid disorders, especially hypothyroidism

• urinary tract infection

• vertebral (spinal) dysfunction

Hypothyroidism has been estimated to exist in up to 15% of women aged 60 and above, and searching for clues may elicit subtle symptoms and signs previously attributed to ageing.

Relationships and psychosocial health. Consider the mental health of patients, particularly the elderly, by enquiring about how they are coping with life, how they are coping financially, about their peace of mind and how things are at home. Focus on the quality of their close relationships (e.g. husband–wife, father–son, mother–daughter, employer–employee). Enquire about losses in their life, especially family bereavements.

Childhood health record books provide an excellent opportunity for communication between different health care givers; parents should be provided with the record books and encouraged to bring them to every visit. Various recommendations for screening are made under the following headings.

Height/weight/head circumference. Record length/height, weight and head circumference at regular intervals. Head circumference can be recorded until 2 years and should increase by 1 cm per month in the first 3 months, then 0.5 cm per month from 3–6 months. It provides further data about a child's growth. It is important to check the fontanelles. Calculate the BMI from 2 years. The adequacy of a child's growth cannot be assessed on one measurement and serial recordings on growth charts are recommended.

Hips. Screen for congenital dislocation at birth, 6–8 weeks, 6–9 months and 12–24 months (see CHAPTER 65).

The flexed hips are abducted, checking for movement and a ‘clunk’ of the femoral head forwards (the test is most likely to be positive at 3–6 weeks and usually negative after 8 weeks). Shortening or limited abduction is also abnormal. Ultrasound examination is more sensitive than the clinical examination especially up to 3–4 months. Observe gait when starting to walk.

Strabismus. Strabismus should be sought in all infants and toddlers by occlusion testing (not very sensitive), examining light reflexes and questioning parents, which must be taken very seriously. Amblyopia can be prevented by early recognition and treatment of strabismus by occlusion and surgery. Early referral is essential.

Visual acuity. At birth and 2 months, eyes should be inspected and examined with an ophthalmoscope with a 3+ lens at a distance of 20–30 cm to detect cataracts and red reflexes. At 9 months gross vision should be determined by assessing ability to see common objects. Visual acuity should be formally assessed at school entry using Sheridan Gardiner charts.

Hearing. Hearing should be tested by distraction at 9 months or earlier; also by pure tone audiometry at 1000 and 4000 hertz when a child is 4 years (preschool entry) and 12 years.

Note: Formal audiological evaluation should be carried out at any time if there is clinical suspicion or parental concern. No simple screening test is very reliable for sensorineural or conductive deafness.

Testes. Screen at birth, and 6–8 weeks, 6–9 months and 3 years for absence or maldescent. Those who have been treated for maldescent have a higher risk of neoplastic development in adolescence.

Oral health/dental assessment/fluoride. Advise daily fluoride drops or tablets, if water supply is not fluoridated. Children's teeth should be checked regularly, particularly if a school dental service is not available. Advice should be given on sugar consumption, especially night-time bottles, and tooth cleaning with fluoride toothpaste to prevent plaque.

Scoliosis. Screening of females by the forward flexion test, which is carried out around 12 years of age, is of questionable value because of poor sensitivity and specificity.

Congenital heart disease. The heart should be auscultated at birth, in the first few days, at 6–8 weeks and on school entry.

Femoral pulses. Testing for absence of femoral pulses or delay between brachial/femoral pulses at birth and 8 weeks will exclude coarctation of the aorta. Refer the child immediately if concerned.

Speech and language. A child's speech should be intelligible to strangers by 3 years. It is related to hearing.

General development

Apart from speech and language, check social and emotional development, toilet habits, behaviour and mood.

This includes ‘parents’ evaluation of developmental status’ (PEDS) (see www.pedstest.com; www.rch.org.au/ccch).

For general checklists, see www.cdc.gov/actearly. Be alert to the ‘Red flags’ of autism spectrum disorder (see CHAPTER 94).

Refer to CHAPTER 8.

The following recommendations apply for adults.

Weight. Weight should be recorded at least every few years. Obesity is a major reversible health risk for adults, contributing to many diseases (e.g. heart disease, diabetes, arthritis). Body mass index (BMI) should ideally be between 20 and 25.

Abdominal obesity is a major risk factor for adults. The waist:hip circumference ratio is regarded as a useful predictor of cardiac disease. Recommended waist:hip ratios are:

• males <0.9

• females <0.8

Blood pressure. Blood pressure should be recorded at least every 1–2 years on all people 16 years and over. There is no dispute that control of blood pressure results in reduced mortality from cerebrovascular accidents and, to a lesser extent, heart disease, kidney failure and retinopathy.

Cholesterol. All adults aged 45 and over should have a 5-yearly estimation of serum cholesterol. Total cholesterol is adequate for screening purposes. HDL levels give additional information. The National Heart Foundation recommends keeping cholesterol levels below 4.0 mmol/L. For most, dietary modification is sufficient to achieve these levels; some may require drug treatment.

Fasting blood glucose. Screen every 3 years for all patients >40 years of age.

Cervical cancer. From age 25 (to age 74), women who have ever been sexually active should commence cervical screening with a HPV test 2 years after their last Pap test. If negative, this can be performed every 5 years. If positive, cervical cytology will be checked with the sample and follow-up is determined according to the national guidelines. Women aged 70–74 should be offered a final ‘exit test’ and can cease screening if negative.

Breast cancer. Mammography should be performed at least every 2 years on women aged 50–74 years. It is not useful for screening prior to age 40 years due to difficulty in discriminating malignant lesions from dense tissue. Women aged 40–49 years may also choose to have a mammogram.¹⁴ Mammography must not be used alone to exclude cancer if a lump is palpable. Such lesions require a complete appraisal since, even in the best hands, mammography still has a false-negative rate of at least 10%. Genetic testing should be considered in those at risk.

Colorectal cancer (CRC). A history should be taken, with specific enquiry as to family history of adenomas or colorectal cancer, past history of inflammatory bowel disease and rectal bleeding. Rectal examination should be performed as part of an examination. Faecal occult blood testing (FOBT) every 2 years is now recommended for screening for people over 50 years without symptoms and with average or slightly above average risk.

Should a positive history be elicited, then the following are recommended:

• past history of large bowel cancer or colonic adenomas—colonoscopy

• past or present history of ulcerative colitis—colonoscopy with biopsies

• familial polyposis, Gardner syndrome—sigmoidoscopy or colonoscopy

Prophylactic colectomy needs consideration in some individuals.

Apart from FOBT screening, the National Health and Medical Research Council (NHMRC) currently recommends 2-yearly colonoscopy for people from 25–30 years of age if there is a family history on the same side of the family of:

• three or more first or second degree relatives with CRC at any age

• two or more first or second degree relatives diagnosed as CRC <50 years of age

• a family member where genetic studies identify a high risk

Refer to the RACGP Guidelines for Preventive Activities in General Practice¹⁴ for further information. Genetic testing should be considered in those at risk.

Prostate cancer. Screening is controversial. The RACGP guidelines do not recommend routine screening with DRE, PSA or transabdominal ultrasound. Patients should make their own decision after being fully informed of the potential benefits, risks and uncertainties of testing. Doctors should also use their clinical judgment for their individual male patients.

Skin cancer. All patients should be informed regularly about the need for protection of the skin and eyes from ultraviolet (UV) radiation, using hats, clothing, sunglasses and sunscreens, and avoiding exposure during peak UV periods (10 am to 3 pm).

Skin cancer, which is increasing in incidence, is common in Australia, particularly in more northern areas. Squamous cell carcinoma, and melanoma in particular, may be lethal. Detection and treatment of early lesions prevents mortality and morbidity. Prevention of skin cancer by reduction of sun exposure should be taught to all patients.

Oral hygiene/cancer. Patients should be counselled about cessation of smoking and alcohol consumption, and dental hygiene should be taught. The oral cavity should be inspected annually in patients over the age of 40 years.

Although oral cancer has a relatively low incidence, premalignant lesions may be detected by inspection of the oral cavity. Its incidence is highest in elderly people with a history of heavy smoking or drinking. Poor dental hygiene may result in poor nutrition, particularly among the elderly.

Cancer screening in summary¹⁴

• Screen for breast, cervical and colorectal cancer.

• Routine population-based screening is at this stage of evidence not recommended for lung, melanoma, ovarian, prostate and testicular cancers.

Children and adolescents should be immunised according to the current NHMRC recommended standard vaccination schedule (www.immunise.health.gov.au).

The NHMRC advises administering intramuscular and subcutaneous vaccines to the anterolateral thighs for children under 12 months, and to the deltoid region in older children and adults. Do not postpone immunisation for minor illnesses such as mild URTI.

All adults should receive an adult diphtheria and tetanus (ADT) booster every 10 years.

All women of child-bearing years should have their rubella antibody status reviewed. During pregnancy, it is recommended to have the seasonal influenza vaccination any time in the pregnancy and a pertussis booster in the final trimester.

Common adverse effects are irritability, malaise, fever and a local reaction to the injection. There is a very small risk of anaphylaxis. It is advisable to wait 15–30 minutes for observation after vaccination. Paracetamol is recommended for fever and local pain; however, routine use at the time of or immediately after vaccination is not recommended.¹⁵

Fever and illness. Children with minor illness (providing the temperature is <38.0°C) may be vaccinated safely. Otherwise it should be delayed. A simple past febrile convulsion or pre-existing neurological disease is not a contraindication to pertussis vaccination. Absolute contraindications include encephalopathy within 7 days of a previous DTP or an immediate severe or anaphylactic reaction to DTP.

The case for vaccines

Influenza. The population needs to be immunised against this ever severe and constantly mutating endemic infection. Influenza immunisation is recommended on an annual basis for persons of all ages with chronic debilitating diseases, especially chronic cardiac, pulmonary, kidney and metabolic diseases, persons over 65 years of age, Indigenous Australian adults over 50 years of age and persons receiving immunosuppressant therapy. Health care personnel may wish to consider it for their own use.

Pneumococcal disease. This should be considered for the same risk groups as influenza vaccine. Those at higher risk of fatal pneumococcal infection (e.g. post-splenectomy or Hodgkin lymphoma), should receive a booster every 5 years. This is currently provided for all children.

Hepatitis A. Immunisation is recommended for:

• certain occupational groups at risk (e.g. health workers, child care workers, sewage workers)

• non-immune homosexual men

• those with chronic liver disease

• recipients of blood products

• travellers to hepatitis A-endemic areas

Hepatitis B. Immunisation is recommended routinely for all children at birth, 2 months, 4 months and at either 6 or 12 months, and for individuals of all ages who, through work or lifestyle, may be exposed to hepatitis B and have been shown to be susceptible. Such groups would include health care personnel, personnel and residents of institutions, prisoners and prison staff, persons with frequent and/or close contact with high-risk groups, and persons at increased risk due to their sexual practices. Household contacts of any of the above groups should be considered for immunisation. Booster doses are not recommended for immunocompetent people but are recommended for immunosuppressed individuals. Universal vaccination represents a preventive step against hepatocellular cancer.

Haemophilus influenza type b. Hib immunisation is recommended for all children, especially those in child care. It is ideal to achieve immunity by the age of 18 months and preferably commencing at 2 months. Risk factors for Hib disease include day care attendance, presence of ill siblings under 6 years of age in the home and household crowding.

Q fever. People at reasonable risk from Q fever, particularly abattoir workers, should be given this vaccine, which is virtually 100% effective.

Measles-mumps-rubella. Both females and males should be immunised against measles, mumps and rubella at the age of 12 months and 4–5 years using the trivalent vaccine. All non-immune women who are postpartum or of child-bearing age should be immunised.

Varicella vaccine. This is available and one dose is given at 18 months. Those over 12 years have a course of two injections.

Meningococcal vaccine. Meningococcal disease is caused by Neisseria meningitides, which has 13 serogroups of which A, B and C account for over 90% of isolated cases, with serogroup B responsible for most cases. A vaccine against serogroup B is available but not yet as part of the recommended schedule as evaluation studies are being assessed. The main vaccine that is available is a quadrivalent polysaccharide vaccine against serogroups A, C, Y and W125 for use in individuals over 2 years as a single injection. Universal prevention by immunisation remains unsatisfactory. It is most useful when a community outbreak due to proven serogroup C occurs.

Rotavirus. A course of two (usually) or three oral live attenuated rotavirus vaccines is given to children to cover a common cause of childhood gastroenteritis. Inform parents of the risk of intussusception with the first dose.

Human papilloma virus. A course of two injections is provided by schools to all pupils aged 11–12 years.

Blood from a heel prick at 48–72 hours following birth checks 25 conditions including cystic fibrosis, phenyloketonuria and hypothyroidism.

Genetic screening

Genetic screening programs are presented in CHAPTER 18.

Australian Government. Australian Institute of Health and Welfare, 3 February 2017, Cat. No. OAN 100.