Volume 210 Issue 7

Coordination is required to future-proof Australia’s capacity and leadership in public health genomics

Deborah A Williamson · Martyn D Kirk · Vitali Sintchenko · Benjamin P Howden

General practitioners provide a flexible response to the changed needs of the disasteraffected population

Penelope L Burns · Kirsty A Douglas · Wendy Hu

Australia urgently needs a new and fairer approach to the provision of quality Medicare‐funded psychological services

Sebastian P Rosenberg · Ian B Hickie

A 68- year- old man presented with hyperacute stroke one hour after symptom onset

Amy Ting · Abhay R Venkat · Yash Gawarikar · Ronak Patel

Eisman JA, White CP. Dispelling confusion about de‐prescribing bisphosphonates. Med J Aust 2019; 210: 17‐19. https://doi.org/10.5694/mja2.12058 In the Editorial above, the final clause on page 17 should read: “that is, for someone whose T‐score is better than –2.5, who have not had any recent fractures, and who have no important risk factors, such as ongoing glucocorticoid or sex hormone ablative therapies.” ◆

A system that integrates all aspects of health care is essential for facing future challenges

Gerard J FitzGerald · Anthony Capon · Peter Aitken

Raising awareness of the disease and ensuring access to vaccination for all at risk should be priorities

Joshua R Francis · Jenny M Robson

Rapid access cardiology services may safely divert people with non-cardiac chest pain from being admitted to hospital

Clara K Chow · Adam Timmis

The known: Opportunistic Q fever serosurveys in Australia suggest that it is underreported, but exposure histories have not been collected.

Heather F Gidding · Helen M Faddy · David N Durrheim · Stephen R Graves · Chelsea Nguyen · Penny Hutchinson · Peter Massey · Nicholas Wood

Rapid PCR testing may have several benefits for patients and for the health care system

Nasir Wabe · Ling Li · Robert Lindeman · Ruth Yimsung · Maria R Dahm · Kate Clezy · Susan McLennan · Johanna Westbrook · Andrew Georgiou

The known: Rapid access chest pain clinics (RACPCs), common in the United Kingdom, could improve the management of patients with chest pain in Australia.

James Andrew Black · Kevin Cheng · Jo‐Anne Flood · Garry Hamilton · Serena Parker · Anees Enayati · Faisal S Khan · Tom Marwick

Updated statement reflects significant advances in the past decade

Scott Dunkley · Julie A Curtin · Anthony J Marren · Robert P Heavener · Simon McRae · Jennifer L Curnow

TO THE EDITOR: After a high‐pressure injection injury with an oil‐adjuvant vaccine many patients are triaged exclusively as a needlestick injury. This incomplete classification reduces the likelihood for early identification of local or systemic infections or injury, zoonoses or allergic or anaphylactic reactions.1 A review of European agricultural workers showed that of 59 patients who experienced needlestick injuries, 20 cases (34%) involved oil‐adjuvant vaccines.2 Surgical intervention was reported in only 25 patients (42%),2 contradicting product label directions, which instruct that the wound should be incised and irrigated to remove the vaccine. A similar need for an improved treatment plan was recently articulated after a high‐pressure injection injury from a ruptured hydraulic hose in an Australian farmer.3,4 Oil in water emulsions are commonly used by Australian farmers to vaccinate sheep and goats against Mycobacterium avium subsp. paratuberculosis, which causes the chronic wasting condition ovine Johne disease in ruminants and camelids. The Australian Pesticides and Veterinary Medicines Authority (APVMA) is the independent federal authority that regulates the safe supply and use of veterinary medicines and agricultural chemicals for sale in Australia. The APVMA maintains the Australian Adverse Experience Reporting Program, which is a post‐market program that monitors roughly 5500 reports received annually from product registrants, medical and veterinary professionals, and members of the public. An epidemiological review shows that the peak time of year for high‐pressure oil‐adjuvant injection injuries in Australian adverse experience reports is in spring and summer (October–February), when livestock vaccination programs for young animals are at their peak. Potentially serious long term adverse outcomes, including amputation, are possible without appropriate early intervention as described on the product label.2,3,4 Of the 210 adverse experience reports in humans related to mineral oil injections reported over the life of all registered products, the most common immediate reactions mimicked those of a sharps injury: needlestick injury, a reaction at the injection site, pain and swelling (Australian Adverse Experience Reporting Program data). In order to be prepared for the high volume season for livestock vaccination programs, the APVMA recommends that medical professionals, particularly those serving populations heavily involved with primary production, revisit best practices for the management of this type of injury (Box). Health services are encouraged to include “high‐pressure injection injury” as a triage entry option to reduce the potential misinterpretation of a “needlestick injury” entry.4 Appropriate early intervention reduces the risk of subsequent complications and adverse outcomes. Underpinning the entire process is a need for health care professionals to receive appropriate training to recognise injuries of this type and initiate early intervention as per the product label and the manufacturer's instructions. Box – An example of appropriate triage and treatment for a patient presenting with a high‐pressure injection injury* *The green box indicates the occurrence of an injection incident, based on data from the Australian Adverse Experience Reporting Program. Checkpoint steps in the process that can have a significant impact on patient outcomes if omitted are indicated by orange boxes. † This is the most common formulation for injections containing Mycobacteria

Elvira Currie · Rhian Cope · Margaret C Hardy

TO THE EDITOR: Skin disease contributes to the health disadvantage of Indigenous Australians, and the recent publication of the healthy skin guidelines is welcome.1 Scabies is a significant health problem for some remote Indigenous communities, and the healthy skin guidelines describe a series of community‐based scabies control programs. These programs resulted in initial reductions in prevalence of scabies, but they were not sustained, as human scabies was eventually reintroduced.1 The guidelines used a systematic literature review to ensure that all relevant research was included. However, since the review of scabies was limited to studies of human scabies, implications of canine scabies may have been overlooked.2,3 Therefore, a statement such as “dog control programs are of no benefit to the community control of human scabies infestations” requires scrutiny. Canine scabies mites are distinguishable from human scabies mites by genotyping.4 Clinically, canine scabies can cause a transient human infestation, with no ongoing transmission cycle. The lesions of canine scabies occur primarily on body areas that have been in contact with dogs, and are intensely itchy after a shorter period compared with lesions of human scabies. The infestation is self‐limiting unless the person is reinfested.5 As with human scabies, the intense itch from infestation by canine scabies can lead to scratching and skin trauma, providing an entry point for bacterial infection. Complications such as post‐streptococcal glomerulonephritis and chronic renal disease can also arise from canine scabies. Moreover, outbreaks of scabies in humans can be caused by repeated transmission of canine scabies.5 Management of people affected by canine scabies includes treatment of affected dogs and their contacts.3 Comprehensive dog health programs provide broad‐based community benefits, including reduced injuries from dog attacks, improved community and workplace safety, reduced sleep disturbance from barking and fighting dogs, and enhanced dogs’ appearance, behaviour and wellbeing. Dogs are considered family members in some Aboriginal and Torres Strait Islander communities, sharing housing, bedding and food; hence, human and dog health and wellbeing are intimately linked. No trials have yet examined the impact of dog health programs on scabies transmission in humans or other health outcomes in the remote Indigenous communities where scabies is a public health problem.2 Without evidence from trials, the impact, or lack thereof, of dog health programs on human health is speculative.

Rosalie Schultz

Dr Penny Burns believes GPs and other primary care healthcare workers need to be actively involved on the ground when trouble comes calling

Cate Swannell