The Melbourne experience
- On 21-22 November 2016, Melbourne experienced the largest thunderstorm asthma event ever recorded
- In the 30 hours from 6pm on 21 November 2016, Melbourne and Geelong public hospital experienced:
- 9,909 total emergency department presentations – 3,643 (58%) more*
- 672% increase in respiratory-related presentations (3365 more than expected)
- 992% increase in asthma-related admissions (476 more than expected), including 30 extra in intensive care unit admissions for asthma
- 9 more deaths occurred in people between 21 and 30 November, with asthma reported as the primary cause of death, than would be expected (and these are currently being investigated by the Coroner’s Court)
- A significant surge in ambulance calls, calls to Nurse-On-Call, pharmacy attendances and visits to general practice both during and after the event
* The increase was based on a comparison with the average over the corresponding time period in the previous three years
Who is at risk of Thunderstorm Asthma?
Management of thunderstorm asthma and educating patients
GPs have a vital role in identifying individuals at risk and in improving awareness of asthma management and allergic rhinitis in the community
Screen all individuals with a history of asthma AND/OR seasonal hay fever/allergic rhinitis for risk of thunderstorm asthma and ensure that all at risk have an in date asthma action plan and appropriate medication (as per chart below).
ICS – inhaled corticosteroids
^ See risk criteria above
* See Therapeutic Guidelines or ASCIA
**Ideally with spacer
# 'Appropriately available' reliever medication indicates that it may not be essential for this group to carry a reliever at all times in grass pollen season. A discussion should be had with the patient or their parents/carers about a practicable arrangement including factors such as age of the person, clinical history, care arrangements (if a child), remoteness and timely access to care. It may be appropriate to agree that a reliever is kept in the family home or car, available at school and make sure all are aware that a reliever can be bought over the counter at pharmacies. In this way the patient has appropriate level of access to a reliever depending upon their individual circumstances.
++ Grass pollen season is generally 1 October to 31 December
Allergic rhinitis (AR) can be categorised as seasonal (SAR) or perennial (PAR). SAR in grass pollen season, is commonly known as hay fever which in Victoria is predominantly includes rye grass pollen allergy. It is currently thought that rye grass allergy is the trigger for thunderstorm asthma, making SAR a clinical marker of this risk. PAR can be caused by an allergy to house dust mite, animal dander etc, that persist in the patients environment year long.
SAR and PAR can coexist and it is important to differentiate and identify those with a seasonal component. If this is not possible from the patient’s history then consider sIgE for rye grass and other allergens to clarify the triggers in your patient. Alternatively make the assessment of your patient’s risk of thunderstorm asthma assuming their AR has a hay fever /seasonal component. Treatment for AR can be found in Therapeutic Guidelines or the ASCIA website. Intranasal corticosteroids assist in reducing general airway inflammation, thereby improving coexistent asthma control. It is the preferred treatment for those at greatest risk of thunderstorm asthma.
Patient educationAll patients at increased risk should:
- be aware of and understand the thunderstorm asthma phenomena
- avoid exposure to thunderstorms in October through December especially the wind gusts that immediately precede them; smoke from bushfires; dust storms and heavy rain storms and go indoors with windows and doors closed and air conditioner on recirculate if in use. If in a car they should have windows up and air conditioner on recirculate
- have an asthma action plan and/or have practical knowledge of 4 step asthma first aid
- have reliever medication appropriately available in grass pollen season and know how to use it correctly (ideally with as spacer). Ensure patients are aware that reliever medication can be bought over the counter without a prescription at pharmacies if required; click here for appropriate adults and children techniques
- have suitable treatment of any coexisting allergic rhinitis
- be aware of forecasts for thunderstorms and pollen counts from networks listed below; download the VicEmergency app and even set up a Watch Zone for alerts if in Victoria
- if reliever medication is needed more than two times per week, attend for GP review
In paediatric patients, ensure that all carers are aware of the patient’s asthma action plan and/or have good knowledge of 4 step asthma first aid. Speak to both parents/carers and, where appropriate, the child, to rigorously assess for possible asthma symptoms. Carers may not be fully aware of intermittent symptoms their child is experiencing.
- Good supply of in date, reliever medication (and spacers) on site
- All clinical and non-clinical staff know asthma first aid
- Clinical staff are up to date with acute asthma management
- Relevant practice staff have downloaded the VicEmergency App and set up a ‘Watch Zone’ to receive epidemic thunderstorm asthma alerts and warnings
- Consider planning in the event of a surge in patients
- Asthma Action Plan, National Asthma Council Australia. For action plans in other languages please click here
- Asthma Emergency: First Aid Steps
- How to use a standard puffer and spacer
If you would like to do a short case study on this topic, you can enrol in the Identifying and managing risk factors for thunderstorm asthma activity on gplearning. Completion of the online activity is worth 2 CPD Activity points.
Asthma action plans
Allergic rhinitis treatment plan
- Australian Society of Clinical Immunology and Allergy (ASCIA). Allergic rhinitis treatment plan
- National Asthma Council Australia. Information paper for health professionals: Managing allergic rhinitis in people with asthma. National Asthma Council Australia, Melbourne, 2017
- Asthma Australia. Asthma Emergency: First Aid Steps
- National Asthma Council Australia. Australian Asthma Handbook
- National Asthma Council of Australia. How to video library on how to use inhalers
- Asthma Australia. Thunderstorm Asthma: What we’ve learned
- Australian Society of Clinical Immunology and Allergy (ASCIA). Information for Patients, Consumers and Carers: Thunderstorm asthma
- Inspector-General for Emergency Management. Review of response to the thunderstorm asthma event of 1–22 November 2016 - Preliminary Report. Department of Justice and Regulation, Melbourne, Victoria. 2017
- National Asthma Council Australia. Information paper for health professionals: Epidemic thunderstorm asthma. National Asthma Council Australia, Melbourne, 2017
- Professor Barry Marshall, University of Western Australia. Nobel Prize Winner explains Thunderstorm Asthma
- Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Melbourne: Victorian Government; 2017
- Victoria State Government Department of Health and Human Services. The November 2016 Victorian epidemic thunderstorm asthma event: an assessment of the health impacts. The Chief Health Officer’s Report, 27 April 2017. Melbourne: Victorian Government; 2017.
- AusPollen – pollen forecasts for major capital cities
- Deakin University (AirWatch) – grass pollen
- Bureau of Meteorology
- Australasian Society of Clinical Immunology and Allergy. Treatment plan for allergic rhinitis (hay fever). ASCIA; 2015.
- D'Amato G, Vitale C, D'Amato M, et al. Thunderstorm-related asthma: what happens and why. Clin Exp Allergy 2016; 46: 390-396.
- Davies J, Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Final report. Melbourne: Victorian State Government Department of Health and Human Services; 2017.
- Hew M, Sutherland M, Thien F, O'Hehir R. The Melbourne thunderstorm asthma event: can we avert another strike? Intern Med J. 2017; 47(5):485-487.
- Waters J, Corbett S, Gibson P, et al. Epidemic asthma surveillance in the New England Region 1990-1992. Public Health Research and Practice 1993; 4.
Victoria State Government Department of Health and Human Services. Better Health Channel: Thunderstorm asthma
Asthma Australia - Asthma App
The Asthma App provides easy access to:
- the latest asthma information
- asthma medication and devices
- device technique videos
- asthma action plans
- asthma first aid steps
- the Australian Asthma Handbook clinical guidelines Available from iTunes.
Asthma Australia website
- Opportunity to speak to an asthma educator
- Receive best practice advice
- Request an Asthma Control Pack Tel: 1800 278 462
- Forecast of pollen in Brisbane, Canberra, Melbourne and Sydney through a number of participating universities and partners
Deakin University (AirWatch)– grass pollen forecast http://www.deakin.edu.au/students/faculties/sebe/les-students/airwatch
- In an emergency, always call triple zero (000)
- Emergency department of your nearest hospital
- Your nearest pharmacy (for medication)
- NURSE-ON-CALL Tel. 1300 60 60 24 – for expert health information and advice (24 hours, 7 days)
- National Home Doctor Service Tel. 13 SICK (13 7425) for after-hours home doctor visits (bulked billed)
Information about asthma
- Asthma AustraliaTel. 1800 ASTHMA (1800 278 462) https://www.asthma.org.au/
- National Asthma Council of AustraliaTel. 1800 032 495 (https://www.nationalasthma.org.au/)
Information about allergies
- Allergy and Anaphylaxis Australia Tel. 1300 728 000
- ASCIA(Australasian Society of Clinical Immunology and allergy
- National Asthma Council Australia. Brochure: Hay fever (allergic rhinitis) and your asthma. National Asthma Council Australia, Melbourne, 2017
- Produced by the School of Bioscience, University of Melbourne
- A free mobile device App (Melbourne Pollen Count and Forecast) provides notifications of high pollen forecast days to users
- Weather information, including forecast thunderstorms are available from the Bureau ofMeteorology and by radio and television news updates
- VicEmergency website and VicEmergency App
- Asthma Australia. Asthma Australia survey shows worrying snapshot of thunderstorm asthma experiences. 2016.
- Asthma Australia. Thunderstorm asthma: what have we learnt? 2017.
- Forouzan A et al. An overview of thunderstorm-associated asthma outbreak in southwest of Iran. Journal of Environmental and Public Health Volume 2014, Article ID 504017.
- Thein F. Thunderstorm asthma: potential danger but a unique opportunity. Asia Pac Allergy. 2017; 7(2): 55–56.
- Victoria State Government. The November 2016 Victorian epidemic thunderstorm asthma event: an assessment of the health impacts. The Chief Health Officer’s Report, 27 April 2017. State of Victoria, Department of Health and Human Services, April 2017.
Leung RC, Carlin JB, Burdon JG, Czarny D. Asthma, allergy and atopy in Asian immigrants in Melbourne. Med J Aust. 1994;161: 418-25.