Letters

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

Elvira Currie · Rhian Cope · Margaret C Hardy

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

Rosalie Schultz

To the Editor: Norman and Teede outline the new international guidelines on polycystic ovary syndrome (PCOS), led by Australia and involving 37 societies and patient support groups and 71 countries.1 These guidelines highlight gaps in evidence and emphasise the critical need for more research into PCOS.2 In the United States, a recent analysis of National Institutes of Health (NIH) research funding from 2006 to 2015 for PCOS concluded that PCOS research may be underfunded by the NIH.3 In Australia, the National Health and Medical Research Council (NHMRC) is the premier funder of medical research and its main funding mechanism is by way of project grants, with over 500 granted annually. Using NHMRC online data (https://www.nhmrc.gov.au/grants-funding/outcomes-funding-rounds/previous-outcomes-project-grants-funding-rounds) and searching for “polycystic” or “PCOS” in the titles of funded project grants, we found only nine grants associated with PCOS from 2003 to 2018. Additionally, while there are many not‐for‐profit organisations raising funds for medical conditions, there are none for PCOS. We have considered the issues that may affect funding for PCOS. It could be that the name PCOS does not accurately describe the condition because having polycystic ovaries is neither needed nor sufficient in order to diagnose PCOS, and the name does not indicate any of the condition's important metabolic symptoms.4 This could potentially lead to grants being assigned to panels without the full expertise required to handle such grants. Barriers to funding in Australia could also potentially include a lack of internationally competitive researchers in PCOS in Australia, but this is not the case. Australia has established an international network in PCOS and led the world by producing the first evidence‐based guidelines.2 Three individual Australian researchers are listed in the top ten in the world in PCOS research (http://expertscape.com/ex/polycystic+ovary+syndrome). This attests to the calibre of Australian researchers in PCOS. We acknowledge that the international guidelines were funded in part by the NHMRC via a Centre for Research Excellence in PCOS. The Centre's efforts have positioned Australia at the forefront of international PCOS activities and have highlighted the vital need for specific dedicated research funding. However, given Australia's leading global role in the development of PCOS guidelines and identification of knowledge gaps, we, along with patient support groups, believe that greater efforts are required to recognise the prevalence, diverse clinical impact and health and economic burdens of PCOS, and to prioritise funding for research into PCOS.

Raymond J Rodgers · Jodie Avery · Veryan McAllister

In reply

Helena J Teede · Robert J Norman · Rhonda M Garad

TO THE EDITOR: In 2016, there were an estimated 490 000 cases globally of multidrug‐resistant (MDR) tuberculosis exhibiting resistance to isoniazid and rifampicin.1 The first case of MDR tuberculosis diagnosed in Tasmania occurred in 2016 in a Vietnamese‐born person. Vietnam was the second highest reported country of birth for overseas‐born patients with tuberculosis notified in Australia in 2014.2 The patient had previously tested positive for tuberculosis infection in an interferon‐γ release assay test performed in Tasmania in early 2016, but at the time, the patient was asymptomatic and had a normal chest x‐ray and a negative sputum culture. After an episode of colitis, a colon tissue biopsy specimen isolated Mycobacterium tuberculosis. Whole genome sequence of the isolate (TASMDR1), identified high confidence mutations for isoniazid, rifampicin, ethambutol and pyrazinamide, in accordance with the culture‐based drug susceptibility testing, and, in addition, it identified a mutation associated with streptomycin resistance.3 We became aware that a household contact of the Tasmania‐located patient with MDR tuberculosis had been diagnosed with pulmonary tuberculosis in Vietnam in 2012 and requested the drug susceptibility testing data for this isolate (VTB1) from the treating hospital in Ho Chi Minh City. VTB1 was resistant to isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin in culture‐based drug susceptibility testing. We therefore obtained a genomic DNA preparation of VTB1 to enable direct comparison with the TASMDR1 isolate collected in Tasmania. Next generation sequencing of VTB1 was performed on an Illumina platform and paired‐end reads were mapped to the M. tuberculosis H37Rv reference genome (NC_000962.3). The Box shows variants associated with drug resistance. In addition to drug resistance mutations, VTB1 shared all previously described variants in TASMDR1 with respect to H37Rv3 and, therefore, the two isolates were genetically indistinguishable. This is strongly indicative of transmission involving the two patients based on established single nucleotide polymorphism thresholds.4 It is most probable that the patient diagnosed in Tasmania contracted the MDR strain of M. tuberculosis during the episode of pulmonary disease diagnosed in the household contact in 2012 and that the infection remained latent until reactivating as extrapulmonary MDR tuberculosis in 2016. In conclusion, the global burden of latent tuberculosis infection has been estimated to be 23% of the world's population, which corresponds to about 1.7 billion people.5 Despite the immense prevalence of latent tuberculosis infection, there are few reports in the literature that confirm using genome variant analyses for the translocation of the MDR form of tuberculosis from one jurisdiction to another as a latent infection and its subsequent emergence as active MDR tuberculosis in a new host country. This type of transit of tuberculosis is difficult to detect with pre‐immigration screening practices that are reliant upon a diagnosis of pulmonary tuberculosis based on a chest x‐ray. The international movement of MDR tuberculosis in latent form, as has been determined in this case, is an area of concern and could be a significant challenge for future tuberculosis eradication. The growing application of genome sequencing in tuberculosis diagnostics and surveillance will help establish the level of MDR tuberculosis cases due to reactivation of latent tuberculosis infection. Box – Drug resistance determining mutations in a contact who presented with tuberculosis in Vietnam in 2012 (VTB1) and in the first confirmed patient with multidrug‐resistant (MDR) tuberculosis in Tasmania in 2016 (TASMDR1). The isolate from VTB1 and TASMDR1 share identical drug resistance mutations Isolates Drug Gene Function Mutation Substitution VTB1 and TASMDR1 Rifampicin rpoB (Rv0667) RNA polymerase β‐subunit gAc/gGc, tCg/tTg D435G, S450L Isoniazid katG (Rv1908c) Catalase‐peroxidase aGc/aCc S315T Pyrazinamide pncA (Rv2043c) Pyrazinamidase/nicotinamidase cCg/cTg P62L Ethambutol embB (Rv3795) Arabinosyltransferase B Atg/Gtg M306V Streptomycin rrs (MTB000019) 16S ribosomal RNA a/c a514c* * Substitution located in a non‐protein coding gene. ◆

Sanjay S Gautam · Greg Haug · Louise A Cooley · Micheál Mac Aogáin · Ronan F O'Toole

TO THE EDITOR: The article by Stevens and Schweitzer1 contains many useful teaching pearls for frontline physicians and generalists. I concur with the final diagnosis reached and the excellent teaching points emphasised in the article. I would like to make two important points regarding localisation. First, binocular diplopia can be caused by diseases in a variety of locations in the neurological axis, not just the extraocular muscle. Other possible locations include the brainstem, the cranial nerves (III, IV and/or VI), the neuromuscular junction and the orbit itself. Accompanying features will help distinguish the location; for example, the presence of hemiparesis, cerebellar signs, or lower cranial nerve abnormalities would localise to the brainstem. Second, localisation is critical before organising neuroimaging, as knowing where the lesion is will prove useful for the radiologist. The likelihood of subtle pathologies being detected by the radiologist increases significantly when the site of potential localisation is included in the clinical request information. This helps to reduce the possibility of false negatives or misinterpretation if clinical correlation is not applied to test requests.2 Finally, there are two differential diagnoses to consider in this case. Myasthenia gravis, an uncommon disorder of the neuromuscular junction, is known to be a great mimicker and can cause various patterns of ophthalmoparesis and diplopia3 and it should be considered in all cases of binocular diplopia. In the article by Stevens and Schweitzer,1 this diagnosis was less likely in the patient given the painful nature of the ophthalmoparesis. The other rare differential diagnosis with serious implications to consider is a dural (or indirect) carotid‐cavernous fistula. Patients with this condition can present with painful diplopia without significant visual loss; they are frequently misdiagnosed by specialists and are eminently treatable endovascularly.4 The absence of orbital signs (eg, proptosis) and ocular signs (eg, arterialised “corkscrew” conjunctival vessels) assisted in excluding this condition as a differential in this case.

Benjamin Nham

TO THE EDITOR: We commend Heldens and colleagues1 for publishing their data on the incidence and in‐hospital mortality of sepsis and septic shock among patients admitted to Australian intensive care units (ICUs). The incidence of sepsis and septic shock in ICUs is estimated to be 101.8 and 19.3 per 100 000 patient‐years, respectively, at an attributable cost of $32 421.2 We concur that sepsis cases captured using the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation database criteria, compared with prospective clinical diagnoses,3 has poor sensitivity for sepsis case ascertainment. Notwithstanding, we propose that the application of a third surveillance metric using coded discharge data could be a viable alternative for sepsis case ascertainment and monitoring in ICUs. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‐10‐AM) diagnostic coding data are feasible to collect with a reduced risk of sampling bias and minimal loss to follow‐up. Using tandem dataset comparison following the implementation of a hospital‐wide sepsis pathway,4 we explored the utility of coding data for sepsis surveillance. We noted that 78% and 74% of ICU cases were designated an ICD‐10‐AM code denoting sepsis at admission and patient level, respectively (Box). Alarmingly, the concordance rate between coded administrative data and clinically verified sepsis diagnoses was even lower in non‐ICU settings. These data are in keeping with international reports.2 Robust and reproducible data are required to evaluate quality improvement regarding sepsis management. Given the poor sensitivity of research criteria and coding data, used in isolation for sepsis identification, a multifaceted approach is required. We hypothesise that the combination of administrative coding data and electronic medical record data, augmented with sepsis screening algorithms, may improve the sensitivity for sepsis case ascertainment in both cancer and non‐cancer settings.5 We encourage Heldens and colleagues to consider these suggestions as an alternative reproducible method needed to elucidate the incidence of sepsis and septic shock in Australian ICUs. Box – Relationship between sepsis cases satisfying clinical criteria and designated coded discharge data in intensive care unit (ICU) and non‐ICU settings, 2012–2014 Year Admission level ICU Non‐ICU All new admissions* ICD‐10‐AM captured cases Concordance All new admissions* ICD‐10‐AM captured cases Concordance 2012 38 27 71% 70 62 89% 2013 39 34 87% 175 103 59% 2014 81 61 75% 331 149 45% Mean (± SD) – – 78% (± 8.3%) – – 64% (± 22%) ICD‐10‐AM = International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification; SD = standard deviation. * Clinically diagnosed sepsis cases according to consensus diagnostic criteria.◆

Jake C Valentine · Gabrielle Haeusler · Leon Worth · Karin Thursky

TO THE EDITOR: We congratulate Heldens and colleagues1 for their work investigating the prevalence and mortality of sepsis within a tertiary hospital intensive care unit (ICU). As the authors rightly point out in their article and podcast, this requires careful screening, consistent diagnostic criteria, and considerable time and effort. The Australian and New Zealand Intensive Care Society (ANZICS) registry provides a highly specific, widely applicable, cost‐effective, timely and practical epidemiological measure of the prevalence and outcomes of sepsis and septic shock as a primary cause of ICU admissions throughout Australia and New Zealand.2 Findings from the registry appear consistent with those of Heldens and colleagues.1 However, their article confirms that there are more patients with sepsis within our ICUs than those who enter with this as an admission diagnosis. Between January 2016 and June 2018, 11.6% (43 529/374 442) of the ICU admissions reported to the ANZICS Adult Patient Database were due to sepsis as defined by the international Sepsis‐3 taskforce.3 In tertiary hospital ICUs, this was slightly higher at 12.1% (19 204/159 067), which is between 14.0% (121/864) by clinical criteria and 11.3% (98/864) by database criteria found within the first 24 hours of ICU admission by Heldens et al. With the recent addition of information about vasopressors and lactate levels, ANZICS can also now confidently identify patients with septic shock. Of 59 069 ICU admissions with available information, 3.3% (1978) had septic shock, again similar to the findings of Heldens et al. ICU admissions in the ANZICS registry due to sepsis or septic shock were associated with mortality of 15.1% and 26.7%, respectively. Heldens et al reported a similar mortality of 24% (8/33) with septic shock identified in the first 24 hours of admission (Appendix, table 4). The study by Heldens et al and the findings from the ANZICS registry are complementary. Together they highlight how the measurement of sepsis depends on the exact definition applied, and the population under consideration, which may vary between clinical practice, prospective observational and interventional studies, and widespread epidemiological comparisons.

David Pilcher · Sue Huckson · Peter Hicks

To the Editor: Schilling and colleagues1 state that the Australasian Rehabilitation Outcomes Centre (AROC) — the national rehabilitation clinical quality registry for Australia and New Zealand — does not routinely collect data on post‐surgery outcomes for private total knee replacement (TKR) recipients. This statement is factually incorrect. All private inpatient rehabilitation services in Australia are members of AROC and routinely submit data (including functional outcomes as assessed by a functional independence measure) describing all episodes of rehabilitation they provide. More specifically, over the period described by Schilling and colleagues,1 AROC received data on outcomes for 93 278 TKRs receiving private rehabilitation. If we restrict the AROC data to match the study data (patients aged 40–89, single TKR, first admission), AROC received data describing 76 847 privately rehabilitated TKRs. In rehabilitation, the Australian National Subacute and Non‐Acute Patient Classification2 is routinely used to classify episodes into resource‐homogeneous groups. In interrogating the AROC TKR data, we concur with Schilling et al1 that the average length of stay in rehabilitation has been declining, with this decline accelerating over the past 5 years. Concurrent with the decline in length of stay, the functional change achieved (both absolute and relative) during rehabilitation has been increasing, and has in fact accelerated over the past 5 years. Achieving more functional change in a shorter length of stay shows that services are becoming more efficient while also continuing to produce positive outcomes for their patients. Moreover, it is also factually incorrect that AROC does not collect data outside of the inpatient setting. In fact, AROC also runs an ambulatory benchmarking initiative, and while coverage is not 100%, it is growing. There are currently 35 private ambulatory rehabilitation services that participate and routinely provide data describing their ambulatory rehabilitation outcomes. In conclusion, we suggest that while the authors provide an interesting analysis, it is incomplete, given that they did not include function — the key driver of cost and outcomes in rehabilitation — as one of the variables they used.

Frances Simmonds · John H Olver

To the Editor: In reply to Shilling and colleagues,1 the Rehabilitation Medicine Society of Australia and New Zealand refers the authors and readers to our position statement regarding referral for rehabilitation in the home after total knee replacement (TKR).2 Shilling and colleagues1 state that the most important determinant for referral to inpatient rehabilitation was the hospital where the TKR took place. Independent researchers might be more circumspect, considering there is no acknowledgement that Medibank Private did not fund rehabilitation in the home nationally during the study period nor whether their data included outpatient rehabilitation carried out as “same day rehabilitation”, usually coded as inpatient. Also, disturbingly, some of the literature is misrepresented. The unblinded Canadian randomised controlled trial3 comparing a publicly funded combination of rehabilitation in the home and hospital‐based outpatient therapy with inpatient rehabilitation is not generalisable to privately insured Australian patients. Moreover, the Australian randomised controlled trial4 showing equivalent outcomes for the same two groups excluded patients who were appropriately referred for inpatient rehabilitation on the basis of numerous patient factors. The present study included few patient factors and not clinically relevant factors, such as obesity, ability to walk after TKR, or complications.1 Finally, while no patient safety or outcome data were included, the choice to include the dollar value of the previous year's private hospital claims seems gratuitous — are those patients with higher cost to insurers more likely to use inpatient rehabilitation, or perhaps they were just sicker? It is interesting that no reference is made to the 2017 study that found that referrals to inpatient rehabilitation were directly influenced by preferences of the patient, the surgeon, therapists, discharge planners, insurers and others.5

Steven G Faux · Lee Laycock

To the Editor: In their recent article and media release, Schilling and colleagues1 concluded that after total knee replacement (TKR) “some inpatient rehabilitation is low value care”. The research was funded by Medibank Private. The article comes at a time of increasing interest in rehabilitation in the home (RITH) for TKR and other rehabilitation problems. Despite widely proclaimed opinions, there is limited high level evidence regarding outcomes for inpatient rehabilitation versus ambulatory rehabilitation. In research examining the benefits of RITH, higher complexity patients are often excluded from the studies.2 One of the limitations of this article is that important “patient‐related factors … including obesity, pre‐operative physical and mental health … functional performance” and others, “were not available”. A significant gap in the current debate is an almost total absence of nuanced thinking regarding which patients are clinically indicated and safe to have RITH. The authors’ conclusion is only a relatively minor aspect of the real problem, which is to ensure the best outcome for the patient. That is, we must confidently identify the right rehabilitation program, at the right time and in the right place. The Australasian Faculty of Rehabilitation Medicine3 is committed to ensuring high quality rehabilitation medicine services. We believe that: while many patients with uncomplicated TKR may be appropriate for RITH, there are many others for whom RITH is inappropriate or unsafe; the appropriate setting for TKR rehabilitation should be determined on evidence‐based clinical indicators and minimum safety standards;4 all patients with TKR (apart from the most uncomplicated cases) require referral to and assessment by or on behalf of a rehabilitation medicine physician (or other appropriately trained physician); and some ambulatory rehabilitation programs may be appropriate for TKR and other rehabilitation, but they must be evidence‐based, interdisciplinary, led by a rehabilitation medicine physician and adequately resourced, and not simply seen as a cheaper panacea for a struggling system. To achieve the best outcome for patients, decisions must be individualised and patient‐centred and they should start with a referral to a rehabilitation medicine physician, who can determine the right rehabilitation program, at the right time and in the right place. There are circumstances in which RITH is an alternative to inpatient rehabilitation for appropriately selected patients.4 Let's ensure, however, that we do not throw the baby out with the bathwater.

Timothy J Geraghty · Andrew M D Cole · Gregory Bowring

In reply

Chris Schilling · Anna Barker · Stephen F Wilson

To the Editor: We write to express our concerns regarding the Clinical Oncology Society of Australia (COSA) position statement on exercise in cancer care published in the MJA1 and promoted in media outlets as a “world‐first” position statement that calls for exercise to be prescribed for all patients with cancer.2 The guideline replicates those first published in Australia in 20093 and in the United States in 20104 as well as by other organisations,5 and are the same as public health recommendations for healthy adults.6 Given the array of cancers, disease stages and treatments and their combinations, it is somewhat surprising that the same general guideline is being prescribed for all patients with cancer and is not differentiated from that for healthy adults — especially, given patient health and comorbidity status and the challenges that a cancer diagnosis and treatment entail. Research in exercise oncology has progressed over the past 9 years, and more targeted and tailored guidelines reflecting the developing evidence base are now required for implementation in this population. Moreover, the majority of patients with cancer are unable to meet the COSA recommendation of at least 150 minutes of aerobic exercise and two to three resistance exercise sessions due to time availability and physical, psychological and financial capacity as well as access, let alone the level of care required for those with advanced disease. It is significant that the COSA recommendation has not been refined through clinical trials in patients with cancer and has the potential to create considerable angst for the patient and raise concerns for clinicians, who know that their patients may not be able to achieve such goals. Moreover, we highlight that there is minimal financial support for patients with cancer to undertake ongoing exercise, making the COSA recommendation somewhat superfluous. When exercise is prescribed, it must be evidenced‐based and tailored to specifically ameliorate adverse health problems, while recognising that certain modes and dosages of exercise may be detrimental. We agree that there is considerable potential for exercise medicine in the management of cancer; however, a more considered approach needs to be implemented rather than the generic exercise recommendations of the COSA statement.

Robert U Newton · Dennis R Taaffe · Daniel A Galvao

In reply

COSA Exercise and Cancer Group Executive Committee

To the Editor: It was a pleasure reading the 20 August 2018 issue of the Medical Journal of Australia, containing many informative, broad‐ranging articles. However, the absence of the authors’ qualifications, which ultimately establish who the authors actually are — possibly reflecting their credibility — may render an article potentially less valid for the readership. This contrasts with the detailed and impressive qualifications of the MJA staff members, faithfully and appropriately listed in each issue, transparently demonstrating their expertise. No MJA author is awarded such recognition. The perspective by Munk and colleagues1 highlighted the threat posed by predatory journals to researchers and academic literature. The MJA lists only their affiliations; therefore, the readership is unable to establish a frame of reference for their opinions. Cursory investigation reveals lead author, Peter Munk, to be a Canadian radiologist, thereby impressing also as an authority on predatory journals. Rochwerg and colleagues2 discuss clinical decision making with network meta‐analysis. Without their qualifications, the reader is unable to determine whether they are physicians, statisticians, health economists or politicians. In their helpful Editorial, Shorthouse and Stone3 examine the need for additional mental health care training for rural medical practitioners. It turns out that both authors are Australian general practitioners — Molly being a rural generalist, and Louise a professorial medical educator. Interestingly, neither is a specialist psychiatrist. Professor Olver4 discusses B‐cell non‐Hodgkin lymphoma in Queensland. Despite his fame, his Editorial would potentially have been augmented had the readership been presented with his impressive research and clinical credentials. It seems reasonable to raise the notion that the absence of authors’ postgraduate and other qualifications could diminish their contribution to the medical literature. Our group has previously documented the importance of journals publishing authors’ qualifications.5 We published that “if the author qualifications are designated, the reader may be quite sure that the article was not written by the medical records librarian, let alone the hospital trolley boy in a moment of inspiration”.5 This is not to say the hospital trolley boy is not entitled to offer his thoughts on a medical subject. Rather, it provides the readership with perspective concerning authors’ expertise and opinions.

Damien L Ling · Anna M Waldie · Ian C Francis

In reply

Nicholas J Talley AC

To the Editor: Doctors for the Environment Australia welcomed MJA’s recent planetary health issue.1 It could not come at a more crucial time. Human health and the environment are inextricably linked, and medical professionals have a vital role in actively protecting health through care of the environment. However, it was disappointing that little emphasis was given to the need to significantly mitigate greenhouse gas emissions, and to the important advocacy role that medical professionals share to raise awareness of the urgency of delivering Australia’s Paris Agreement commitment. Global temperature rises greater than 1.5–2°C will adversely affect planetary health, sustainable development and nearly all future health goals.2 Further temperature increases will be catastrophic to sea level rises and the food and ecosystems on which human life depends. While countries such as France and China move ahead on mitigation measures, Australia is, at best, slow to understand the urgency or, at worst, an active global laggard. Australia is one of the OECD countries most vulnerable to climate change;3 it is among the top seven countries contributing to 60% of the world’s biodiversity loss,4 and yet it is not transitioning jobs or future wealth towards sustainable energy. All while human-induced environmental threats to the global riches of the Great Barrier Reef, the Northern Territory and the Pilliga and Tarkine forests are fast becoming this generation’s environmental legacy. Doctors should urgently raise awareness of the threats to health from climate change, advocate to mitigate the threats, and show in practice that transitioning to low carbon societies in energy, diet and transport have health co-benefits. The greatest global health threat of the 21st century posed by climate change is also health’s greatest opportunity.5 Australian medical staff can systematically push the planetary health agenda into university training, specialist colleges, hospitals, clinics and communities. We are well placed to do so.

Selina N Lo · Kaiya Ferguson · Eugenie Kayak · Kingsley Faulkner

To the Editor: In 2007 and again in 2012, we highlighted in the Medical Journal of Australia1,2 the limited access Australian prisoners had to essential health protection measures. Six years on, we can only report that progress has been minimal (Box). In August 2012, the Australian Capital Territory Chief Minister announced the implementation of a needle exchange program for prisoners in the ACT; 6 years later, the ACT government retracted its commitment. Canada has recently agreed to a pilot prison-based needle exchange, with a commitment to national implementation in 2019. Human immunodeficiency virus (HIV) is still not a concern in Australian prisons, although bleach provision and condoms are still severely restricted in Queensland and the Northern Territory, and effectively not available in Victoria and Tasmania. Hepatitis B immunisation coverage continues to improve, and chronic hepatitis B infection is not increasing among Aboriginal and Torres Strait Islander prisoners.3 The availability of direct-acting antiviral treatments for hepatitis C infection for all Australians, including prisoners, has some Australian prisons already reporting treatment achievements commensurate to international treatment targets for 20304 — the term “micro-elimination” has been applied to facility by facility reduction of burden of this infection. However, despite reductions in hepatitis C in Australian prisons, the risk of transmission is ever present.5 The predictors of successful return to the community include housing, employment and maintenance of relationships;6 yet, private family (conjugal) visits are only allowed in some Victorian prisons and in one South Australian prison farm. Visits are definitely not available to ACT prisoners, since previous enabling policy was repealed in 2014. Safer sex is still an elusive aspiration for the majority of Australian prisoners and their families. Tattoo and body piercing programs are being implemented in prisons in Luxembourg and Catalonia, Spain. Despite this activity being successfully regulated in the community, there are still no verifiable reports of sanctioned programs in Australian prisons. In 2012, we questioned Australia’s commitment to protecting the health of prisoners.2 With changes in prison harm reduction programs internationally (notably, Canada) underpinned by legal challenges, we foresee that similar proceedings could have a place in finally driving reform in Australia. Box – Progress in Australian prisoners’ access to essential health protection measures Jurisdiction Changes since 2012 Australian Capital Territory Bleach available in single unit sachets; micro-elimination of hepatitis C from the only prison; private family visits ceased; support for a prison needle exchange program withdrawn New South Wales Micro-elimination of hepatitis C from several prisons Northern Territory No notable changes Queensland Still considering opiate replacement therapy; micro-elimination of hepatitis C from one prison South Australia Private visits available at one prison farm Tasmania Micro-elimination of hepatitis C from one prison Victoria Micro-elimination of hepatitis C from several prisons Western Australia Poor uptake of hepatitis C treatment

Michael H Levy · Carla J Treloar