Letters

Gordon Broderick Executive Director, Distilled Spirits Industry Council of Australia, 1st Floor, 117 Ferrars Street, South Melbourne, VIC 3205. gordonbATdsica.com.au To the Editor: In their article on risk-taking behaviour among young Australian women, Carr-Gregg and colleagues make a number of statements about alcohol consumption among young women.1 Unfortunately, these statements are not supported by the facts. The authors assert, citing a national study of 14 762 women aged 18–23 years,2 that “seventy percent of young women engage in ‘binge drinking’ (5 or more drinks on one occasion) at some time, with 19% doing so on a weekly basis”. The level and frequency of alcohol consumption that constitutes “binge drinking” is a matter of conjecture. The National Health and Medical Research Council (NHMRC), in guidelines released in 2001,3 state that “binge drinking” is “not a preferred term due to its lack of consistent and specific meaning”. The NHMRC guidelines on short term risk specify 5–6 alcoholic drinks for a female on any one day as being “risky” for health, and 7 drinks or more being “high risk”. For long term risk, 3–4 drinks on an average day, or 15–28 drinks a week, is considered “risky”, with any more constituting “high risk”. Applying these guidelines to the Women’s Health Australia dataset shows that 5.1% of young women engage in drinking that is “risky” or “high risk” in the long term. Of the remaining 94.9%, 14.4% drink 5 or more drinks weekly or more, and 51.9% drink five or more drinks monthly or less. This is a more revealing (and accurate) picture than the blanket statement that “70% of young women are ‘binge drinkers’ ”. Carr-Gregg and colleagues also claim that “22% of females aged 14–19 years drink between 9 and 30 alcoholic drinks a day”. The source for this statement is a survey conducted for the Salvation Army.4 The survey has several limitations, not least the small sample size. The survey sampled 614 respondents, of whom 70 were aged 14–19 years. The assertion that 22% of females in this age category were “binge drinkers” is based on just seven respondents. This number is well below what is required for any reliable statistical estimation. Encouraging responsible drinking among younger people is a major goal of health professionals and the alcohol industry. A constructive policy debate on this issue requires sound, objective evidence about alcohol consumption among younger people. The article by Carr-Gregg et al does not represent progress towards providing that evidence.

Gordon Broderick

Alex J Chamberlain,* John W Kelly† * Registrar, † Head, Victorian Melanoma Service, The Alfred, Prahran, VIC. alex_chamberlainAThotmail.com To the Editor: Janda and colleagues’ survey of skin screening by general practitioners in regional Queensland1 demonstrated that only 20% of participants had undergone a total-body skin examination in the previous 3 years and that examination rates were slightly lower for patients 50 years of age and older. They conclude that those at greatest risk (older people, especially men) will need to be targeted if screening programs are to reduce melanoma mortality. In the same issue of the Journal, a study by English and colleagues of excisional biopsies of pigmented lesions by Perth GPs showed that the excision rate for patients under the age of 50 years (62%) is nearly twice that for patients over 50 years (38%), and that in the younger cohort this is primarily harvesting benign naevi.2 They conclude by encouraging GPs to increase their suspicion and lower their biopsy threshold in older patients in order to detect more melanomas. These studies serve to remind us that it is predominantly older people (and especially men) who are at greatest risk of thick (and potentially lethal) melanoma.3 The evidence provided by these studies of mismatch between skin cancer risk and resource allocation to surveillance and excisional surgery might help explain why recent advances in early detection seem to have bypassed elderly men. It is of continuing concern that despite the fact that melanomas are currently diagnosed at an earlier stage when compared with 20 or 30 years ago, the background incidence of thick melanoma has remained stable, both in Australia and around the world. In a recent study conducted in Victoria,4 we found that thick melanomas (≥ 3 mm) were predominantly nodular melanomas, primarily affecting people over 50 years of age and especially men. This elusive subtype frequently fails to fulfil the “ABCD” (asymmetry, border, colour, diameter) diagnostic criteria in that they are more often uniform in colour, symmetric in shape and predominantly amelanotic.5 A possible aide-mémoire that we have suggested elsewhere for identifying nodular melanoma is the addition of “EFG” (“elevated, firm, growing for more than 1 month”) criteria.6 The observation that nodular melanomas grow quickly, leading to deep invasion within a few months, poses a significant obstacle to the potential success of community-based screening programs.1 It is likely that many nodular melanomas will escape early detection by such programs, as they will evolve significantly in the interval between screening examinations.4,5 It is important that all clinicians recognise this subtype if we hope to reduce melanoma mortality in Australia.

Alex J Chamberlain · John W Kelly

Stephanie L Jones,* Eugene Athan,† Daniel O’Brien,† Stephen R Graves,‡ Chelsea Nguyen,§ John Stenos¶ * Infectious Diseases Registrar, † Infectious Diseases Physician, Geelong Hospital, Ryrie St, Geelong, VIC 3220; ‡ Medical Microbiologist, § Scientist, ¶ Senior Scientist, Australian Rickettsial Reference Laboratory, Barwon Health, Geelong, VIC. StephljonesATyahoo.com To the Editor: Murine typhus (caused by Rickettsia typhi) has not been previously described in the state of Victoria, although it is well known in Western Australia, Queensland and South Australia. In 2002, a 49-year-old man presented to Geelong Hospital, Victoria, with a 10-day history of fever, myalgia, rigors, headache, rash, sore throat, dry cough and pleuritic chest pain. On examination, he had a fever (temperature, 39.2°C), hypoxia (oxygen saturation, 91% in room air), tachycardia, a central maculopapular rash and conjunctivitis. Blood tests revealed hyponatraemia, thrombocytopenia, white cell count in the reference range, with left-shifted neutrophil change (toxic granulation and increased immature forms) and a C-reactive protein level of 377 mg/L (reference range, < 10 mg/L). The patient lived on a hobby farm close to Geelong. Two weeks before becoming unwell, he had cleaned out the contents of a shearing shed, including two rotten sheepskins in which rats had been nesting. He reported generating a lot of dust and debris in the air. He had not noticed any tick, flea or other insect bites. Serological testing was performed for rickettsia. Baseline serum, taken 10 days after symptom onset, showed antibodies to the typhus group of rickettsiae, R. typhi (murine typhus) and R. prowazekii (epidemic typhus), with a titre of 2000. The titre rose over the following 4 days to 64 000, a fivefold increase, diagnostic of typhus group infection. Antibody titre to the spotted fever group of rickettsiae was significantly lower (peak titre, 8000). The patient was treated with oral doxycycline and recovered completely. Murine typhus was first described in Adelaide in 19221 and is now considered endemic in parts of Western Australia and Queensland.2,3 A possible case reported from Melbourne4 was, in retrospect, probably Brill–Zinsser disease (relapsed epidemic typhus). Murine typhus has an incubation period of 8–16 days and is generally self-limiting, although fatalities have occurred.1 The disease typically presents with fevers, prominent myalgia, a central rash, nausea, conjunctivitis, and often significant pulmonary involvement. Unlike the tick-borne spotted fever group of rickettsiae, R. typhi is transmitted by rodent fleas. Transmission occurs either by aerosolisation and inhalation of infected flea faeces, often during demolition or cleaning of rat-infested environments, or, less commonly, by inoculation of faeces into a fleabite. Murine typhus is usually diagnosed retrospectively by serological testing using microimmunofluorescence. Antibodies are usually detectable 7 to 9 days after disease onset, and IgG may persist for years. Cross-reactivity is seen between R. typhi and R. prowazekii; it is not possible to identify the pathogen by serological testing alone.5 Specific diagnosis is based on known local epidemiology and, as epidemic typhus does not occur in Australia, we believe this was a case of murine typhus, the first described in Victoria.

Stephanie L Jones · Eugene Athan · Daniel O’Brien · Stephen R Graves · Chelsea Nguyen · John Stenos

Mark Little,* Peter L Pereira,† Richard Mulcahy,‡ Teresa Carrette,§ Jamie Seymour¶ * Emergency Physician, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009. † Director, ‡ Emergency Physician, Cairns Base Hospital, Cairns, QLD. § Research Officer, ¶ Senior Lecturer, Department of Tropical Biology, James Cook University, Cairns, QLD. Mark.littleAThealth.wa.gov.au To the Editor: We are concerned that a recent report announced that the Queensland Ambulance Service now treats patients with hypertension caused by Irukandji syndrome with sublingual glyceryl trinitrate, based on an uncontrolled, unrandomised, unblinded “trial” of three patients.1 We believe the authors have made the justification for such treatment on questionable assumptions. The authors claim that venom from Carukia barnesi is a sodium channel agonist that causes massive noradrenaline release. This claim is based on a letter which reported whole C. barnesi being crudely blended and injected into piglets.2 There is no mention in this letter of any proven sodium channel agonist action.2 We are unconvinced that it was solely the venom of the jellyfish that resulted in a rise in noradrenaline levels in the piglets, especially since there has been a recent report of toxicity from homogenised jellyfish with the nematocysts (ie, venom) removed.3 While we believe that magnesium may be a promising treatment for patients with Irukandji syndrome, there has only been one case reported,4 and we are aware of several anecdotal failures, including the first patient in the letter by Fenner and Lewin.1 This does not constitute the justification for “proven effective treatment”. Fenner and Lewin claim that patients were envenomed by Carukia barnesi and yet provide no evidence. Carukia barnesi has yet to be discovered or reported south of Townsville. Two of us have reported that more than one jellyfish is responsible for Irukandji syndrome, and a second jellyfish has recently been identified.5 Accurate identification of the envenoming animal is essential in toxinology. Patients who present with Irukandji syndrome are in severe pain, and pain is a well known cause of hypertension. In a series of 116 patients with Irukandji syndrome, the mean dose of morphine administered was 31 mg.6 In the three patients reported by Fenner and Lewin, all were in severe pain, but only received 10 mg of morphine. In light of subtherapeutic analgesia, attributing the persistent hypertension solely to an unmanageable disease process is therefore premature and possibly incorrect. As a further confounder, might the reduction of blood pressure in two patients have resulted from the delayed onset of action of intramuscular morphine and promethazine? Without the addition of control patients to this trial, no conclusions can be drawn on the causative factors associated with this treatment. Too often in the past, unsupported treatments have been adopted, only to be abandoned several years later when shown to be ineffectual, or even dangerous to patients. There are too many assumptions, unsupported claims and confounders in Fenner and Lewin’s letter. Toxinology research needs good science and not poor anecdotes.

Mark Little · Peter L Pereira · Richard Mulcahy · Teresa Carrette · Jamie Seymour

Geoffrey K Isbister Toxicologist, and Consultant Clinical Toxicologist, NSW Poisons Information Centre, Newcastle Mater Misericordiae Hospital, Locked Bag 7, Hunter Region Mail Centre, NSW 2310. gsbiteATferntree.com To the Editor: Fenner and Lewin describe three cases of Irukandji syndrome in which glyceryl trinitrate (GTN) was used to transiently lower blood pressure.1 However, they provide no evidence that this relieved the patients’ pain or improved their ultimate outcome (development of pulmonary oedema or myocardial injury); they therefore do not show sufficient evidence for instituting such therapy. It is worrying that, with little evidence, sublingual GTN is now recommended as a prehospital treatment in Irukandji syndrome. Although GTN has been used safely in other conditions, its use without adverse effects in three patients is not evidence that it can be used safely in treating jellyfish envenoming. It is of concern that the treatment of bites and stings remains based on anecdotal evidence, and that clinical toxinology has not moved with the rest of medicine to developing evidence-based approaches. Fenner and Lewin state, in their second paragraph, that intravenous magnesium has proven to be effective in treating symptoms of Irukandji syndrome. This is based on a single case report and no controlled trials. It simply provides a starting point so that properly designed studies can be done to determine if magnesium is effective and safe in Irukandji syndrome. It is not appropriate to suggest that magnesium is a proven therapy without further investigation. Are we not learning from previous problems in clinical toxinology and prehospital care? Both are areas of medicine where treatment protocols are rarely based on substantial evidence.2,3 The pressure immobilisation bandage was introduced for the first-aid treatment of Chironex fleckeri stings with no supporting evidence, and it has taken two well designed animal studies to show that this is dangerous.4,5 A recent well designed study in the United States showed that prehospital intubation by paramedics of patients with head injury resulted in transient desaturation in 57% of patients and significant bradycardia (< 50 bpm) in 19%.6 This occurred despite the paramedics describing the intubation as “easy” in 84% of the patients who desaturated. This shows that it is essential to properly evaluate the safety and efficacy of treatments before recommending them for prehospital use. Although the infrequency of many envenoming syndromes makes controlled studies difficult to do, it is essential that clinical investigators collaborate to institute such studies. This is now happening in Australia with the commencement of randomised controlled trials on redback spider antivenom, magnesium in Irukandji syndrome and hot-water first-aid in jellyfish stings. Hopefully we will move from anecdote to evidence in clinical toxinology with collaborative studies such as these.

Geoffrey K Isbister

Peter J Fenner National Medical Officer, Surf Life Saving Australia, Sydney, NSW, and Associate Professor, School of Medicine, James Cook University, Townsville, QLD; PO Box 3080, North Mackay, QLD 4740. pjfennerATozemail.com.au In reply: We did not provide evidence of any effect on pulmonary oedema, myocardial injury or any effect in stopping pain, as that was not our intention. Also, even intravenous nitrates that have been used for many years in hospital are ineffective in reducing the muscle-cramping pains of Irukandji envenomation, and, although they reduce hypertension and ischaemic myocardial pain, there is no correlation or evidence that they prevent pulmonary oedema or myocardial injury. The assumption that the Queensland Ambulance Service (QAS) introduced this treatment after our trial is incorrect. The QAS Medical Director will confirm that it was introduced independently of our trial and actually before we treated our first case. While pain causes hypertension, in our Patient 1 effective analgesia had been attained without any effect on his hypertension. Also, many patients with Irukandji syndrome have pain without hypertension, while others have severe hypertension even with effective pain control.1 Further evidence that the venom from Carukia barnesi is a sodium channel modulator has been submitted for publication (Ken Winkel, Director, Australian Venom Research Unit, Melbourne, personal communication). Carukia barnesi has now been caught in the Mackay region, 400 kilometres south of Townsville (identified by me, and confirmed by L A Gershwin, PhD student in cubozoan taxonomy, James Cook University, 2003, personal communication). A number of other species can cause the Irukandji syndrome, but the jellyfish causing the sting is rarely caught, so cause and effect are hard to establish at present. Our aim was to present early evidence that sublingual nitrates may be effective in reducing the hypertension that occurs in some cases of Irukandji syndrome; our suggestion was that they be further trialled.2 It seems worthwhile to do so, especially as sublingual nitrates have also been shown to be effective in dysreflexia from spinal injury,3 where hypertension also occurs from the massive release of similar catecholamines. At least two deaths have occurred after Irukandji envenomation, both as a result of cerebrovascular accidents from severe hypertension.4 When treating a patient with severe hypertension from Irukandji envenomation in a prehospital situation, it is reasonable to try to reduce the hypertension. Doing so might reduce the risk of a cerebrovascular accident and possible death, and so further trials of this prehospital treatment must take place. Other prehospital treatments must also be trialled, especially those for pain. Early promising leads need to be published early for all to evaluate. The Irukandji syndrome is a dreadful experience for the victim; all possible prehospital relief measures must be tried and evaluated.

Peter J Fenner

Richard J G Bonham Medical Director, Queensland Ambulance Service, PO Box 1425, Brisbane, QLD 4001. rbonhamATemergency.qld.gov.au Comment: I would like to clarify a few points. Firstly, all Queensland Ambulance Service (QAS) paramedics use glyceryl trinitrate (GTN) frequently to treat cardiac chest pain, and have done so for many years. They are very familiar with its effects and interactions. Secondly, a small number of intensive care paramedics (ICPs), the top tier of officer, with many years of training and experience and tertiary qualifications, have, for a number of years, been authorised to consult with the senior doctor at the receiving hospital for use of GTN to treat acute severe hypertension. In Queensland, GTN has been used for this indication in one or two patients per year, compared with its use in 25 000 patients with cardiac chest pain. Finally, QAS reviewed its protocol for managing marine envenomation after two people died from Irukandji syndrome two years ago. The current protocol for suspected Irukandji stings is now standard care, including oxygen, and vinegar if there is a visible sting, followed by aggressive pain management, including up to 30 mg of morphine intravenously. If the patient has significant hypertension (> 200/120 mmHg) after effective analgesia, ICP officers are able to consult with a senior doctor to administer GTN according to the above protocol. Obviously, the concern of the QAS Medical Advisory Council (comprising representatives of all medical specialty colleges and other medical groups) was to prevent avoidable cerebral haemorrhage or acute heart failure, as occurred in the two deaths from Irukandji syndrome, but, to date, such use of GTN has not been invoked.

Richard J G Bonham

Peter A Leggat,* Robin Griffiths† * Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Townsville, QLD 4811; † Senior Lecturer in Occupational and Aviation Medicine, Wellington School of Medicine, University of Otago, Wellington, New Zealand. Peter. LeggatATjcu.edu.au To the Editor: Grace and Penny present some fascinating “travellers tales” concerning travel insurance and medical evacuation.1 Although I recognise that there may have been difficulties with individual cases, the article probably paints an unnecessarily bleak picture of travel insurance and medical assistance companies. About a fifth of travel insurance claims involve the successful use of the emergency assistance service, which mostly does not involve aeromedical evacuation.2 Evacuation by a dedicated air ambulance is uncommon among travellers.2 Almost all travellers in need of medical and dental treatment source treatment locally, for which they are generally reimbursed. Aeromedical evacuation, where needed, is more likely by scheduled airlines with or without an escort. The article may raise unrealistic expectations among travellers for aeromedical evacuation. Air ambulances do not operate and respond in the same way as ground ambulances. Time is required to assess and prioritise cases, select suitable aircraft, obtain flight plan clearance, check and equip aircraft, brief retrieval and receiving hospital personnel, and develop contingency plans. Aircraft may be required to refuel en route, as air ambulances tend to be based where they can be maintained and staffed adequately and safely — this may be far from the retrieval site. It is useful to raise travellers’ awareness of the possible difficulties in accessing adequate medical facilities in many developing countries, especially where tourism is promoted, and create a sense of travellers’ responsibility for their own health, safety and welfare. The International Society of Travel Medicine has articulated this in a recently released policy statement.3 Readers should be wary of generalising from a small number of case studies from a “popular tropical island holiday destination”.1 It would be useful to collect data on medical retrievals and emergency assistance provided from various sources and consult all interested parties before attempting to establish guidelines for medical evacuation. Grace and Penny do raise the important issue of the need for appropriate travel insurance for all travellers. This message needs to be conveyed by the travel industry and by travel health advisers. The article referred to a study of the travel health advice provided by general practitioners in New Zealand, but did not mention that only about half the GPs in that study routinely discussed travel insurance.4 A similar study in Australia indicated that less than 40% of GPs routinely give advice on travel insurance.5

Peter A Leggat · Robin Griffiths

Fred Gilligan,* Peter Sharley,† Andrew Berry‡ * Emeritus Director of Retrieval and Resuscitation, † Director, Retrieval Services, RAH Mediflight, Royal Adelaide Hospital, North Terrace, Adelaide SA 5000; ‡ Director, NSW Newborn & Paediatric Emergency Transport Services, Sydney NSW. To the Editor: As consultants in intensive care, experienced in transporting critically ill patients within Australia and internationally, we have also received complaints from clients about some travel insurance organisations.1 Poor service appears due partly to economic restrictions and partly to the paucity of experienced staff and specialised aircraft available. Assistance companies implement travel insurance policies for underwriters, quoting 24-hour emergency call centres. Some companies economise by subcontracting (eg, episodic diversion of calls to another organisation). This can result in coordinators lacking an understanding of regional geography, population and medical services and omission of the early, vital input of senior medical advisers. Information relayed between several people can be lost or distorted. Failure to ask key questions can result in inappropriate clinical planning. Furthermore, time zone differences can result in calls being received late at night, further reducing availability of immediate expert opinion. Only a well-organised (and thus expensive) control centre with a critical care focus can manage all these variables. Furthermore, it is difficult for a company to permanently employ current, high-grade healthcare staff in adequate numbers. Current critical care retrieval staff in Australia are confined to a few stand-alone aeromedical organisations or public hospitals which run aeromedical services for state governments and other organisations, using their regular anaesthesia, intensive care or emergency medicine staff. Reliable assistance companies tend to contract with these retrieval organisations or their off-duty staff. In Australia, ambulance aircraft able to travel offshore, with adequate oxygen systems, stretcher attachments, electrical power, and so on, are uncommon and expensive to equip. Portable equipment to care for a critically ill patient represents a capital investment of over $100 000, and some services try to achieve results with inadequate tools or by borrowing. ISAS (the International Society of Aeromedical Services, Australasian Chapter) promotes standards on staffing and equipment,2 including the Australian and New Zealand College of Anaesthetists/Australian College for Emergency Medicine standard for transporting the critically ill.3 Based on critical care practice, the standards are not legally binding, but one suspects they would be quoted in any litigation. It behoves all travellers to scrutinise their travel insurance policies closely — many think of them only in terms of lost or stolen baggage. Following serious injury or illness, the policy may dictate what kind of care is offered.

Fred Gilligan · Peter Sharley · Andrew Berry

Howard Roby Specialist in Anaesthesia and Intensive Care; and Medical Director, Customer Care Medical Assistance, Private Bag 913, North Sydney, NSW 2059. macrobyATozemail.com.au To the Editor: As the medical director of Customer Care Medical Assistance, which manages the travel insurance policies of most travelling Australians, I wish to reassure readers that none of the experiences chronicled by Grace and Penny1 related to our company. I have previously described the activities of Customer Care in the Journal.2 I would welcome any enquiries from colleagues about the way our company functions. I note that there was no declaration by Grace and Penny of their competing interests.

Howard Roby

Kirsty L Buising,* Karin A Thursky,† James F Black,‡ Graham V Brown§ * Clinical Research Fellow, † Infectious Diseases Physician, ‡ Head of Epidemiology, § Head, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050. Kirsty.buisingATmh.org.au To the Editor: The 2003 Australian guidelines on antibiotic therapy suggest that the Pneumonia Severity Index (PSI) may be used to triage site of care and antibiotic selection for patients with community-acquired pneumonia.1,2 The PSI was developed as a mortality prediction tool, using data from over 14 000 patients with community-acquired pneumonia.3 The antibiotic guidelines suggest specifically that PSI classes I and II represent patients suitable for outpatient therapy, and that class V can identify patients likely to require intensive care and broad-spectrum antibiotic therapy. We believe this is beyond the previously recommended applications of the PSI and advise caution about its use to identify patients with severe pneumonia. In the cohort used to validate the PSI, only 32% of patients with severe pneumonia (requiring intensive care) were in class V, indicating that the PSI has poor sensitivity for severe pneumonia.3 This finding has been reflected in other studies.4 The strength of the PSI lies in its ability to identify low-risk patients, as the title of the validating article suggests.3 The PSI is so heavily weighted by age and comorbidities that younger patients needing intensive care are unlikely to accumulate enough points to reach class V. This is important, as early identification of patients with severe pneumonia and initiation of broad-spectrum antibiotic therapy and intensive-care support improves outcomes. We are concerned that the PSI may be widely accepted for a purpose for which it was not intended and has not been validated. In underestimating the severity of illness in two-thirds of patients with “severe pneumonia”, the guidelines may provide false reassurance, while clinicians may lose confidence in the PSI if they find it “misses” most patients requiring intensive care. Current evidence does support use of the PSI to guide decisions about inpatient or outpatient therapy. However, the modified British Thoracic Society (BTS) Severity Score is a simpler, better-validated tool to identify patients with “severe pneumonia” who are likely to need intensive care assessment5 (Box). This tool is useful for junior staff to “flag” patients with potentially severe pneumonia and ensure that they are discussed with a senior clinician. As always, the final management and antibiotic selection should be guided by clinical judgement. We believe that the antibiotic guidelines are valuable to encourage appropriate antibiotic use; our aim is to promote discussion of their content relating to this particular condition. Suggested alternative approach to assessing patients with community-acquired pneumonia Step 1: Does the patient need admission to hospital? Assess with the Pneumonia Severity Index (PSI). Class I or II: consider outpatient management (but also need to consider comorbidities, social supports, likelihood of compliance). Class III-V: likely to need inpatient management. Step 2: Does the patient need admission to the intensive care unit? Assess with the modified British Thoracic Society (BTS) Severity Score. Class as severe if two or more of the following features are present on initial assessment or within 24 hours of presentation (and are not attributable to another cause): Confusion (acute onset) Serum urea level > 7 mmol/L Respiratory rate ≥ 30 breaths/minute Systolic blood pressure < 90 mmHg or diastolic blood pressure ≤ 60 mmHg If severe, discuss the case with a senior clinician and consider intensive-care review and aggressive broad-spectrum antibiotics.

Kirsty L Buising · Karin A Thursky · James F Black · Graham V Brown

Wenbiao Hu,* Anthony J McMichael,† Shilu Tong‡ * PhD candidate, Centre for Health Research, Queensland University of Technology; † Director, National Centre for Epidemiology and Population Health, Australian National University, Canberra; ‡ NHMRC Senior Research Fellow, School of Public Health, and Centre for Health Research, Queensland University of Technology, Kelvin Grove, QLD 4059. s.tongATqut.edu.au To the Editor: We examined the possible association between the Southern Oscillation Index (SOI) and the occurrence of hepatitis A in Australia using a Seasonal AutoRegressive Integrated Moving Average (SARIMA) regression model.1 Our results indicate that the SOI is statistically significantly associated with the transmission of hepatitis A. We obtained data on the monthly counts of hepatitis A cases in Australia and the monthly SOI between 1 January 1991 and 31 December 2000 from the Commonwealth Department of Health and Ageing and the Australian Bureau of Meteorology, respectively. Data on population sizes were obtained from the Australian Bureau of Statistics. Cross-correlations were used to compute a series of correlations between SOI and the incidence of hepatitis A over a range of time lags (defined as the time span between the SOI and the incidence of hepatitis A). A SARIMA model was used to estimate the independent contribution of SOI in our study. We adjusted for seasonality by “seasonally differencing” (ie, replacing each observation by the difference between it and the observation from the previous year). In the modelling process, attention was paid to observations well outside the main body of the data (outliers) and the only outlier was excluded in the final SARIMA model. We used the SARIMA [1,0,0] [1,1,0]12 model (ie, first-order autoregressive combined, first-order seasonal autoregressive, after adjustment for first-order seasonal integration) to assess the association between SOI and the incidence of hepatitis A. We found that a decrease in the SOI (ie, warmer and drier conditions) was statistically significantly associated, at a lag of 1 month, with an increase in the monthly incidence of hepatitis A (β = − 0.01; P = 0.001). Two El Niño events (1991–92 and 1997–98) were also clearly associated with an increased incidence of hepatitis A (Box). The results suggest that there was an increase of about 360 cases per year in Australia for an, on average, interquartile range decrease in the SOI. The residuals in the model fluctuated randomly around zero, and there was no apparent autocorrelation between residuals at different lag times (data are available from the corresponding author). These results indicate that the model fitted the data well, with no violation of assumptions. The significant association between SOI and the incidence of hepatitis A remained when the outlier was included in the model (β = − 0.013; P = 0.001). El Niño Southern Oscillation (ENSO) has been found to be related to various health outcomes, including waterborne disease, vectorborne disease, and natural disaster-related deaths (eg, floods, bushfires and cyclones).2-4 Our study adds further evidence of ENSO-related health effects. Infectious diseases are, in general, sensitive to climate variability, as climate can influence the development and transmissibility of pathogens, and can also affect people’s behaviour.3,5 If the relationship between ENSO and hepatitis A is confirmed by other studies, these findings may facilitate the development of early warning systems for controlling and preventing this widespread communicable disease. Incidence of hepatitis A in Australia and the Southern Oscillation Index between January 1991 and December 2000 Negative values of the SOI are associated with El Niño conditions (dry and warm in Australia), and positive values with La Niña conditions (wet and less warm in Australia).

Wenbiao Hu · Anthony J McMichael · Shilu Tong

Simon G A Brown Emergency Physician, Fremantle Hospital & Health Service, and Clinical Senior Lecturer in Emergency Medicine, University of Western Australia, Department of Emergency Medicine, Fremantle Hospital, Alma Street, Fremantle, WA 6160. simon.brownAThealth.wa.gov.au To the Editor: Gawarammana et al present an interesting study of premedication to prevent adverse reactions to snake antivenom,1 but I have concerns with the data presentation and analysis. The 95% confidence intervals presented in Box 3 of their article are impossibly narrow. For example, recalculation of the first cell (hypotension rate for treatment A) by the binomial method gives a 95% confidence interval of 12%–62%, not 30%–36% as presented. Also, my analysis of the aggregate endpoint differs. Using the Fisher exact test to compare reaction rates in the hydrocortisone + antihistamine group (11/21) with placebo (13/16), for the difference in proportions of 0.29 I obtain a 95% confidence interval of 2 0.04 to 0.58. This has a P value of 0.14 using a 2-tailed test, according to the program Analyse-it.2 This comes as no surprise given that steroids take hours to work, and that histamine is just one of many mediators released during anaphylaxis, rising early and only transiently during severe and protracted anaphylactic reactions.3 Although antihistamines reverse the effects of histamine infusions which mimic anaphylaxis, animal studies indicate that they are ineffective for treating anaphylaxis mediated by mast-cell degranulation.4,5 Human studies have shown that H1 blockade is useful in preventing mild reactions to immunotherapy that are confined to the skin, but do not appear to prevent severe reactions.6,7 One human study has compared H1 + H2 blockade with H1-only blockade for the management of mild allergic reactions, finding a small benefit of combined H1 + H2 blockade.8 However, a confounder was that adrenaline was administered more frequently in the combined H1 + H2 antihistamine treatment group. A study of reactions to immunotherapy has failed to show any benefit from H1 + H2 blockade.7 I suspect that, instead of proceeding to study combination prophylaxis with antihistamines, steroids and adrenaline, it might be better to examine the preparation for and management of allergic reactions to antivenom. Many doctors fear intravenous adrenaline infusions, but in our experience this approach to managing anaphylaxis is safe, well tolerated and immediately effective, without the unpredictable, unpleasant, and (in the setting of venom-induced coagulopathy) potentially dangerous side effects sometimes seen with intramuscular, subcutaneous and intravenous bolus injections.9 Perhaps it is time for a trial of premedication with subcutaneous adrenaline versus an “as required” approach using a carefully titrated intravenous infusion.

Simon G A Brown

S Abeysingha M Kularatne,* Indika B Gawarammana† * Senior Lecturer, † Lecturer, Department of Medicine, Peradeniya University, Sri Lanka. samkulATsitnet.lk In reply: Brown has pointed out some interesting observations about antihistamines and mediators such as histamine, released during anaphylactic reactions. First, we must address the statistical issues. We are grateful to Brown for detecting an important error in Box 3 of our article.1 When we were asked to calculate confidence intervals for the percentages, we used a formula recommended by Spiegel.2 As this formula was not available in our software packages, we programmed it ourselves. We made an error in our programming and we apologise for this. (See Correction, page 428.) For the difference in reaction rates for the treatment regimens, we used the following calculation. The difference P1 – P2 = − 0.2887 To calculate the confidence interval, we calculated the standard error (SE) of the difference by the following formula. This interval does not include 0, so Brown’s P value of 0.14 is not reasonable. We do accept that the statistical significance is marginal. We agree that antihistamine is ineffective as a prophylactic agent in anaphylaxis. This was observed in studies in Sri Lanka and Brazil, where chlorpheniramine and promethazine, respectively, were used to prevent reactions to antivenom.3,4 However, we defended the observed reduction of mild to moderate acute reactions to antivenom in our study by highlighting the counter-effect of antihistamine on released histamine after mast-cell degranulation.1 Our study was to test the usefulness of an established practice in Sri Lanka, where steroid infusion is used to counter reactions to antivenom. The crux of the problem is the highly antigenic antivenom preparations used in Sri Lanka, despite ever-increasing reaction rates, because of the lack of facilities for developing purified antivenom. The proposal of using intravenous adrenaline infusion to reduce allergic reactions is novel and exciting. This should be tested by randomised controlled trials.

Indika B Gawarammana

Val J Gebski Principal Research Fellow, NHMRC Clinical Trials Centre, Level 5, Building MO5, Mallett Street Campus, University of Sydney, NSW 2006. valATctc.usyd.edu.au Comment: Kularatne and Gawarammana compared the proportion of side-effects given in their table above using the well-known (and easily understood) test of the difference between two proportions using the normal distribution. However, as each of these proportions follows a binomial distribution (13 “successes” out of 16 trials and 11 “successes” out of 21 trials), the normal approximation is only useful if the number of trials is greater than 30. Because of the small sample sizes, “exact” methods better reflect the true difference (in terms of P values and confidence intervals) between the two proportions. The more complicated methods (different formulations of the exact test) and the resulting confidence intervals provide a clearer indication of whether the proportions are indeed different (statistically). In this instance, the evidence is not sufficient to declare the two proportions statistically different.

Val J Gebski

Michael A Quinn Director, Oncology and Dysplasia Unit, Royal Women's Hospital, 5th Floor, 132 Grattan Street, Carlton, VIC 3053. michael.quinnATmaynegroup.com To the Editor: A recent article by Zorbas et al1 highlights some of the many difficulties experienced by Australian women in accessing multidisciplinary care after they have been diagnosed with breast cancer. A multidisciplinary approach to women with gynaecological cancer has been the cornerstone of care since the establishment of gynaecologic oncology units in Australia in the early 1980s. Over 20 years’ experience has reinforced the value of this approach. By and large, however, the success of this model has very much depended not only on the skills of the multidisciplinary team but also on the readiness of referring doctors — in this case, specialist gynaecologists — to refer patients for management that is often surgical and could easily be done by themselves. Reinforcing the concept that care of the patient is holistic and that surgery plays an important (but not definitive) role in overall care has led to increased referrals, but there are still many to convince. For instance, a survey published in the Journal in 20022 showed that in the late 1990s more than half the women with ovarian cancer in Victoria were still being operated on outside established gynaecologic oncology units or by a non-gynaecological oncologist. It is to be hoped that new National Health and Medical Research Council guidelines on the management of ovarian cancer (soon to be released) will reduce this deficit and thereby improve outcomes for women with ovarian cancer. Much of the development of this benchmark care has come from patients, who, thankfully, are becoming increasingly articulate in their expectations of optimal clinical outcomes. The question of rural patients is an extremely important one. In Victoria, over a period of more than 10 years, the three major metropolitan gynaecologic oncology centres have established satellite clinics in country towns to facilitate patient follow-up, often involving local specialists and family doctors. This system seems to have worked well and is worthy of assessment as a model that might be transferable to other specialties. In conclusion, it is all very well setting up multidisciplinary teams, but the key to their success has to be the recognition of professional equality. If teams are based on a hierarchical setup they are likely to fail in their major aim, which is to provide the best care available based on input from a broad range of professionals and from patients themselves.

Michael A Quinn

Susan C Pendlebury,* Katherine J Clark,† Martin H N Tattersall‡ * Radiation Oncologist, † Palliative Care Physician, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; ‡ Professor of Cancer Medicine, University of Sydney, Sydney, NSW. spendlebATemail.cs.nsw.gov.au To the Editor: Zorbas et al1 have highlighted both the complexities and resource intensiveness of multidisciplinary care for women with early-stage breast cancer. The same arguments exist in advanced disease, where input from many disciplines is the norm. However, there is no evidence that such a process improves outcomes in the Australian setting. The references the authors draw upon relate to regions in which breast cancer outcomes have historically been poor. Evidence from Australian studies suggests higher standards of care and appropriate changes over time. 2,3,4 The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer5 provide an evidence-based strategy for managing the disease. Enshrined within them is the concept that many different treatment approaches are equivalent and that patient preferences are important. Patient input into multidisciplinary case conferences is frequently minimal. Case conferences can be confusing for patients, and it may not be clear to them who is their doctor. Many clinics include a breast nurse, who commonly acts as a patient advocate. Zorbas and colleagues note the different models of multidisciplinary care, but the minimum approach required to achieve good outcomes has not been established. It is not surprising that 34% of rural surgeons find it difficult to implement a service in which all women have access to a full range of treatment options in a multidisciplinary setting. There is no evidence, however, that their patients are more unhappy or that management outcomes are inferior. Similarly, the guidelines correctly promote the importance of psychosocial support for patients, but the suggestion that this can be better achieved by a psychologist via teleconferencing rather than by the patient’s general practitioner is purely speculative. None of the multidisciplinary models suggested by Zorbas et al addresses the management of patients at relapse, and yet data and clinical experience indicate this is the time of greatest stress for patients, 6 a time when input from a number of specialties — medical care, radiation oncology, palliative care — is the norm. Multidisciplinary care appears to be beneficial regardless of the stage of disease. However, the execution of some of the models is resource-intensive. We need to evaluate not only whether the objectives of the NHMRC guidelines are met, but whether patient satisfaction and participation are enhanced, survival outcomes are improved and care through all stages of the disease is optimal. Currently, by such measures, multidisciplinary care has not been shown to be superior to a small number of well-directed, evidence-based selective consultations.

Susan C Pendlebury · Katherine J Clark · Martin H N Tattersall

Helen M Zorbas,* Bruce H Barraclough,† Katherine J Rainbird,‡ Karen A Luxford,§ Sally Redman¶ * Clinical Director, ‡ Manager, Treatment Program, § Program Director, National Breast Cancer Centre, Locked Bag 16, Camperdown, NSW 1450; † Director of Cancer Services, Department of Surgery, Royal North Shore Hospital, St Leonards, NSW; ¶ Director, Institute for Health Research, Sydney, NSW. karenlATnbcc.org.au In reply: We agree with the comments by Pendlebury et al that knowledge about outcomes for patients receiving multidisciplinary care in Australia is limited. Hence, the National Breast Cancer Centre has investigated the application of multidisciplinary care and outcomes for women with breast cancer. Our article focused on the “Principles of multidisciplinary care” developed as a basis for a subsequent project (outcomes yet to be published). It was necessary to define such principles at the outset, as there is not yet an agreed view about what constitutes “multidisciplinary care” within the Australian healthcare context. We also agree that the standard of clinical care in Australia is generally good. However, delivery of care is often fragmented and inconsistent.1 In other countries with high quality services, multidisciplinary meetings have been found to result in care that is more in accord with the evidence than non-multidisciplinary care.2 The Principles emphasise the role of the general practitioner, while recognising that some patients will require appropriate specialist referral.3 They also state that living in a rural area should be no impediment to accessing care. We agree that multidisciplinary care is as important in advanced breast cancer as it is in early disease. The Principles were developed before the release of the guidelines for advanced breast cancer and it would be useful to extend them in the future. The importance of one main contact for women is acknowledged. The purpose of a multidisciplinary case conference is to identify treatment options and their relative merits. This ought to assist communication with women and enable them to make a more informed choice.

Helen M Zorbas · Bruce H Barraclough · Katherine J Rainbird · Karen A Luxford · Sally Redman

John Fraser,* Christian Alexander,† Berniece Simpkins‡ * Director, † Senior Research Fellow, ‡ Health Career Promotion Project Officer, New England Area Rural Training Unit, New England Area Health Service, PO Box 83, Tamworth, NSW 2340 jdfraserATdoh.health.nsw.gov.au To the Editor: We read with interest the recent article concerning Australian medical workforce issues.1 Brooks et al comment on feminisation, lifestyle changes, increased community demand and globalisation as major issues for the future medical workforce. Here, we present data from recent rural high school health career promotion activities, describing student interest in health careers. These data further support this trend in feminisation. Promotion of health careers in high schools is a core long-term rural workforce strategy in Australia.2 It is justified, as rural origin is an important predictor of medical graduates pursuing a rural health career.3 The New England Area Rural Training Unit (NEARTU) promotes rural health careers to school students, undergraduates and postgraduates in north-west New South Wales. Multidisciplinary regional health career expos were offered to all high school students in Years 9 to 12 from 2000 onwards in the regional centres of Armidale, Tamworth and Moree. Medical, nursing and allied health professionals and undergraduates (of both sexes) staffed the expos. Inquiries were recorded by sex, year at school and health career. Students could enquire about multiple careers. In 2000, 453 high school students (394 female; 59 male) expressed an interest in health careers at expos. The Box displays that, for both female and male Year 9 to Year 11 students, interest in a nursing career far exceeds interest in either allied health or medicine, and, for Year 12 students, an interest in allied health far exceeds interest in either nursing or medicine. Enquiries were more frequent from females than from males, ranging from just over four times (medicine) to eight times more frequent (nursing). In 2000, 60% of these students’ enquiries (270 enquiries) referred to nursing, 33% (151 enquiries) referred to allied health and 7% (32 enquiries) referred to medicine. Compared with the Australian Bureau of Statistics 2001 data, which showed a 50.4 to 49.6 ratio of females to males in the region’s high schools, our increased interest by females is statistically significant (P < 0.01). In other careers projects by NEARTU in 2000–2002 (eg, work experience placements, and health career promotion at local agricultural field days), similar sex differences were observed (female-to-male ratio range, 10:1 to 3.5:1). Increased interest by female high school students is consistent with other reports of high school students’ health career preferences in the United States. 4,5 Registering interest is only the first step in considering a health career. The higher proportion of females expressing this interest in rural high schools is important for rural workforce planning. Interest in health careers by high school students in 2000

John Fraser · Christian Alexander · Berniece Simpkins

Andie S Lee,* John R Dyer† * Registrar, † Senior Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. John.dyerATfmc.sa.gov.au A 79-year-old man presented with 5 days of right-leg pain, high fever, severe headache and deteriorating conscious state. He was previously fit and healthy and took no medications. The patient appeared unwell, had a temperature of 39.5°C, moderate irritability and depressed conscious state. There was marked neck stiffness and his left wrist and right knee joints appeared swollen and inflamed. There was a cardiac systolic murmur, but no stigmata of bacterial endocarditis. Aspirates of the left wrist and right knee yielded purulent fluid containing numerous gram-positive cocci. The patient was admitted to the intensive care unit and treated with high dose benzylpenicillin plus vancomycin. A cerebral computed tomography scan was normal; lumbar puncture was not performed. The affected joints were washed out within 24 hours. All cultures of blood and synovial fluid yielded a Lancefield Group C β-haemolytic streptococcus, identified further using the ID 32 Strep strip (BioMerieux, Marcy l’Etoile, France) as Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) based on its ability to ferment sorbitol and not trehalose. This isolate was shown to be sensitive to penicillin (minimum inhibitory concentration, < 0.1 mg/L). Intravenous penicillin therapy was continued. Transoesophageal echocardiography showed echodensities close to the aortic valve which suggested vegetations. The patient’s condition improved steadily, and he ultimately received intravenous antibiotics for 6 weeks. Further history revealed that the patient collected fresh horse manure for his garden daily from a local paddock. He reported no direct contact with animals or ingestion of unpasteurised dairy products. S. zooepidemicus could not be cultured from a single specimen of horse manure collected from the paddock, and it was not possible to collect clinical specimens directly from any of the horses that used the paddock. Human infection with S. zooepidemicus can usually be traced to an animal source.1 Outbreaks associated with ingestion of unpasteurised milk and cheese have also been described.2,3 Likely entry routes include the respiratory or gastrointestinal tract and skin.1 Severe sequelae of S. zooepidemicus infection include endovascular infection, meningitis, septic arthritis, and epidemic post-infectious glomerulonephritis. Our patient’s clinical picture indicated multifocal sepsis, with polyarthritis, endocarditis, and probable meningitis. In a recently reported case of S. zooepidemicus meningitis, pulsed-field gel electrophoresis showed molecular identity between patient isolates and a throat swab isolate from a horse with which the patient had been in close contact.4 Our patient was most likely infected via the respiratory or cutaneous routes, or by ingestion after contact with respiratory secretions of horses deposited in the environment. Exposures in the garden can lead to a variety of severe infections.5 This is the first reported case where S. zooepidemicus infection appears to have been acquired through gardening. Severe disease with this organism can be a particular hazard in elderly gardeners with comorbid conditions.1

Andie S Lee · John R Dyer

John Coutsouvelis,* Carmela E Corallo† * Oncology Pharmacist, † Deputy Director of Pharmacy, Box Hill Hospital, Nelson Road, Box Hill, VIC 3128. John.coutsouvelisATboxhill.org.au To the Editor: Thalidomide has recently been approved for use in treating recurrence of erythema nodosum leprosum and multiple myeloma after failure of standard therapies. Common side effects of thalidomide treatment include drowsiness, sedation, rash and paraesthesiae.1 Dizziness, hypotension and bradycardia occur less commonly.1-3 Of 91 patients treated with thalidomide (80 with multiple myeloma), we have had one case of symptomatic bradycardia. We describe this patient, who was able to continue treatment on a reduced dose of thalidomide. A 71-year-old woman, with a history of breast cancer (treated with radiotherapy and tamoxifen), arthritis, crush fractures, and hip and knee replacement, was diagnosed with multiple myeloma. She was prescribed intravenous pamidronate 90 mg every month and oral therapy with melphalan, but she experienced haematological toxicity and the melphalan was stopped. After progression of the disease, 100 mg of thalidomide was commenced at night, with the aim of increasing the dose by 100 mg every fortnight until a response was achieved. Three weeks later, the patient presented to hospital for pamidronate infusion complaining of a 2-week history of shortness of breath, especially on exertion. There was no oedema present, and her blood pressure was 135/70 mmHg. Electrocardiography showed sinus bradycardia, with a heart rate of 46 beats/min. The dose of thalidomide had been titrated to 200 mg at night. Thalidomide was stopped, and the patient was referred to a cardiologist, who performed an echocardiogram, 24-hour Holter monitoring and a stress test. The results from these tests showed no underlying cardiac disease or abnormalities. Six weeks later, on review, the bradycardia had resolved (heart rate, 60 beats/min). Thalidomide was recommenced at 100 mg daily. However, after a further 6 weeks, her heart rate had decreased again to 45 beats/min, and the dose of thalidomide was reduced to 100 mg on alternate days. Thalidomide therapy has been continued in this patient at 100 mg on alternate days. Her heart rate has stabilised between 50 and 55 beats/min, and she has remained asymptomatic. The multiple myeloma is responding to treatment, as indicated by symptom control and serial measurements of IgG kappa. She continues to take hydroxychloroquine, rofecoxib and sertraline. Bradycardia is a rare side effect of thalidomide therapy, with an incidence of 0.12%.1,2 The mechanism is unknown, but could be related to thalidomide’s central sedative effect.1 There are isolated published case reports of thalidomide-induced bradycardia; in all cases the drug was stopped.2-5 Thalidomide is being used for various conditions for which no alternative therapy exists. As the drug is now commercially available in Australia, its use is likely to increase. In all patients taking thalidomide, we recommend measuring heart rate; and in those with underlying heart disease, or who are taking medications that can precipitate bradycardia, we recommend electrocardiographic monitoring. Our findings in this patient suggest that thalidomide-induced bradycardia can be successfully managed with dose reduction and regular monitoring.

John Coutsouvelis · Carmela E Corallo

Kerry-Ann F O’Grady,* Terence M Nolan† * Senior Research Officer, Vaccine and Immunisation Research Group, Murdoch Children’s Research Institute, Flemington Road, Parkville, VIC 3052; † Head, School of Population Health, University of Melbourne, Melbourne, VIC. k.ogradyATunimelb.edu.au To the Editor: In Australia, personal and health information that identifies an individual cannot be used or disclosed for research without specific requirements being met.1 Even if these requirements are met, data custodians may still refuse access if their views are discordant with those of the relevant human research ethics committee (HREC). It is now evident that there are adverse consequences of this well-meaning legislation. Our research group conducts community-based vaccine trials. Recently, we attempted to use school enrolment lists to mail information to parents about a study. Despite approval from the Royal Children’s Hospital HREC, one major governing body of Victorian public schools rejected our proposal on privacy grounds, as did several independent schools. Only a small number of schools raised no privacy concerns at all. The main concern expressed was that the use of these registers for health research was not related to the primary purpose of collection, and families had not consented to this use. The net result was substantially reduced access to the population eligible for recruitment. We now have a situation in which the legislation may actually do more harm than good. This is an emerging issue here in Australia and overseas.2,3 Even more worrying are the findings of an Australian survey in which 61% of adults believed that even their de-identified health information should not be used for research purposes without their consent.4 Health research is dependent on access to population datasets to recruit participants, monitor health indicators, identify risk factors and inform interventions. Non-representative access threatens a study’s validity, resulting in poorly informed interventions, policy and funding decisions. The situation may now have progressed beyond reasonable trade-offs between the public good and individual privacy to the point where important research cannot be done at all, and the opportunity for advances in health are lost. Despite statutory guidelines,1,5 there are widespread differences in interpretation of the legislation, particularly regarding the terms “practicable” and “public good”. Amendment of the legislation in this respect is therefore urgently required, together with clauses which facilitate a researcher’s ability to inform the public of a particular project and enable individuals, not organisations, to decide whether they wish to participate. There needs to be greater effort in gaining public understanding of the legislation and its intent with respect to research. In addition, upfront declarations and “opt-out” clauses about the use of personal information for health research must also be included in the privacy statements that organisations are now legally required to provide to individuals at the point of data collection.

Kerry-Ann F O’Grady · Terence M Nolan

Paul Chadwick,* Beth Wilson† * Information Privacy Commissioner, † Health Services Commissioner, Office of the Victorian Privacy Commissioner, GPO Box 5057, Melbourne, VIC 3000. enquiriesATprivacy.vic.gov.au In reply: We are familiar with concerns such as those expressed by O’Grady and Nolan, and we are grateful for this opportunity to respond, so that readers can consider the views side by side. Privacy is not new. Ethical obligations of confidentiality in medical settings date back to Hipprocrates. New privacy legislation — Health Records Act 2001 (Vic); Information Privacy Act 2000 (Vic); Privacy Act 1988 (Cwlth) — clarifies these obligations and also sets a higher standard of accountability. (Other states and territories also have legislation or are contemplating it.) The new laws cover all sorts of personal information, but health information is especially delicate. Wrongly handled, it can lead to discrimination — not just embarrassment or loss of dignity. In Victoria, this was recognised by Parliament when it passed the Health Records Act as a separate piece of legislation to deal specifically with health information. The policy behind the privacy laws is aimed at promoting trust between health service providers and the public by reassuring them that their personal information will be respected, particularly in an electronic age in which information can be speedily transmitted far and wide. If surveys show the public to be wary about the use of their health information for research, it would seem to be in the best interests of the research community to embrace new standards rather than to seek to unravel or avoid them. Privacy legislation was drafted after extensive consultation, taking into account competing factors and the need to balance respect for privacy with other public interests, including research. Research is very important, and privacy is a cherished and longstanding value. Reputable research can coexist with the recent statutory expressions of privacy, just as reputable research has always coexisted with respect for privacy. Many data custodians perhaps do not yet realise that privacy laws rarely require an existing legitimate practice to cease completely, but rather may require the practice to be adapted to meet new standards. For example, for researchers seeking to recruit subjects for a study, the data custodian may disseminate the researchers’ initial letter rather than hand over lists of names and addresses to researchers. Once recipients opt in, direct consensual dealings with the researchers proceed as usual. Researchers can always use properly de-identified information, or they may use information with the consent of the subject. As with all new laws, the privacy laws will become better understood with time and experience. Some data custodians are understandably overcautious, while others have blamed privacy laws for preventing them from providing information in situations in which disclosure is permitted. Many adapt with ingenuity and effectiveness. Privacy Commissioners and the Health Services Commissioner are available to explain the laws. We, along with everyone with an interest in collecting and using the sensitive information of others, must recognise and consider the subtleties inherent in balanced privacy protection.

Paul Chadwick · Beth Wilson

Robert N Atkinson Orthopaedic Surgeon, 135 Hutt Street, Adelaide, SA 5000. wattle135ATozemail.com.au To the Editor: In response to Leeder,1 there is no community in this world that can provide free, at the point of contact, healthcare for all its citizens to the current limits of modern medical technology. This problem will in fact become greater as the technology increases and becomes more expensive. Within the available healthcare resources, there is some medical treatment that is essential and there is some that is quality-of-life treatment; where the two merge depends on one’s point of view. If you choose to play sport and injure your knee, the question of who should pay for the treatment arises. If you smoke or have any other lifestyle risk factors, how much should be funded by you, and how much by others? And, within a healthcare system where there is patient contribution, does this contribution empower and encourage individuals to adopt a healthy lifestyle? In essence, I believe the debate in healthcare should be about accessibility of limited resources. Who draws the line, how is the line drawn, and at what level is it drawn? Pouring money into the public health sector may well parallel the analogy of adding another lane to the motorway. We must be careful to share the responsibility of healthcare between the individual and the healthcare providers in an inclusive and not exclusive manner.

Robert N Atkinson

Elizabeth Harris,* Sarah J Simpson,† Rosemary Aldrich,‡ Jenny Stewart Williams§ * Director, † Program Manager, Centre for Health Equity Training Research & Evaluation (CHETRE), University of NSW, LMB 7103, Liverpool BC, NSW 1871. ‡ Conjoint Academic, School of Medical Practice and Population Health, § Research Officer, Newcastle Institute of Public Health; University of Newcastle, Newcastle, NSW. elizabeth.harrisATswsahs.nsw.gov.au To the Editor: Leeder rightly points out that increased funding of the healthcare system does not necessarily result in improved equity within the health system or better health outcomes for the population.1 This challenges us to develop ways of systematically examining how current healthcare practices either increase or decrease equity. The following two Australian initiatives illustrate how we might work to achieve equity in health — that is, provide opportunities for all Australians to achieve their full health potential.2 Clinical practice guidelines (CPGs) are one mechanism frequently used to facilitate improvements in the quality of clinical practice and healthcare. However, the evidence on which CPGs are based often excludes, or does not consider, the needs of relatively disadvantaged populations.3-5 Recognising this gap, the Health Advisory Committee of Australia’s National Health and Medical Research Council published a handbook for developers of guidelines about ways to access, review and collate evidence of the effect of socioeconomic position on health, and apply that evidence when developing CPGs.5,6 At the policy level, Health Impact Assessment (HIA) is gaining increasing recognition as a tool for assessing the potential effects of a policy or program on health. Health Impact Assessment that systematically addresses equity may also offer a way of incorporating equity concerns into the decision-making process. However, HIA is a comparatively new field, and decision makers are not usually trained in assessing the impact of policy decisions on equity. Through the Public Health Education and Research Program, the Australian Government has commissioned the development of an HIA framework to assist decision makers in systematically identifying potential health equity impacts of policies. This equity-focused HIA framework is currently being tested (through case studies in Australia and New Zealand) to assess whether and where it adds value to the decision-making processes. These two examples illustrate practical ways in which decisions by practitioners and policy makers can routinely incorporate equity issues in the Australian healthcare system. Ongoing investment and commitment is required to evaluate whether such initiatives make a real difference in achieving equity in health.

Elizabeth Harris · Sarah J Simpson · Rosemary Aldrich · Jenny Stewart Williams