Melbourne is dealing with a 2-pronged problem – successive surges of COVID-19 circulation coupled with under-vaccination and under-treatment with antivirals.
Early in January The Age reported that Victoria was currently experiencing a “wave on wave” of COVID-19 infections. Infections by a new variant, called JN.1, were piling up on top of those caused by the already widespread XBB.
It was noted that hospital admissions and antiviral prescribing were up, but that most eligible populations had poor uptake of booster doses.
As of December 2023, only 23.2 per cent of adults over 75 had received a booster dose in the previous 6 months. In an analysis led by cohealth’s Dr Nicole Allard and published in the Medical Journal of Australia, it was estimated only 40 per cent of covid-positive patients over 70 had received antiviral treatments, despite the clear evidence of benefit for this high risk group in reduction of severe disease, hospital admissions and deaths.
The reasons for poor booster uptake and poor uptake of antivirals are no doubt complex, and beyond the scope of this article, but covid apathy, both in the community and in the general practice workforce, is no doubt high and a contributing factor.
Against a background of increasing demands on our time, how can we encourage our eligible patients to seek antiviral prescriptions when they are covid-positive? And how can we re-engage with promoting boosters?
Antivirals – which one and who is eligible?
There are 2 COVID-19 antivirals available in Australia: molnupiravir (marketed as Lagevrio and made by MSD Australia) and combined nirmatrelvir plus ritonavir (known as Paxlovid, from Pfizer Australia).
Paxlovid is more effective, with a greater reduction in mortality and hospitalisations than molnupiravir. However, it is also more complicated, with more side effects and drug interactions, and a more detailed contraindication profile.
Dr Allard and her co-authors observed: “The more complicated therapeutic profile of nirmatrelvir/ritonavir has likely contributed to the fact that despite being the preferred option … it was less commonly prescribed”.
Here are some resources to make prescribing easier:
- Prescribing considerations for nirmatrelvir plus ritonavir (Paxlovid), National Clinical Evidence Taskforce. A comprehensive one-pager including all of the contraindications.
- Liverpool interactions checker: a simple tool to cross-check drug interactions. Also available as an iPhone and Android phone app.
- HealthPathways Melbourne, contains general information plus advice on how to dose adjust based on renal function.
- eGFR table, for dose adjustments with Paxlovid.
PBS eligibility, current at January 2024, is for these cohorts:
- 70 or older, regardless of risk factors and with or without symptoms;
- 50 or older with any additional risk factor for developing severe disease;
- First Nations people, 30 or older and with one additional risk factor for developing severe disease;
- 18 and older re-infected who have previously been in hospital from COVID-19; and
- 18 and older who are moderately to severely immunocompromised.
Visit health.gov.au for more information on eligibility, risk factors and immunocompromising conditions.
COVID-19 treatment planning
Proactive treatment planning can reduce the burden when an eligible patient becomes covid-positive.
A COVID-19 treatment plan:
- provides information for the patient about when and how to test;
- provides information for the patient on how to access antivirals both in and out of hours;
- records the patient’s current medical history, medications and estimated glomerular filtration rate (eGFR) should they need to seek antiviral treatment elsewhere;
- records the recommended antiviral treatment after contraindications and interactions have been considered, which can significantly reduce the time needed to prescribe
- can be an opportunity to ensure your patient is up to date with vaccine boosters.
Here is an example of a covid treatment plan (.pdf), which can be adapted for your own needs.
Consider sending an SMS to all eligible patients inviting them to book a proactive COVID-19 treatment planning appointment.
Access to appointments for antiviral prescribing
Access to covid antivirals must be within 5 days of symptoms starting or testing positive for COVID-19, although the earlier the better.
Appointments for antiviral access are ideally by telehealth. There is no need to see the patient face-to-face just for the purposes of prescribing, unless there is clinical concern necessitating this sort of review.
Being covid positive remains an exemption to the established clinical relationship requirement, also known as the 12-month rule for telehealth.
Note there is a dedicated MBS item, 93716, for telephone consults lasting more than 20 minutes for the purpose of prescribing of antivirals. Confirmation of infection can be by conversation between a patient and GP.
How do patients access appointments for antivirals at your practice? Do you have a policy dealing with covid-positive patients seeking antiviral treatment? Do you save some urgent on-the-day appointments for those eligible for antivirals?
What arrangement do you have for those seeking antivirals after-hours or on weekends?
You could record this in COVID-19 treatment plans, advising patients that if Day 5 is a Sunday they may need to contact the practice locum, the local Priority Primary Care Centre or the Victorian Virtual Emergency Department. Provide training for your reception team to manage these urgent appointment requests.
What about PCR testing?
COVID-19 antivirals must be prescribed by Day 5 of illness, and rapid antigen tests unfortunately can throw up false negatives, especially with emerging variants which may evade them.
Many people can’t afford to do multiple RATs over 3 or 4 days to capture a positive result. So, there are times when PCR testing remains appropriate.
Discuss with your patient how they will access a PCR test. Many pathology services offer COVID-19 PCR testing, so you might provide a signed pathology form at the time of COVID-19 treatment planning. Another option is to provide a COVID-19 swab and pathology form to self-test at home.
As noted, COVID-19 booster rates among high-risk populations are low, with figures published in December 2023 showing that only 23.2 per cent of adults over 75 had received a booster dose in the previous 6 months.
The current ATAGI advice is for those over 75 to have a booster every 6 months. Those between 65 and 75, and people of any age with immunocompromise, should consider a 6 monthly dose. No doubt further advice will be forthcoming in 2024. The preferred vaccine is the monovalent Omicron XBB.1.5 ones manufactured by Pfizer and Moderna.
How can general practice keep our patients safe by helping them stay up to date with COVID-19 vaccine boosters?
- Discuss the current recommendations at a team meeting so everyone is aware of what vaccinations are being recommended and to whom.
- Incorporate a COVID-19 booster discussion into health assessments, such as those for patients aged between 45 and 49, patients with diabetes, and patients 75 and over.
- Adopt an “every patient, every time” approach to health promotion and get in the habit of asking as many patients as possible where they are at with their COVID-19 vaccination status.
- Have a “covid booster month” – hand out reminder cards to all patients arriving at the clinic.
- Identify certain consults – such as those concerning diabetes, heart disease or obesity — for targeted promotion.
- Have a targeted SMS campaign, for instance to all patients over 65 or 75, reminding them about COVID-19 boosters. If you aren’t a vaccinating practice, you might include where they can get one.
- Display posters in your waiting room promoting COVID-19 booster doses and where to get them.
- Audit your nursing home residents to ensure they are up to date with COVID-19 boosters.
- Use the reports function in the Australian Immunisation Register (via Proda/HPOS) to run a report and identify those who are under vaccinated. It’s worth noting that AIR reports use Medicare data so will pick up patients vaccinated elsewhere.
Don’t forget about aged care
The responsibility for vaccinating aged care home residents technically lies with the homes themselves, but practically it is visiting GPs who are best placed to keep them up to date. Do you have a reminder system that can prompt you on this matter? Can your nurse visit the home with you to assist with vaccinating residents?
COVID-19 vaccination in-reach service
North Western Melbourne Primary Health Network (NWMPHN) offers an in-reach home visit services to provide COVID-19 vaccinations to people who cannot leave the home. This service is funded by the Australian Government and is for homebound people including but not limited to the frail aged and elderly, and people living with a disability or a mental health condition which prevents them from leaving their home.
For more information:
- HealthPathways Melbourne
- National Clinical Evidence Taskforce – Prescribing considerations for nirmatrelvir plus ritonavir (Paxlovid) – a comprehensive one pager including all of the contraindications
- Liverpool interactions checker (also available as an iphone and android phone app). Simple tool to cross check drug interactions.
- eGFR table for dose adjustments with Paxlovid