Volume 206 Issue 7

The challenge will be changing the way doctors practice so that low value intervention use decreases

Denis Spelman · Adam W Jenney · David P Burgner

Pieces of the plan are in place, but we must continue to strengthen preparedness research capacity

Jodie McVernon · Tania C Sorrell · Jenny Firman · Brendan Murphy · Sharon R Lewin

Integrating contemporary microbiology with new sequencing technologies will allow us to better understand our microbiome and its relationships with health and disease

Mark Morrison · Gerald Holtmann

Clinicians should remain alert to the possibility of HEV infection, particularly in immunocompromised patients

Veronica C Hoad · Tristan Gibbs · Madhur Ravikumara · Monica Nash · Avram Levy · Samantha L Tracy · Catherine Mews · Zofia Perkowska-Guse · Helen M Faddy · Scott Bowden

Last night, a neo-Nazi tweeted me a picture

Shaindel Beers

the poplars have half turned

Christine Burrows

The ASID perspective on the most important infectious diseases problem of 2017 and beyond

Cheryl A Jones · Joshua S Davis · David FM Looke

Awareness of the problem is the first step towards control

David CB Lye

As travel to Asia increases, it is vital that clinicians can recognise and manage dengue

Alex YC Tai · Sarah L McGuinness · Roselle Robosa · David Turner · G Khai Lin Huang · Karin Leder · Tony M Korman · Irani Thevarajan · Andrew J Stewardson · Alexander A Padiglione · Douglas F Johnson

HBV prevalence is still higher among Indigenous than non-Indigenous women, despite a successful vaccination program

Lucy Deng · Joanne Reekie · James S Ward · Andrew Hayen · John M Kaldor · Marlene Kong · Jennifer M Hunt · Bette Liu

Data sharing between states is needed to determine how many people complete treatment

Rowena Boyd · Vanessa Johnston · Belinda Farmer · Vicki L Krause

Wound infections are common after crocodile attacks and, therefore, prophylactic antimicrobial therapy is advised

Simon Smith · Richard J Bagshaw · Josh Hanson

Hepatitis C can be eradicated as a public health problem — if GPs are familiar with it

Joshua S Davis · Amanda Tapley · Simon Morgan · Mieke L van Driel · Parker J Magin

An update to the 2009 guidelines

Nadia J Chaves · Georgia A Paxton · Beverley-Ann Biggs · Aesen Thambiran · Joanne Gardiner · Jan Williams · Mitchell M Smith · Joshua S Davis

We are diagnosing CAP too often and treating it for too long

Sarah Sparham · Patrick GP Charles

Rickettsial infections are the most common, but ongoing research will likely reveal new tick-borne viral, bacterial and protozoal infections

Stephen R Graves · John Stenos

To the Editor:Hepatitis E virus (HEV) genotype 3, the most common genotype in high income countries, is transmitted by ingestion of high risk food — including pork, deer and shellfish — and by blood transfusion. Rural residence, travel to hyperendemic areas (eg, southern Europe) and animal exposure are other risk factors.1 Both de novo and reactivated HEV infection can lead to chronic infection in up to 60% of immunocompromised patients, particularly in solid organ transplant (SOT) recipients.1,2 Moreover, 10% of patients who are chronically infected develop cirrhosis.1 In a 2013 study, the seroprevalence of HEV in Australian blood donors was 5.99%.3 Autochthonous transmission in Australia, including one patient who was a liver transplant recipient, is well documented.4,5 However, the seroprevalence and rate of chronic HEV infection in SOT recipients in Australia are unknown. We carried out a study to investigate this in an Australian tertiary hospital. In phase 1 of our study, we recruited renal transplant recipients attending routine outpatient follow-up in 2014–15; phase 2 was limited to seropositive participants from phase 1. The study was approved by the Northern Sydney Local Health District Human Research Ethics Committee (LNR/14/HAWKE/300). Seventy-four patients consented to participate in phase 1, and post-transplant stored serum was tested for HEV IgG. Six participants were HEV IgG positive. One seropositive participant died of invasive fungal infection before phase 2. The remaining five participants who were seropositive consented to phase 2, of whom one was HEV IgM positive. We tested plasma for HEV RNA and no phase 2 participants had evidence of ongoing chronic infection. While our study had limitations and we did not identify any participant with chronic infection, it is important to note that Australian SOT recipients are exposed to HEV and are at risk of chronic infection. Effective therapy for chronic HEV is available; therefore, we recommend that SOT recipients who have abnormal liver function tests should be tested for HEV RNA in blood to maximise early diagnosis. In addition, with respect to risk mitigation, previous Australian research supports a link between local pork consumption and HEV infection,4 and French guidelines suggest that SOT recipients should avoid consuming food containing pork liver.6 We believe that similar advice should be given to SOT recipients in Australia. Moreover, consideration should be given to screening donated blood in Australia for HEV RNA, as done in France and the United Kingdom, with experts calling for such screening across the European Union.7,8 The Australian Red Cross Blood Service has undertaken a large scale screening study of donated plasma for HEV RNA to estimate the local risk of HEV transmission by blood transfusion, with results currently pending.9

James P Newcombe · Stella McGinn · Bruce Wong · Archie Darbar · George Kotsiou

To the Editor:We report an extensive investigation into a cluster of five confirmed cases of Legionnaires’ disease in Sydney’s Inner West in May 2016. The patients were aged 62–89 years, four were men, all were ex-smokers, and four had significant comorbidities, such as immunosuppression. Hospitalisations lasted a median of 6 days and one patient died. All patients tested positive for Legionella pneumophila serogroup 1 urinary antigens; however, L. pneumophila was isolated by culture in only one patient. Patients were interviewed to obtain the histories of where they had been in the 2–10 days before the onset of symptoms (the incubation period), and then, to identify the focus for our environmental investigation, we mapped the locations against water source locations.1 Local councils assisted in the collection of water samples: 86 samples were obtained from cooling towers and 15 from other sites, such as fountains. At the time of sampling, requests were made for immediate cleaning of all visibly unclean air conditioning cooling towers or those with cloudy water. Only one sample tested positive for Legionella: a fountain with a low positive result of Legionella anisa. If Legionella isolates are genetically indistinguishable, the genomic sequencing of clinical and environmental samples is a useful tool that can link cases to each other and to an environmental source. In this investigation, L. pneumophila was cultured in only one case and in no environmental samples; therefore, we could not link cases to each other or to an environmental source by genotyping, leaving the possibility that cases were unrelated and sporadic. Despite this investigation, no environmental source for these infections was identified. It is uncommon in an investigation of this size to not detect L. pneumophila in any cooling towers — a routine New South Wales survey found L. pneumophila in 2% of cooling towers in a non-outbreak situation.2 Possible explanations for not detecting Legionella include low sensitivity of sampling at one point in time, incidental and possibly unrelated cleaning of the source cooling tower before sampling, or underestimating the distance that contaminated aerosols may travel, meaning that the source cooling tower was not sampled.3 No further cases with similar exposures were reported in the period immediately after the environmental investigation. This suggests that the extensive public health interventions taken at the time to remedy the problems identified may have been effective, or that incidental cleaning of cooling towers before our sampling may have eliminated the potential source.

Marianne Dowsett · Emma Quinn · Leena Gupta

To the Editor:Biobanking involves the collection, processing, storage and distribution of biospecimens and data, and, in recent years, it has rapidly evolved to become an integral component in biomedical research.1 Biobanks may range in complexity from a single researcher storing their own material to large stores of material used by multiple researchers. This diversity has complicated the standardisation of biobanking practices,2,3 sometimes compromising biospecimen quality and storage capacity4 and the security of funding. In turn, irreproducible research results, poor biospecimen access and decreased public confidence may ensue.4 Therefore, New South Wales Health Pathology — a statewide clinical diagnostic service — has adapted and launched a Biobank Certification Program in conjunction with the Canadian Office of Biobank Education and Research and the Canadian Tissue Repository Network, where the program has been operating successfully for 4 years.5 This voluntary program aims to improve the quality of biobanking practices and raise standards through the provision of education modules and document templates. To encourage participation, the program is free for NSW biobanks and associated pathology laboratories for the first year. Nominal fees will subsequently apply for non-NSW Health organisations. Certification requires the biobank or pathology leader to register details of the biobank and complete (with team members) up to nine pertinent education modules, submit a declaration of compliance to adhere to best practices and upload key documents for auditor review. Moreover, biobanks may also opt to be listed on a publically available biobank locator. The program is designed as a first step towards improving the quality of biobanks for stakeholders, including researchers, multicentre trials, ethics committees, funders and the public. Current biobank practices are diverse, making a formal accreditation system impractical for some biobanks to undertake. It is envisaged that the program — subject to evaluation and uptake of staff education modules — may provide a foundation for a future accreditation program. Further information is available at https://nsw.biobanking.org.

Jane E Carpenter · Amanda Rush · Candace Carter

To the Editor:In our study,1 we engaged the services of a third party online panel to recruit survey participants. Pre-existing information on private health insurance status, smoking status and exercise participation for those completing the survey was provided by the third party, who has now confirmed that the data initially labelled as “private health insurance” were actually “smoking” status. All other demographic information used in our analysis was collected directly from participants completing the online survey. We initially reported a positive association between private health insurance and being bulk-billed (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.09–1.78). However, the discovery of this labelling error better explains the positive association we initially reported for those data; it is smokers who are more likely to be bulk-billed than non-smokers, not those with private health insurance being more likely to be bulk-billed than those without private health insurance. Retaining these data on smoking status in our model, and adding in the correct data for private health insurance status, we observe that those with private health insurance are less likely to be bulk-billed than those without it (OR, 0.63; 95% CI, 0.51–0.77). The remaining relationships between individuals’ characteristics and the likelihood of being bulked-billed are unchanged from those reported previously. The results from the updated multivariate logistic regression analysis are provided in the Box. Box – Odds ratios for factors associated with bulk billing (n = 2467) Multivariate regression statistic Wald χ2 = 234.63 (P = < 0.001). Bars represent 95% confidence intervals (CIs). For each category, except age, the base factor appears without a 95% CI and straddles the line at 1. The number of respondents included was reduced by ten due to six missing observations for age and four missing observations for concession card status. * P = < 0.05 compared with the base factor.

Richard De Abreu Lourenco · Patricia Kenny · Marion R Haas · Jane P Hall

Dr Sam Brophy-Williams is an advanced paediatrics trainee and is just back in Australia after 6 months in Afghanistan with Me´decins Sans Frontières

Cate Swannell

Six University of Sydney-affiliated scholars have won $2m from $6m in new grants announced by Cancer Council NSW to make ground-breaking advancements in cancer research. Dr Ken Micklethwaite of the UoSydney and Westmead Institute was awarded $450 000 to test the impacts of genetically modified immune cells to fight cases of leukaemia. Dr Micklethwaite’s research centres on the use of a new “PiggyBac” technology to make cell and gene therapy simpler and more broadly available. Currently, the technology for making cancer-fighting immune cells is unable to introduce the genes needed to defeat cancer. The PiggyBac system has the ability to make these changes but is yet to be adapted for clinical use. Dr Micklethwaite’s team will optimise PiggyBac for use in clinical trials and develop the technology so researchers have a choice of established tools that can be used to create cancer-fighting cells. Associate Professor Greg Neely was awarded $450 000 to progress research on the treatment of pancreatic cancer. Professor Neely’s research team hopes to detect molecular “signatures” that define drug resistance and thereby allow researchers to find ways to make current and future treatments more effective. The research will be used to test combinations of drugs to either overcome cancer drug resistance or prevent resistance from occurring. Dr Elizabeth Hovey an Honorary Associate, at the NHMRC Clinical Trials Centre, at Sydney Medical School was awarded $186 540 to test an alternative treatment for a type of glioma brain cancer, which could be less toxic and more effective than current therapy. Dr Hovey’s work will investigate whether PCV treatment could be substituted by the less toxic drug temozolomide to treat this cancer. Dr Eva Segelova, a medical oncologist at St Vincent’s Hospital, was awarded $213 460 to conduct a multinational trial on colorectal cancer to determine whether aspirin can be used to reduce relapse and death rates. Previous research has shown that patients with colon and rectal cancer who take aspirin after being diagnosed appear to live longer than those who do not. The trial will aim to determine whether taking aspirin will improve survival rates without adding significant side effects. Associate Professor Jeffrey Holst from the Sydney Medical School and the Centenary Institute, was awarded $449 174 to complete research into manipulating cancer cells into using biological pathways that will trigger their own death. Cancer cells develop stress-response techniques to promote their survival and so researchers will hijack these responses and force the cancer cells to choose a path that will lead to their death. Professor Stephen Ackland, also from the NHMRC Clinical Trials Centre, was awarded $449 490 to complete a phase 2 trial testing whether statins can reduce the side effects of rectal cancer treatments. Previous studies have shown that people taking statin drugs before treatment for colorectal cancers have better treatment responses and fewer side effects during radiation. http://sydney.edu.au/news-opinion/news/2017/03/02/university-of-sydney-researchers-win--1-5m-to-defeat-cancer.html Menzies School of Health Research in Darwin has awarded five career fellowships as part of their collaborative program Improving Health Outcomes in the Tropical North (HOT NORTH). The 3-year fellowships have been given across five themes – skin health, respiratory health, chronic diseases, antimicrobial resistance, and mosquito-transmitted diseases. Dr Matthew Grigg (Menzies School of Health Research) will work on a project called “Antimicrobial resistance: epidemiology and treatment of malaria in Sabah, Malaysia: longitudinal patterns of disease, acquisition risk factors, antimalarial drug resistance, and adjunctive therapy for acute kidney injury”. Associate Professor Heidi Smith-Vaughan (Menzies School of Health Research) will work on “Respiratory health: genomic public health in Australian Indigenous communities and developing countries”. Dr Karla Canuto (James Cook University) will work on “Chronic diseases: Torres Strait healthy young women”. Dr Dagmar Meyer (James Cook University) will work on “Vector-borne and emerging infectious diseases: can mosquito excreta be used to enhance detection of Australian vector-borne diseases?” Dr Timothy Barnett (Telethon Kids Institute) will work on “Skin health: do group A streptococcus isolates causing skin infections in remote WA encode genes that correlate with disease severity, antibiotic resistance, or adverse immunological outcomes?” Four researchers affiliated with the University of Sydney have been awarded $250 000 by MS Research Australia as part of $1.5 million in new funding to support promising new ways prevent and treat multiple sclerosis. Dr Grant Parnell of the UoS and the Westmead Institute was awarded $158 000 over 3 years to investigate how vitamin D protects against MS. A low level of vitamin D is a known risk factor for developing MS however the benefit of vitamin D in the treatment and prevention of MS is largely unknown. Dr Joshua Barton of the UoS and the Brain and Mind Centre was awarded $67 000 over 2 years to investigate new ways of detecting sub-clinical changes in the brains of MS sufferers. The current methods used by clinicians to monitor the impact of the disease on patients are insensitive and measured over long periods of time. Dr Barton aims to use the brain’s visual systems to monitor disease progression and the effectiveness of therapies for MS in real time. Associate Professor Scott Byrne was awarded $18 000 to find out how sunlight suppresses the immune system. A/Professor Byrne’s research will examine the relationship between UV light exposure, the immune system and MS. There is increasing evidence that a number of environmental factors are important in the development and course of MS, which is more prevalent in Scandinavian countries with low UV exposure. UoS PhD student Angelica Panopoulos was awarded $6000 to investigate how immune cells enter the brain and spinal cord. Typically, immune cells are blocked from entering the brain via the blood brain barrier, which is faulty in MS sufferers. The hope is her research will help develop a better understanding of whether tiny cell fragments called microparticles can breach the blood brain barrier and therefore contribute to the early stages of MS. http://sydney.edu.au/news-opinion/news/2017/03/07/university-of-sydney-researchers-win-grants-to-fight-ms.html Professor Michael Parker has been appointed as the new Director of the University of Melbourne’s Bio 21 Molecular Science and Biotechnology Institute. One of Australia’s leading protein structural biologists, Prof Parker will take up the role as part of a joint appointment between the University and St Vincent’s Institute of Medical Research (SVI). The joint appointment will see Prof Parker take up the Bio21 Director role while also remaining the Head of SVI’s Structural Biology Unit. His academic appointment at the University of Melbourne will be as a Professor in the Department of Biochemistry and Molecular Biology in the Faculty of Medicine, Dentistry and Health Sciences. While several of the Unit’s research teams will relocate to Bio 21 in a staged process over the next few months, others will continue to be based at SVI. http://newsroom.melbourne.edu/news/new-director-bio-21-announced Director of Clinical Haematology at Monash Health Professor Stephen Opat has been acknowledged for his significant achievements with an academic promotion at the School of Clinical Sciences at Monash Health, Monash University. Professor Opat’s research aims to improve outcomes for patients with lymphoma and chronic lymphocytic leukaemia, and to achieve these ends he has employed a number of strategies. As Director of the Monash Haematology Clinical Research Unit, Professor Opat has also been principal investigator in over 40 studies in lymphoma and chronic lymphocytic leukaemia. Another research interest of Professor Opat’s is improving the understanding of lymphoma biology to facilitate the rational application of targeted therapy. Professor Opat is President of the Haematology Society of Australia and New Zealand; Chair, Steering Committee, Lymphoma and Related Diseases Registry; and Chair, Melbourne Genomics Health Alliance Lymphoma Flagship. http://www.monash.edu/medicine/news/latest/articles/director-of-monash-haematology-receives-academic-promotion Neonatalogist Arvind Sehgal has been recognised for his research with an academic promotion at Monash University. Adjunct Professor Sehgal, Department of Paediatrics, is a Neonatal Consultant at Monash Children’s Hospital. His recent research focuses on the cardiac and vascular impact of fetal growth restriction. “Using advanced ultrasound modalities, we have noted early vascular ageing in this cohort alongside mal-adaptive coupling with cardiac function,” said Professor Sehgal. “Early identification of arterial and ventricular changes would detect those premature infants at high risk for long term cardiovascular compromise, and allow early intervention and/or increased monitoring.” This research also formed the focus of Professor Sehgal’s recently completed PhD. http://www.monash.edu/medicine/news/latest/articles/neonatologist-receives-academic-promotion-at-school-of-clinical-sciences-at-monash-health

Cate Swannell