Letters

Benjamin C Cowie,* Alan Breschkin,† Heath Kelly‡ * Infectious Diseases Physician, † Senior Scientist, Infectious Disease Serology, ‡ Head of Epidemiology, Victorian Infectious Diseases Reference Laboratory, 10 Wreckyn Street, North Melbourne, VIC 3051. Benjamin. CowieATmh.org.au To the Editor: Hepatitis E virus (HEV) infection is uncommon in Australia. The HEV cases detected are almost always in patients who have recently arrived from HEV-endemic regions of the world.1 We previously reported a significant increase in highly reactive serology results for anti-HEV IgG antibodies measured by enzyme im-munoassay (EIA) at the Victorian Infectious Diseases Reference Laboratory (VIDRL) in the first 6 months of 2004.2 Nine of the 10 Victorian patients with highly reactive samples in the previous report had had a history of recent clinically compatible illness and travel in a disease-endemic region within the incubation period (2–9 weeks). This indicated a strong association between highly reactive anti-HEV IgG measured by EIA and acute HEV infection, as has been shown previously.3 At the time, we hypothesised an association with overseas HEV epidemics, particularly in India, as seven of the nine patients with acute HEV infection had travelled there. We have now reviewed HEV serology results at VIDRL for the subsequent 9 months and compared them with our ex-perience of the past 5 years (Box). In the first quarter of 2005, we recorded the highest quarterly number of highly reactive anti-HEV serology results since testing commenced at VIDRL. Also marked on the figure are the dates, over the same time period, when an outbreak of hepatitis in India (either suspected or confirmed to be caused by HEV) was reported on ProMED-mail, the global electronic reporting program for emerging diseases hosted by the International Society for Infectious Diseases (http://www.promedmail.org). It would appear that epidemic HEV activity in India is reflected in significant increases in the number of highly reactive anti-HEV serology results in our laboratory. In fact, as shown in the Box, increases in highly reactive anti-HEV serology at VIDRL have sometimes preceded an outbreak noti-fication on ProMED-mail, and may provide early warning of such an event. A similar association is not observed for epidemics in other countries. Travellers to developing countries must be advised of preventive measures against HEV and other enterically transmitted diseases, and a diagnosis of HEV infection should be considered in any febrile traveller recently arrived from an HEV-endemic area, particularly if jaundice or abnormal liver function tests are present. This is especially important in pregnant women because of the risk of fulminant hepatitis, with maternal mortality in excess of 20% in the third trimester.4 All cases should be notified to state health authorities. Highly reactive anti-HEV IgG EIA results at VIDRL per quarter, 1 Apr 2000 to 31 Mar 2005. Also marked are confirmed (in bold) or suspected epidemics of HEV in India listed on ProMED-mail* during the same period EIA = enzyme immunoassay. HEV = hepatitis E virus. VIDRL = Victorian Infectious Diseases Reference Laboratory. * Available at <http://www.promedmail.org>.

Benjamin C Cowie · Alan Breschkin · Heath Kelly

Noelene S O'Keefe,* Kristina A Heinrich-Morrison,† Bruce McLaren‡ * Project Officer, Legionella Program, Environmental Health, † Public Health Nurse, ‡ Medical Officer, Communicable Diseases Section, Department of Human Services, 17/120 Spencer Street, Melbourne, VIC 3000. bruce.mclarenATdhs.vic.gov.au To the Editor: A 23-year-old man presented to a Victorian hospital with a 4-day history of fever, rigors, confusion and malaise. A chest x-ray showed left lower-lobe pneumonia, and Legionella pneumophila serogroup 1 antigen was detected in his urine. No respiratory specimens were obtained. He recovered completely after treatment for community-acquired pneumonia, including intravenous ampicillin and oral roxithromycin, and returned to work 16 days after onset. Investigations for the source of the infection included environmental review and sampling of cooling towers near his workplace, home, and other sites visited during the incubation period. Active workplace surveillance prompted testing for and detection of L. pneumophila serogroup 1 urinary antigen in a second employee, a 53-year-old man who had presented 2 days earlier than the patient above to another Victorian hospital with fever, abdominal pain and diarrhoea. Legionellosis was not suspected on presentation. He had no symptoms, signs or radiological evidence of pneumonia. Treatment, including intravenous ampicillin and oral roxithromycin, began when the antigen result was obtained, and he was discharged after 10 days in hospital, although he felt unwell for 2 or 3 weeks after discharge. The two men worked near each other in a welding area. A water tank was placed at the entrance to the area, with the cover left open. This acted as a heat exchange for the welding cooling system. A high count of L. pneumophila serogroup 1 (1300 colony-forming units/mL) was grown from a sample of this water. It was common on hot days to cool the work place with an industrial fan. The open water tank was between the fan and the two employees during the incubation period. No L. pneumophila isolates were found in any linked cooling towers. Remedial action included commencing a disinfection program for the water reservoir, and a request to fit the cover correctly and move the fan. No further cases were detected. Because no clinical isolates were obtained, a direct subtype match between clinical and environmental specimens was not possible. Urine antigens are considered definitive laboratory tests given a compat-ible illness (fever or cough or pneumonia).1 Outbreaks of Legionnaire’s disease and Pontiac fever (legionellosis without pneumonia) with industrial sources other than cooling towers have been reported.2,3 This outbreak demonstrates that a simple change in the environment (adding a fan) and an apparently low-risk source (a warm water bath) have the potential to give rise to significant disease. It also shows the value of active workplace surveillance after a single case.

Noelene S O'Keefe · Kristina A Heinrich-Morrison · Bruce McLaren

Osman Mansoor,* Nick Wilson† * Public Health Physician, Public Health Consulting Ltd, Wellington, New Zealand; † Senior Lecturer, Department of Public Health, Wellington School of Medicine, Otago University, PO Box 7343, Wellington South, New Zealand. nwilsonATactrix.gen.nz To the Editor: How marvellous to see the recent editorial by Zwi and colleagues on Australian overseas aid.1 They elegantly (and disturbingly) make the case for increasing development aid, and more specifically, for AusAID support of health programs. They suggest investments are needed in health and education primarily because we care about other people. But there are many other reasons (including enlightened self-interest) for Australia and New Zealand to increase health development assistance, especially in the South Pacific region.2 One reason for reluctance of donors to provide aid is concern that the aid will not be effective or sustainable. Therefore, we would like to briefly report about a joint Australian and New Zealand aid project that has not only been very successful and effective, but has probably saved the taxpayers of both countries millions of dollars in future costs. The two countries jointly funded a 5-year Pacific hepatitis B project that successfully integrated hepatitis B vaccine into the immunisation program of 10 Pacific island countries. The project provided technical support and 5 years’ funding for hepatitis B vaccine on a reducing scale: from 100% (1996–1998) to 75% (1999) to 50% (2000). Since 2001, the Pacific island countries have taken over the funding of hepatitis B vaccine (as they do for the other Expanded Programme on Immunization vaccines). Thus this short-term intervention has provided sustainable gains in hepatitis B control in the Pacific — one of the areas with the highest rates of hepatitis B infection in the world. An initial evaluation in four Pacific island countries demonstrated reduced transmission as a result of the project. For these four countries, the program was estimated to have reduced chronic hepatitis B virus (HBV) infection among preschool children by 81% (95% CI, 69%–88%), with an estimated cost of US$190 per premature death prevented.3 Reducing HBV transmission in the Pacific is likely to reduce disease transmission in Australia and New Zealand (associated with travel movements and migration). But it will also affect health services, as some people born in Pacific island countries will either become long-term residents of these developed countries or travel there for specialist care. The cost of a single case of chronic HBV infection to a developed country’s health services is likely to cover several years of vaccine cost for many of the smaller Pacific island countries. In summary, Australians and New Zealanders should be proud of this particular project. It supports Zwi and colleagues’ call for much more investment in development assistance in health.

Osman Mansoor · Nick Wilson

Stephen E Cains Medical Director, The Fred Hollows Foundation, Locked Bag 3100, Burwood, NSW 1805. scainsAThollows.org To the Editor: I read with interest the personal perspective by Baker, describing her recent visit as part of an ophthalmic surgical team.1 Such teams from Australia have a long and creditable record of service in the Pacific, and their work has been of great value to the people in the countries involved, and of considerable personal satisfaction to those who have taken part in them. The experience of ophthalmic surgeons working with The Fred Hollows Foundation in developing countries certainly confirms Baker’s observations that the density of the cataracts found in these circumstances commonly makes them unsuitable for phacoemulsification. This does not, however, lead to the conclusion that modern small-incision surgery is not suitable for cataract patients in the developing world. Sutureless small-incision cataract surgery (SSICS) by manual means has been practised in many parts of the developing world for many years, with a range of techniques being used to extract the nucleus without phacoemulsification.2,3 Such techniques have been shown to give better uncorrected vision when compared with standard extra-capsular surgery, and are quick4 and economical, with fewer problems requiring follow-up than extracapsular surgery.5 The Fred Hollows Foundation, along with many other non-government organisations and authorities, is actively teaching and promoting the use of SSICS in its programs as the operation of choice for cataract extraction in the developing world. In light of this, I was surprised to see mention of the introduction of phacoemulsification to the Solomons by the team. Not only is this procedure not suitable for a large proportion of the presenting cataracts, but the cost of equipment and consumables in phacoemulsification is several times that of SSICS, and the time taken for surgery is often longer. In an environment where people suffer vision impairment simply from lack of glasses, and where surgeons are available who can perform modern small-incision sutureless cataract surgery, I wonder if this is an appropriate technology to introduce to the region.

Stephen E Cains

John L Szetu Ophthalmologist, Vanuatu National Eye Care Program, Port Vila, Vanuatu. fhfvaneyeATvanuatu.com.vu To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program. The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”. Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs. The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara. Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams. Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner. Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.

John L Szetu

Michelle L Baker,* Geoffrey T Painter† * Resident Medical Officer, Neurosurgery Department, Royal Melbourne Hospital, 46-58 Drummond Street, Carlton, VIC 3053. † Ophthalmology Coordinator, Royal Australasian College of Surgeons Pacific Islands Project, Melbourne, VIC. michellelouisebakerATyahoo.com In reply: Despite increased efforts over the last decade, the burden of blindness due to cataract is still immense. With over 18 million people in the world blind because of cataract1 there is an obvious need for an affordable and efficient cataract surgery technique. We agree that sutureless small-incision cataract surgery (SSICS) does have an important place in cataract surgery in the developing world. It has advantages over extra-capsular cataract extraction (ECCE) in the longer term, such as decreased cost,2 reduced astigmatism and decreased surgery time.3 There is increasing interest in SSICS among Australian ophthalmologists, and instruction courses are to be held at the forthcoming Royal Australian and New Zealand College of Ophthalmologists meeting. On the other hand, SSICS can be more difficult to learn, and for inexperienced surgeons, there are risks of complications when it is used for a bulky dense cataract.3 ECCE is continuing to evolve, with modern surgical blades giving significantly shelved wounds, which are potentially safer and require fewer sutures, and still has a place. In the Solomon Islands, ECCE and SSICS are the predominant techniques because phacoemulsification is unsuitable for most patients as their cataracts are too dense.3 SSICS was used successfully for suitable cases by Szetu, who is very experienced in the technique. The phacoemulsification machine was brought to Honiara to perform vitrectomy (which the machine is capable of) for diabetic retinopathy in patients who otherwise would have needed expensive treatment in Australia. Phaco-emulsification was purposely used only as a trial (hence, in only three patients), but in the subsequent Pacific Islands Project (PIP) visit, six children with congenital and traumatic cataracts were successfully treated with with phacoemulsification/lensectomy and the insertion of folding intraocular lenses (these were six of a total of 260 operations). In this group it is an ideal technique.4 Currently, it is sustainable to use phacoemulsification because of generous donations. With the advent of low cost phacoemulsification machines (as presented at the Australasian Society of Catar-act and Refractive Surgeons conference in Broome in 2004) and low cost disposables, it is likely the technique will be increasingly used when the backlog of dense cataracts are reduced. Phacoemulsification is the accepted standard of care for cataract surgery in the developed world,2 and there are valid reasons for introducing it into developing countries. Professional development is important, and we must consider the aspirations of our colleagues; the appropriate introduction of phacoemulsification can aid this. We are pleased to hear of Szetu’s return to Honiara, and are sure this technology will have a small, but useful, place in his clinical practice in the future. We cannot agree more strongly that so-called “medical tourism” is wrong. It provides no significant benefit to the community and is disruptive, unhelpful and is, at worst, a burden to the local medical and nursing staff. Unrequested, unhelpful and short-term visits should not be undertaken. The PIP was specifically set up to avoid the abovementioned problems by providing aid that was substantial and well funded (by AusAID), and teaching trips to countries that have made specific requests at the government level for assistance. Such assistance is provided only with the total cooperation and support of local ophthalmic staff, and is run to the highest standards by experienced and committed volunteers. It has been well received in all Pacific countries visited. Ultimately, PIP was intended only as a transitory phase in Pacific development and, as each country achieves self-sufficiency through infrastructure development, visits will be scaled down. We are looking forward to the Solomon Islands regaining the place it once had in Pacific ophthalmology before the civil unrest, and look forward to continuing to help develop the Eye Department in the years ahead. We hope that the close to 1500 operations the PIP team have performed over the eight visits since 2000 have been of help during this troubled time.

Michelle L Baker · Geoffrey T Painter

Graham K Wong,* John W G Tiller† * Psychiatrist, † Professor of Psychiatry, Albert Road Clinic, University of Melbourne, 31 Albert Road, Melbourne, VIC 3004. wonggrahamATmh.org.au To the Editor: We were interested in the recent finding of Simpson and colleagues that a public hospital-based psychiatric assessment service was poorly utilised by general practitioners.1 We established a comparable service in a private setting, with very similar results. In 2002, the senior psychiatry trainee at the Albert Road Clinic (a private psychiatric hospital in Melbourne) established a GP psychiatric assessment service in response to a previously established need.2 The additional aim was to reduce waiting times and patient costs of seeing a private psychiatrist. There were no out-of-pocket expenses for patients. The service was promoted to 300 local GPs with an individually addressed flyer; a notification was published in the local Division of General Practice newsletter; and discussions were held with the local public mental health service to redirect appropriate referrals from GPs. A survey evaluated GPs’ subsequent satisfaction with the service after a patient was referred and seen. Over a recruitment period of 15 weeks, an average of only one patient per week was referred. The referring GPs were happy with waiting times (well within a week), the quality of the service, and the communication received by the assessing senior psychiatry trainee. The similarity between these independently established services and the findings are striking. Of note, was the paucity of referrals from GPs despite clearly expressed needs. We wonder to what extent GPs’ perceptions of difficulties accessing psychiatric assessment from the private sector are the result of a small subset of difficult patients, rather than the general rule. There are numerous GP and psychiatrist-focused initiatives to overcome reported difficulties accessing specialist psychiatric input for GPs. Most recent of these is a new Medicare Benefits Schedule item that increases remuneration for psychiatrists to outline a detailed management plan for the GP to continue care of the patient. The findings of these types of psychiatric services directed at GPs highlight the limitations of GP uptake of such incentives. At the very least, there is a requirement for adequate promotion, education and ongoing reinforcement of the referral model to psychiatrists, GPs and practice managers alike.

Graham K Wong · John W G Tiller

Umberto Boffa Medical Director, BUPA Australia Health Insurance, 600 Glenferrie Rd, Hawthorn, VIC 3122. umberto.boffaAThba.com.au To the Editor: Taylor and colleagues have provided an excellent analysis of the prevalence and causes of vision loss in Australia.1 However, their conclusion that vision loss in Australia is a much bigger problem than is usually recognised and requires “save your sight” public promotion bears some discussion. The main outcome measure used was impairment in visual acuity. Impairment does not necessarily equate with disability. Disability has been defined as an alteration of an individual’s capacity to meet personal, social or occupational demands, or statutary or regulatory requirements, because of an impairment.2 An impaired person is not necessarily disabled. The study of Taylor et al did not use measures of visual disability, such as the VF-14 (Visual Function Index). Participants were asked to complete a questionnaire that included information about “symptoms of eye disease”, but it is not clear that the questionnaire explored self-perceived problems with vision. Nor does the study seem to have looked at the level of cognitive impairment within this aged population. Tielsch et al, in a similar study,3 made the point that whether people who have both a treatable loss of vision and cognitive impairment should receive ophthalmological intervention depends on the cause and severity of the cognitive deficit. Further, Taylor and colleagues stated that, after undercorrected refractive error, cataract is the most common cause of low vision and is also comparatively easily treated, but they did not objectively evaluate the relative risks and benefits of such interventions. The study provides interesting data on the extent of visual impairment in Australia, but the authors are presupposing that the uncovered prevalence of visual impairment necessarily constitutes a social problem requiring “save your sight” public health measures. Reference should be made to patient goals and needs, and an objective cost–benefit analysis, before such a conclusion can be reached.

Umberto Boffa

Konrad Pesudovs,* Douglas J Coster† * Deputy Director, † Director, NHMRC Centre for Clinical Eye Research, Department of Ophthalmology, Flinders Medical Centre and Flinders University, Bedford Park, SA 5042. Konrad. PesudovsATflinders.edu.au To the Editor: The timely report of Taylor and colleagues of large numbers of Australians suffering visual impairment caused by refractive error raises some important questions.1 Firstly, is it reasonable to assume that visual acuity of less than 6/12 is disabling and demands intervention? The correlation of visual acuity and visual disability is tenuous.2-4 This is not surprising. Visual acuity measures a narrow domain of visual function. Different abnormalities differentially impact across wide domains of visual function. Everyday sight-dependent functions will be affected differently. For example, people with cataracts may experience reduced contrast sensitivity and colour discrimination, while those with advanced glaucoma will lose visual field, but those losses will affect a person’s life independent of visual acuity. Conversely, myopia acquired in old age may reduce visual acuity to less than 6/12 but may also provide spectacle-free near vision adequate for reading and other daily tasks. This may not cause any disability for an elderly person whose life is spent predominantly indoors. Therefore, it seems inappropriate to assume that the 62% of people with visual impairment caused by refractive error suffer visual disability to the extent of those with glaucoma or age-related macular degeneration. A better approach to measuring visual impairment would be to use patient-centred measures, which consider the impact of eye disease on visual performance, rather than the convenient but narrow measure of visual acuity. If visual acuity is to be used, its limitations as an indicator of visual disability should be considered, and inferences about visual impairment should remain constrained by these limitations. The second question which follows from the report that uncorrected refractive error is responsible for 62% of visual loss below 6/12 is: why do people so affected not wear spectacles? Perhaps there are barriers to acquiring spectacles, such as access. However, this seems unlikely as there is an optometrist in every major shopping centre. Certainly, cost may be a barrier, and a study from our Centre has shown that spectacle correction may reduce quality of life in the domains of wellbeing, convenience, and economic concerns.5 Therefore, it seems likely that the cost–benefit balance is such that these people are not sufficiently dis-abled by their vision to go to the inconveni-ence and expense of acquiring spectacles. The authors have raised important issues which require clarification. Is it that visual acuity overestimates the impact of refractive error on visual disability, or is the system for supplying spectacles to Australians failing?

Konrad Pesudovs · Douglas J Coster

Jill E Keeffe,* Hugh R Taylor† * Director, Population Health Division, Department of Ophthalmology, University of Melbourne, and Royal Victorian Eye and Ear Hospital, Locked Bag 8, East Melbourne, VIC 8002; † Professor, Centre for Eye Research, University of Melbourne, VIC. jillekATunimelb.edu.au In reply: Boffa and Pesudovs and Coster all correctly point out that a reduction in visual acuity does not always lead to dis-ability, and that not all people with impaired vision are disabled or report impaired quality of life. Large Australian and American population-based studies have shown that visual acuity below a critical level of 6/12 is associated with disability and affects participation in chosen activities and quality of life.1 When compared with people with normal vision (≥ 6/12), those with impaired vision have an increased risk of falls and hip fractures, depression, difficulties with activities of daily living and social functioning.1 Not all people with reduced visual acuity are affected in the same way at any vision threshold, even if there is a demonstrated statistically significant association between poor vision and visual function and quality of life. For example, not all people with severe visual impairment (visual acuity < 6/60) report an impact on their own visual functioning or quality of life. The impact of poor vision on functional ability is similar for conditions such as cataract or acute macular degeneration as for refractive error. The impact has been shown with both correctable and uncorrectable vision impairment.2 The VF-14 (Visual Function Index) can be used as a measure of visual disability, as suggested by Boffa. It was used in the Melbourne Visual Impairment Project and confirmed the functional implications of vision impairment (visual acuity < 6/12).3 Studies show unequivocally that vision impairment is a social3 and economic4 problem, and suggest the need for health promotion campaigns. Pesudovs and Coster ask why, in a country such as Australia, with optometrists “in every major shopping centre”, do people with refractive error not have the correct spectacles? They suggest some barriers of access to care. The Brotherhood of St Laurence has shown that affordability of glasses and rural disadvantage are barriers to access and equity of use of eye care services.5 Our report highlighted the fact that catar-act is an important cause of vision loss that is highly amenable to surgical intervention.6 We did not discuss the relative risks and outcomes of cataract surgery, which is well documented to be highly successful, with low complication rates (< 2% for most complications),7 and very high cost-effectiveness.

Jill E Keeffe · Hugh R Taylor

Heather Cleland Director, Burns Unit, The Alfred Hospital, Commercial Road, Prahran, VIC 3181. burnsunitATalfred.org.au To the Editor: While mention is made in the recent position statement1 of the inappropriateness of home oxygen use in association with continued smoking, I wish to highlight the fact that the dangers of this activity — and indeed of any open flame in proximity to oxygen delivery units — constitutes significantly more than a theoretical hazard. In the past 4 months, the Victorian Adult Burns Service at The Alfred Hospital, Melbourne, has admitted two patients with severe burns sustained in fires caused by smoking in association with domiciliary oxygen use. Both these patients died of their burn injuries, and the cases have been reported to the coroner. I am aware of at least one other fatality that occurred under similar circumstances in the same time period in Victoria. If patients or people living with them continue to smoke, oxygen therapy should be withdrawn. I also suggest that the position statement should emphasise the need for adequate and regular domiciliary assessments of people using this therapy and the importance of ongoing education about the dangers of oxygen use in association with any open flame.

Heather Cleland

Peter M Herriot OACIS Clinical Sponsor, Noarlunga Health Services, Alexander Kelly Drive, Noarlunga Centre, SA 5168. herriot.peterATsaugov.sa.gov.au To the Editor: Readers may be interested to learn of an SMS notification system introduced in South Australia to facilitate the retrieval of cornea donations. The South Australian Department of Health has recently completed the 5-year implementation of its “careconnect.sa” clinical information system (formerly known as the OACIS program), a system which supports clinical activities across the eight major Adelaide metropolitan public hospitals.1 A relatively simple and inexpensive enhancement to the system has been the use of short message service (SMS) text messaging to notify the Eye Bank of South Australia of a potential corneal donor. Following the recording of an inpatient death in the hospital patient administration system, an SMS death notification comprising the relevant medical record number, hospital location and time of death is automatically generated by the OACIS gateway and sent to selected recipients, including the Eye Bank of South Australia. Staff can then check the potential donor’s clinical details online via OACIS to obtain accurate information on the person’s suitability as a donor and also to cross check the National Organ Donor Registry to determine whether the person is registered as a donor. Before SMS notification, Eye Bank staff made many calls daily to the major public hospitals to obtain information on recent deaths. Medical or nursing staff would then sift through the medical record to determine whether the patient might be a potential donor and to obtain next-of-kin details. SMS notification has resulted in less disruption to hospital staff, as well as considerable time savings. The whole process of retrieval is now easier and timelier. The actual number of corneal retrievals has increased since the introduction of the new SMS notification system. There has also been a substantial reduction in the number of corneal transplants postponed because no cornea was available. Donations are now retrieved earlier and more efficiently. The development of the system also corresponds with a shift to South Australia becoming a net exporter of corneal tissue. The SMS notification system demonstrates how relatively simple information and communications technology can be applied to make a substantial impact on clinical practice and outcomes.

Peter M Herriot

Peter C Arnold Former General Practitioner, PO Box 280, Edgecliff NSW 2027. peterATarnold.name To the Editor: Schofield and Beard,1 discussing demographic shifts among doctors, raise the spectre of “workforce shortages within the next 5 years”. For decades, Australian health authorities have used various proxy indicators, ranging from Medicare utilisation to World Health Organization and other comparative data, to deny the existence of shortages of doctors. Based on those faulty premises, government policies have aggravated these shortages. The Oxford English Dictionary defines a “shortage” as “a deficiency”. For many years, there have been deficiencies in services provided by Australia’s doctors, including, among others: General practitioners available for house calls and visits to nursing homes; working past 6:00 pm on weeknights or on Saturday mornings; available at nights and on weekends; offering prompt appointments; and being available in locum tenens. Specialist initial consultations within a week or two, especially dermatologists, oncologists, neurologists, and, more recently, neurosurgeons and obstetricians. And all this in our cities and large towns. The sho rtages of all medical personnel in rural and remote areas has long been obvious. Our current reliance on overseas-trained doctors is undeniable proof of the existence of those shortages. For more than three decades, the general practice “positions available” advertisements in the medical newspapers have far outnumbered advertisements from doctors seeking GP positions.2 None of the proxy indicators of workforce adequacy, so beloved of politicians and bureaucrats, can rival the plain truth that the supply of doctors, probably in every field of medicine and in every region of Australia, is plainly insufficient to meet reasonable demand, and has been so for at least 30 years.

Peter C Arnold

Graham D Hocking Child Psychiatrist, 25 High St South, Kew, VIC 3101. ghockinATiprimus.com.au To the Editor: Catto-Smith gives a very good account of the medical management of constipation and soiling in children,1 but fails to mention psychological, interpersonal and social factors in the main part of his article. He does mention “behavioural abnormalities” towards the end, in the section “When to refer”. I think it is generally accepted among paediatricians and child psychiatrists that the problem of constipation and soiling, or encopresis, often has multiple determinants and varied psychological effects on the child and the family. Certainly, the older the child is, the more likely these effects will be present.2 If this condition is to be managed in general practice over a period of “6–12 months”, general practitioners need to be aware of these factors so they can be addressed. Twelve months is a long time in the life of a 5 year old, and in that time pathological patterns can become well established and hard to shift. Most children over 5 years with soiling have developed secondary psychological problems as a result of the soiling.3 At this stage, assessment by a child psychiatrist will often reveal that the child has developed a pathological fantasy world around what they believe is happening inside them. The physical management of constipation and soiling is an essential part of the management no matter what the aetiology, but addressing the psychological interpersonal and social factors is equally important. If these factors are obvious to the GP and are not responding to intervention, the family should be referred to a child psychiatrist. With children over 5 years, the secondary effects have almost always become significant, and I believe that all these families should be referred for assessment. Catto-Smith quotes a 30%–50% relapse rate,1 and “there is evidence that they do not improve on reaching puberty”. This is not my experience with families that have the benefit of a multidisciplinary approach to the disorder.

Graham D Hocking

Anthony G Catto-Smith Director, Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052. tony.cattosmithATrch.org.au In reply: Hocking emphasises secondary behavioural and emotional effects that occur in some children with longstanding faecal soiling. Fortunately, there is good evidence that these tend to resolve with effective multimodal treatment of the constipation.1 The relatively high long-term relapse rate of soiling among children who have been treated in tertiary centres has only recently been recognised,2 but the psychological features of this relapsing group are not well defined. My review was directed toward general practitioners and was as much as possible evidence-based. I am unaware of any good quality evidence to support Hocking’s assertion of the benefits of automatic referral to a child psychiatrist of all children over the age of 5 years with ongoing faecal soiling. Given the beliefs of both myself and Hocking, that constipation and soiling are likely to have multiple determinants and varying psychological effects, it would seem to be appropriate to triage “problem” patients through a general paediatrician, with referral for psychological assistance if deemed appropriate. This is best summed up in my article in the section that Hocking mentions, “When to refer”.3

Anthony G Catto-Smith

Preeti Sachdev,* Simon Chapman† * Postgraduate Honours Student, † Professor, School of Public Health, University of Sydney, NSW 2006. simonchapmanAThealth.usyd.edu.au To the Editor: Smokeless tobacco products (with the possible exception of Swedish “snus”1) are carcinogenic.2 They cause oral cancer, sometimes rapidly (within 7 years of use).3 A pinch of smokeless tobacco held in the mouth for 30 minutes delivers as much nicotine as 3–4 cigarettes.4 Sachet of smokeless tobacco In Australia, the sale of smokeless tobacco was first banned in 1986, in South Australia.5 Thereafter, all states enacted legislation outlawing its sale, and, in 1991, an amendment to the federal Trade Practices Act 1974 banned the manufacture, importation and commercial supply of the products.6 Nevertheless, permits to import smokeless tobacco for personal use were issued on application, and, in March 2002, an amendment to the federal Customs (Prohibited Imports) Regulations 1956 allowed importation without a permit of amounts up to 1.5 kg for personal use.7 Between September 2000 and March 2002 (when permits were still required for all importations), 2270 permits were issued, while between March 2002 and December 2004, a further 88 permits were issued for amounts exceeding 1.5 kg (Mr Tim Pulford, Australian Competition and Consumer Commission, Canberra [which administers permits], personal communication). Following observations of smokeless tobacco being sold in south Asian shops in Sydney, New South Wales, we sought to assess its availability. We selected 14 Sydney suburbs with large populations of residents from south Asia (defined as the Indian subcontinent), and surveyed all south Asian mixed businesses in the shopping precincts of these suburbs in March 2005. If no smokeless tobacco products were displayed, the person serving was asked if they had any “paan masala or guthka” (Hindi expressions for smokeless tobacco) for sale. Fifty of the 53 shops surveyed (94%) sold smokeless tobacco: 31 (62%) of these kept it under the counter, 14 (28%) on display behind the counter, and five (10%) on shelves accessible to consumers. No shopkeeper advised that sale of the products was illegal. The prevalence of “under the counter” storage suggests widespread awareness that it is illegal to sell the products. The federal Customs (Prohibited Imports) Regulations do not restrict the number of times a person may import up to 1.5 kg of smokeless tobacco for personal use without a permit. A typical sachet of guthka (Box) weighs 4.6 g, meaning that around 320 sachets could be legally imported for personal use. It would be entirely legal for a shopkeeper and each family member to import up to 1.5 kg on a daily basis if it was intended for personal use. Diversion of this into retail trade appears easy. The ease with which we were able to obtain smokeless tobacco suggests that the law prohibiting sale is not being enforced. The New South Wales Public Health Act 1991 empowers officers, such as environmental health officers, to investigate breaches of the Act. These officers should undertake surveillance of the readily identifiable shops in the manner that we did, confiscate the products being sold and warn that future sales will result in prosecution.

Preeti Sachdev · Simon Chapman

Chris E Rissel Clinical Associate Professor, School of Public Health, University of Sydney, Level 9, King George V Building, Missenden Road, Camperdown, NSW 2050. crissATemail.cs.nsw.gov.au To the Editor: The editorial by Sharman about exercise and air pollution1 makes the point that cars contribute substantially to air pollution, and air pollution is known to have adverse health effects. Therefore, Sharman posits that exercise, which is unequivocally good for human health, is best done away from sources of air pollution. This “common-sense” maxim to avoid air pollution when exercising is superficially reasonable as far as it goes, but is a very weak response to the health and social problems generated by motor vehicles or the need for increased levels of physical activity in the population. With only half the Australian population achieving adequate levels of physical activity,2 recommendations to patients to be more physically active are essential. To simultaneously promote exercise and then put a health warning on this physical activity effectively undermines the recommendation. Part of the difficulty in judging the actual risks from air pollution and benefits of physical activity is that the science of pollutant exposure is not well understood at the individual level. It is not currently possible to say that exercising in a particular environment will have a net negative effect. Thinking laterally, perhaps physical activity even boosts the immune response in a way that helps the body resist adverse effects of air pollution? Perhaps only under more extreme conditions would outdoor activities need to be curtailed. One body of relevant research that Sharman did not consider is the research on pollutant exposure by travel mode, which clearly indicates that car drivers and passengers have pollutant exposures at least twice that of pedestrians walking on the same street.3,4 The longer people sit in cars, the greater their exposure to air pollutants, not to mention the increased risk of obesity.5 Therefore, a highly sensible approach is to recommend to patients that they avoid travelling in cars, particularly if the patient is sensitive to air pollutants or if traffic is congested. The most obvious common-sense solution to reduce air pollution and increase individual and population levels of physical activity is to recommend to patients that they replace short car trips with walking or cycling. As little as two 15-minute active transport trips per day can achieve recommended levels of physical activity to maintain health. It is possible to change travel behaviour, and this is a far better recommendation for all patients than telling them not to exercise near traffic.

Chris E Rissel

Louis A du Plessis Former Senior Lecturer, School of Applied Science, Riverina–Murray Institute of Higher Education, Wagga Wagga, NSW (retired). eldupeATbigpond.com To the Editor: Health professionals in the Sydney Greater Metropolitan Region have been found to be less aware of air pollution and its health effects than are patients susceptible to such effects.1 Therefore Sharman’s brief review of the harmful effects of air pollution is welcome.2 In offering advice on how to minimise the exacerbation of pollution-induced harm by exercise, Sharman concentrates on the spatial distribution and temporal variation of traffic. The advice is sound for the metropolitan population, but incomplete for non-metropolitan residents exposed to smoke from burning biomass. Australia’s National Environment Protection Measure defines limits for inhalable particulate matter suspended in ambient air (PM10). The NSW Department of Environment and Conservation operates a network of monitoring stations to measure PM10 and other pollutants, and posts the results daily on its Internet site <www.epa.nsw.gov.au/index.htm>. The National Environment Protection Measure requires environmental authorities to work towards reducing the number of days on which PM10 exceeds the daily limit to no more than 5 days per year. This goal is far from being realised in some places. One such place is Wagga Wagga, NSW, where monitoring of PM10 started on 11 April 2001. From that date up to 6 July 2005, the city experienced 118 days on which PM10 exceeded the limit, as well as many days of pollution near but below the limit. In the same period, monitoring stations in the Sydney Greater Metropolitan Region registered between 11 and 33 days of excess PM10. Of the 118 days of above-limit PM10 in Wagga Wagga, 30 occurred in the period from 30 October 2002 to 26 January 2003, when there were severe bushfires in south-eastern Australia. Most of the rest had a cause that is very evident in the surrounding countryside in autumn — the burning of paddocks to prepare them for sowing. Rural residents’ health is worse than urban residents’ health for many reasons, but biomass burning is not widely recognised as one of them. The Australian Medical Association’s Rural Reference Group, which is being convened to improve rural health,3 may wish to add environmental health to its agenda. There are two steps that the Group could take to lessen the effects of smoke from burning biomass. The first is to acquaint rural doctors with information such as that presented by Sharman. The second is to persuade the Department of Environment and Conservation and NSW Health to issue rural health warnings based on the continuous, real-time output of PM10 monitors in regional centres.

Louis A du Plessis

James E Sharman Postdoctoral Research Fellow in Cardiovascular Physiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102. jsharmanATsoms.uq.edu.au In reply: As emphasised in my editorial, regular aerobic exercise is to be encouraged, as it is of undeniable benefit to health.1 The crux of the intended message was for people to undertake an exercise program, but not near busy roads. There was no suggestion to curtail outdoor activities. Although the effect of traffic pollution on an individual is not well understood, there are many hundreds of scientific papers consistently finding that whole automotive pollution, or components thereof, damage biological tissue and promote disease.2 The World Health Organization recognises urban air pollution as a major risk to human health, with exposure to particulate matter alone accounting for an estimated 800 000 deaths a year globally.3 Would it be ethical to confine this information to the annals of scientific literature, or should some attempt be made to inform those who may be unknowingly and unnecessarily exposing themselves to veritable risk? People should have access to all the available information so that they can make an informed decision on where to exercise. Not only is it common sense, but it is entirely reasonable to suggest that people would be better off avoiding exercise alongside roadways congested with traffic. Quite separate to the question of exercising beside busy roads, but equally important from a health perspective, is the issue of persistently high ambient levels of particulate air pollution in certain regions. The air quality problem encountered in Wagga Wagga is exacerbated by geographical and climatic factors that encourage entrapment of air pollution, owing to a temperature inversion layer that is particularly apparent during winter. Other cities, such as Launceston, Tasmania, suffer the same fate and, in both cases, smoke from domestic wood-heaters is thought to be the biggest contributor to poor air quality. What are people to be told regarding exercise in these regions? It may be reasonably argued that habitual exercise in such environments would be detrimental to health, but it would be a very poor public health outcome if people were advised to stop exercising. In the affected areas mentioned, community education programs have been in existence for years, but these appear to be of limited value, as daily air pollution limits are regularly exceeded,4 as highlighted by du Plessis. Although unpopular, the answer lies in stricter regulations to clean the air, such as banning wood-heaters and tighter monitoring of rural burning.

James E Sharman

Robert D Goldney Professor of Psychiatry, University of Adelaide, The Adelaide Clinic, 33 Park Terrace, Gilberton, SA 5081. Robert.goldneyATadelaide.edu.au To the Editor: Two recent items in the Journal might potentially lead to misinterpretation of the evidence on managing depression in young people. The first was the book review entitled Darker side of “wonder drugs” by Jureidini1 in which there was no disclosure that the author of the review is president of Healthy Skepticism, a body which has been quite strident in its opposition to antidepressant therapy. The second was the unattributed comment in the editorial by Rey and Dudley describing “parents who believe their children killed themselves because they were taking SSRIs [selective serotonin reuptake inhibitors] . . .”,2 which may imply subtly that this has occurred frequently. In a review of the United Kingdom General Practice Research Database of more than three million people,3 there were no suicides among the 6976 aged 10–19 years who had been prescribed one of two SSRIs or two tricyclic antidepressants; however, 15 people in that age group who had not received an antidepressant drug died by suicide. Furthermore, in a review of 14 857 suicides in Sweden, of the 52 involving people under 15 years, no SSRIs were detected, and in the 15–19-years age group, those taking SSRIs had a lower relative risk of commiting suicide than those taking other antidepressants.4 Clinicians with responsibility for children and adolescents can be reassured by these data, and also by the fact that the American Food and Drug Administration “black box” warning (their most potent warning) about antidepressants has recently been modified.5 Furthermore, the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association have provided a new resource about the use of medication in treating childhood and adolescent depression,6 which has been endorsed by over a dozen United States organisations comprising a “national coalition of concerned parents, providers, and professional associations”. This should allay questions that have rightly been raised, but that have been answered in favour of the judicious use of antidepressants, along with other therapeutic measures for children and adolescents with severe depression. In view of the strong association between child and adolescent mood disorders and suicide,7 the above research findings and the recommendations of respected professional bodies raise the issue of potential legal action for not at least trialling antidepressant medication in young people with severe depression if non-pharmacological measures are ineffective.

Robert D Goldney

Peter R Mansfield,* Melissa K Raven,† Jon N Jureidini‡ * Research Fellow, University of Adelaide, SA; † Lecturer, Flinders University, Adelaide, SA; ‡ Head, Department of Psychological Medicine Women's and Children's Hospital, Adelaide, SA. peter.mansfieldATadelaide.edu.au To the Editor: Rey and Dudley cite clinical experience as the basis of their recommendation of selective serotonin reuptake inhibitors (SSRIs) — chiefly fluoxetine — for youth with severe depression plus severe impairment or failure of non-drug therapy.1 They do not discuss the evidence on efficacy because they claim that it is “ambiguous enough for scholars to be divided”. It is true that industry-funded scholars are continuing to suggest that SSRIs (chiefly fluoxetine) provide a worthwhile benefit.2 However, the evidence is unambiguous. The four published comparisons of fluoxetine versus placebo for children and adolescents have all been negative on their pre-specified primary endpoints.3,4 A tiny average benefit is likely, but the magnitude of this benefit is unlikely to exceed the magnitude of less frequent but more severe harms. Furthermore, the common clinical impression of worthwhile benefit is to be expected given the large average improvements seen in placebo groups. Rey and Dudley speculate that psychosocial treatments may be less effective with uncooperative teenagers.1 However, that group may also be at higher risk of the dangers of intermittent use of, and overdosing with, antidepressant drugs. Rey and Dudley cite Timimi’s critique of the concept of childhood depression5 as supporting “treating depression primarily as a moral or social problem”. However, Timimi did not even allude to depression as a moral problem, and advocated a multi-perspective approach that normalises emotional responses to adverse life experiences and includes interventions addressing biological factors, such as diet, exercise, and cognitive abilities. Rey and Dudley use a related straw-man argument in their final sentence when they suggest that the only alternatives to SSRIs are tricyclic antidepressants, victim blaming, and non-treatment. Rey and Dudley deny being influenced by the gifts and funding that they have received from drug companies. There is compelling evidence that gifts and funding are effective, on average, for influencing beliefs, especially among people who have an illusion of invulnerability.6 We are not aware of any way that any individual can know that he or she has not been influenced.

Peter R Mansfield · Melissa K Raven · Jon N Jureidini

Joseph M Rey,* Michael J Dudley† * Professor, Psychological Medicine, University of Sydney, PO Box 142, North Ryde, NSW 1670. † Senior Lecturer in Psychiatry, University of New South Wales, Randwick, NSW. jreyATmail.usyd.edu.au In reply: The data available are inconclusive, but suggest that treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the short-term (less than 14 weeks) risk of suicidal thoughts or self-harm in children and adolescents slightly, by about 2%. However, SSRI treatment may actually decrease the number of completed suicides,1 as Goldney also highlights. To show whether SSRIs influence the risk of completed suicide, a rare event, requires a randomised trial including up to two million individuals.2 This will not happen. Hence, clinicians must rely on accumulated data from experimental, epidemiological, and observational studies. Disagreements about interpretation will doubtless continue. In response to Mansfield and colleagues, we personally know of media reports influencing some practitioners to revert to using tricyclic antidepressants, and child psychiatrists to avoid treating depressed adolescents. We do not shrink from our interpretation of the implications of Timimi’s reconceptualisation of “depression” as “unhappiness”. Regardless of how childhood depression is classified or named, we remain concerned that the impetus for clinicians to diagnose and treat it not be lost. Its social correlates include stigma and racism, which often involve seeing mental health problems as moral failures of character. Our view is that fluoxetine shows a favourable harm–benefit profile in moderate to severe depression. According to the Treatment for Adolescents with Depression study,3 which was not funded by drug companies, four children need to be treated with fluoxetine for one to show much or very much improvement attributable to medication. This compares with having to treat 21 children for one to display a widely defined harm-related event. The numbers improve further when fluoxetine is combined with cognitve behavioural therapy (3 and 50, respectively). Pending new studies, clinicians would be unwise to ignore these data when treating serious depression in young people, a recurring illness that produces much suffering, physical and psychosocial disability, and suicide (odds ratio estimates ranging from 11.0 to 27.0).4 Our opinions are consistent with those of the recently released joint clinical guidance by the colleges of psychiatrists, general practitioners, and physicians.5 Mansfield and colleagues suggest that our editorial’s content might have been influenced by drug company gifts. We provided the educated readers of the Journal with information to judge this for themselves.

Joseph M Rey · Michael J Dudley

Duncan Topliss Chairman, Adverse Drug Reactions Advisory Committee, Therapeutic Goods Administration, Department of Health and Ageing, Canberra, ACT 2601. adracAThealth.gov.au Comment: Three essentially independent reviews of the use of selective serotonin reuptake inhibitor (SSRI) antidepressants in children and adolescents have been undertaken in Australia in the past 9 months.1-3 The review by the Adverse Drug Reactions Advisory Committee1 had input from representatives of the Royal Australian and New Zealand College of Psychiatrists and the Division of Paediatric and Child Health, Royal Australasian College of Physicians (RACP). All three reviews noted the paucity of information to support the efficacy of these and other antidepressants in children and adolescents, and the frequent observation of increased suicidal thoughts and self-harm in clinical trials. The colleges’ review2 and the National Prescribing Service Rational Assessment of Drugs And Research (RADAR) review3 support the ADRAC advice that: Any use of SSRIs in children and adolescents with MDD [major depressive disorder] and other psychiatric conditions should be undertaken only within the context of comprehensive management of the patient. Management should include careful monitoring for the emergence of suicidal ideation and behaviour which may particularly develop early in therapy, or if therapy is interrupted or irregular because of poor compliance. Cognitive behaviour therapy, if it is available, may enhance the outcome in MDD. An SSRI should be chosen for a child or adolescent with MDD or other psychiatric condition only after taking into account the recent evaluations of clinical trial data and the Australian product information. Prescribers should be aware that the marketers of fluvoxamine and sertraline (indicated for obsessive compulsive disorder) advise against their use in children and adolescents with MDD, and the marketers of citalopram, escitalopram, paroxetine, venlafaxine and fluoxetine warn or caution against their use in patients aged less than 18 years for any indication. It is important to note that children and adolescents who are being treated for MDD with an SSRI should not have their medication ceased abruptly.

Duncan Topliss

Gordon R W Davies Psychiatrist, 33 Smith Street, Wollongong, NSW 2500. alienistATihug.com.au To the Editor: The recent editorial by Andrews1 quotes a report suggesting that the integration projects funded by the Australian Government produced substantial benefits to patient care at no extra cost. Working in an area in which one of these projects was funded, I suggest that such an inference is unwarranted, particularly as many patients report increased difficulty in accessing public mental health services. The Illawarra, being geographically circumscribed and with a relatively small medical population, has always had a high degree of interaction between services, although it is true to say that these have somewhat declined in recent years with larger bureaucracies and increased privacy concerns. In my early days in the area, there was a monthly meeting involving police, Youth and Community Services, the Housing Commission, school counsellors, and hospital and community social and mental health workers to coordinate the management of problem families. Sadly, this no longer occurs. Unfortunately, the major effect of the integration project was simply to add a management structure to the prior interaction, and not to significantly increase it. It seemed that the core issue was control and not service provision. Useful coordination projects, such as some commonality of core records, never seemed to happen, and with the passing of the project, things have, in fact, been worse, as fundamental community services such as the crisis team and chronic care components have been cut. I have always been a strong supporter of a more integrated approach to care, but one that does not grow primarily from the workers involved in day-to-day clinical care and that addresses their needs is unlikely to be lasting and successful.

Gordon R W Davies

Andrew S Kemp Professor, Allergy Immunology and Infectious Diseases, The Children’s Hospital at Westmead, Locked Bag 4001,Westmead, NSW 2145. andrewk5ATchw.edu.au To the Editor: Publicity such as that on the recently televised “Sunday” show (Channel 9) entitled “When food can be fatal” (http://sunday.ninemsn.com.au/sunday/cover_stories/transcript_1770.asp), which contained statements that “30 in every 1000 [3%] children in Australia are at risk of a severe allergic reaction [anaphylaxis] to a food”, and a reference to a “tsunami of children” with serious allergies, provokes understandable concern and anxiety. Some perspective on this issue is required. To determine the risk, it is essential to study a population-based cohort. Allergies to peanuts or tree-nuts are the most common cause of severe childhood food anaphylaxis and death.1 What is the risk for Australian children of peanut-induced anaphylaxis that is likely to require adrenaline? Of a population-based cohort of 456 Tasmanian children aged 7–8 years, none reacted to a peanut skin-prick test.2 In the Australian Childhood Asthma Prevention Study (CAPS),3 a high-risk cohort, 4.9% of 3 year olds were prick-test positive to peanut (unpublished data) using a liberal cut-off of ≥ 2 mm (for clinical testing the usual cut-off is ≥ 3 mm). Perhaps the most helpful information comes from a population-based study of 13 971 preschool children in the United Kingdom who were followed from birth to 6 years of age. Forty-nine (0.35%) children had an allergic reaction to peanut, of whom only two (0.014%) had what was described as anaphylaxis.4 Thirty-six of the children underwent formal peanut challenge, 23 reacted and three had reactions for which adrenaline was given. Combining these three with the previous two gives a severe reaction rate requiring adrenaline of 0.036%. This suggests that, of the 49 children in the UK study who had an allergic reaction to peanut, only 10% were at risk of a severe reaction requiring adrenaline. Only a third to a half of children with a positive peanut skin test will react if exposed.5 Applying these considerations to Australian children indicates that the proportion at risk of a severe peanut reaction is only 0.25% (4.9% × 1/2 × 5/49) even in a high-risk cohort such as the CAPS. This would be substantially lower in a population-based cohort. For the cohort of 7–8-year-old Tasmanian children referred to above, the risk would be much less than 0.2%, considering none of 500 children was prick-test positive to peanut allergen. There has been a substantial increase in childhood food allergy in recent decades;5 however, sensationalist statements and inaccurate figures are unlikely to be helpful in developing appropriate responses. The Australasian Society of Clinical Immunology and Allergy recently published guidelines for the prevention of food anaphylactic reactions,6 and has other useful information for patients and medical practitioners on its website (http://www.allergy.org.au/).

Andrew S Kemp