Letters

To the Editor: We read with interest the report by Sitas and colleagues about the Australian Broadcasting Corporation (ABC) breast cancer cluster investigation.1 After publication of the final report on the ABC cancer cluster,2 the Public Health Unit of Sydney South West Area Health Service undertook a similar investigation. In May 2007, our Public Health Unit was contacted by an occupational health representative after reports of five recent cases of breast cancer among women working in two departments at a Sydney hospital between 2002 and 2006. Four of these cases were confirmed, and all four women had offices in the same area of the hospital. Based on the assumption that women employed in these two departments between 2001 and 2006 (a total of 69 women) were the population “at risk”, we found that there was an excess of observed cases over expected cases (standardised incidence ratio [SIR], 15.1 [95% CI, 4.1–38.8]; P < 0.001). There were no known hazards affecting these women that would not be present elsewhere in the hospital, so an expert panel recommended a hospital-wide epidemiological investigation and environmental survey. The case definition was any woman diagnosed with invasive breast cancer while working at the hospital between 1 January 1998 and 31 August 2007. To ascertain cases, we wrote a letter to all current employees and issued a media release. A dedicated telephone hotline received 147 calls from 19 July to 31 August 2007. We confirmed 24 cases meeting the case definition. These women had a mean age of 51 years at diagnosis, had worked at the hospital for a median of 11 years, were not clustered by work location or type, and had similar risk factors for developing breast cancer to women in the New South Wales population as a whole. From employment records and NSW cancer statistics, we calculated that 23 cases of invasive breast cancer would be expected based on the age structure and size of the female workforce at the hospital over the study period. The observed number of cases was not significantly different from the expected number (SIR, 1.1 [95% CI, 0.7–1.6]; P = 0.44).3 In the environmental survey, no unusual hazards were identified. Breast cancer is the most common invasive cancer diagnosed in Australian women.4 In most cases, potential “clusters” are probably a chance occurrence, even when the number of cases is statistically significantly higher than expected, with no plausible explanation identified.5 Our investigation found no excess of cases of breast cancer in women employed at the hospital over the study period. Guidelines6 are helpful in defining a consistent approach to cluster investigation, but such investigations are resource intensive. Careful initial analysis of information is important to determine whether further investigation of a reported cluster is warranted. In our study, we concluded that a broader investigation was justified.

Catherine Francis · Trish F Mannes · Leena Gupta · Stephen J Conaty

To the Editor: Flitcroft and colleagues’ discussion of the National Bowel Cancer Screening Program provides a useful reminder of how political, institutional and financial issues can affect evidence-based policy.1 Bowel cancer is second to prostate cancer as the biggest cause of cancer death in Australian men, and men are more likely than women to be diagnosed with bowel cancer. There are no indications, however, that the screening program has sought to engage men as a target group. Men and women think about and act on their health in different ways and respond differently to messages, sources of information and modes of information delivery.2 Men are less likely than women to undergo preventive screening and are more likely to seek treatment at a later stage in a disease. A report for the Australian Government noted that, before receiving the Bowel Cancer Screening Pilot Program material, men were less likely to have been aware of preventive or pre-emptive behaviours “unless their GP had actually raised the subject with them, or a close friend had suffered, bringing the issue to a more personal level”.3 Further evidence indicated that fewer than one-third of men participated in the screening from mid 2006 to mid 2007, despite men aged 55 and 65 years being more likely than women to return positive results; among men aged 55 years, only 28% chose to participate.4 Participation rates during the 2-year screening period ending August 2008 were estimated to be 39.2% for men and 46.7% for women.5 Despite the considerable evidence that the “doing of health” is a highly sex-dependent activity, a population-based, “one size fits all” approach appears to have been adopted. Adding further insult to injury, men were blamed for their lower participation rate and for failing to understand “that screening for cancer saves lives”.6 A disappointing response to a free breast cancer screening initiative, on the other hand, prompted an investigation into the relationship between the wording of the screening invitation letter and the level of screening attendance.7 With around one in 19 men predicted to develop bowel cancer before the age of 75 years, men’s under-representation in bowel cancer screening is a serious problem. There is a need for more attention to be given to men’s attitudes and beliefs about risk and prevention, with a view to developing specific approaches to increase men’s participation in screening.8 It should not be too much to expect that Australia’s first National Men’s Health Policy, and an updated National Women’s Health Policy, will result in sex being taken into account in the design and implementation of national health initiatives.

Margo H Saunders · Anita Peerson

To the Editor: Flitcroft and colleagues’ historical report of bowel cancer screening in Australia is helpful to those new to this internationally accepted life-saving practice.1 One inaccuracy needs correcting. Lung cancer is the leading cause of cancer death in Australia — not prostate or breast cancer. Flitcroft et al appear to have quoted the Australian Institute of Health and Welfare data for new diagnoses, not cancer deaths.2 This error reflects the general lack of community focus or interest in the more than 7000 Australians who die each year from smoking-related lung cancer.3 An update is also warranted. Since submission of their article, once-only flexible sigmoidoscopy screening has joined faecal occult blood test (FOBT) screening in having randomised controlled trial evidence. Results of a recent British study point to the necessity of looking for this occult disease with flexible colorectal endoscopy.4 The study showed a massive 43% reduction in colorectal cancer mortality and a 50% reduction in incidence of invasive rectal cancer, owing to early flexible sigmoidoscopic diagnosis of colonic polyposis followed by polypectomy performed at subsequent colonoscopy. These techniques save thousands of lives worldwide each year. Flitcroft et al state that “A staged roll-out is a sensible approach”, but many of us who perform colonoscopic polypectomies on a weekly basis strongly disagree. Which is better — to be on a waiting list for a colonoscopy with a positive FOBT result, or to be ignorant of the possibility of a growing cancer in the colon? It is time to give people the opportunity of FOBT with or without further investigations. Flitcroft et al rightly point out that the National Health and Medical Research Council recommended that we should have at least biennial FOBT screening for individuals over 50 years of age.5 Australians have been very tardy in terms of adopting this recommendation. We don’t need an “age-specific cost-effectiveness analysis”. The argument should be about introducing flexible sigmoidoscopy. Like Semmelweis and hand washing back in 1847, history will judge our current generation harshly for ignoring the original life-saving FOBT research that was published in 19936 and allowing thousands of Australians to die unnecessarily from bowel cancer since then. It is time for us to take our heads out of the sand and introduce a proper national bowel cancer screening program. Thank you to Flitcroft and colleagues for helping us take another step in this direction.

Guy R Hingston

To the Editor: As public health professionals, we strongly support Givney’s call for the creation of an Australian national authority for disease prevention and control.1 This proposal is by no means a new one,2 but its relevance has, if anything, increased with time. Such an authority would structure and coordinate responses to emerging disease threats, as well as ensure that Australia has the national public health infrastructure required to coordinate the increasingly complex strategies needed for disease surveillance more generally. Human papillomavirus (HPV) surveillance is a recent case in point. Between 2007 and 2009, Australia delivered what remains the world’s most widely targeted HPV vaccination program, offering free vaccination with quadrivalent HPV vaccine to all girls and women aged 12 to 26 years. Australia’s excellent cancer registries will be able to accurately monitor the anticipated decline in cervical cancer incidence, but it will not occur for decades. In the meantime, we need to track more immediate vaccine impacts, such as the incidence of genital warts, incident Pap smear abnormalities and type-specific HPV infection. Specialist groups are initiating their own studies in these areas, with funding from a combination of government and industry sources, but there is no coordinated system for bringing together the key components of surveillance, and for ensuring that they are properly funded and analysed. The surveillance requirements for an HPV vaccination program are complex because of the multiple outcomes of vaccination, varying time scales over which these outcomes are expected, and the range of stakeholders involved in the fields of immunisation, cancer control and sexual health. No clear ownership or responsibility for comprehensive surveillance is apparent in Australia. In the United States, the Centers for Disease Control and Prevention have taken responsibility for coordinating HPV surveillance,3 and in the United Kingdom efforts are led by the Health Protection Agency, with planning and funding for comprehensive surveillance having been established at the outset of the immunisation program. The creation of an independent, well resourced body that is expert in disease control and prevention will ensure that Australia is best placed to respond to emerging disease threats as well as able to obtain maximum value from the implementation of prevention strategies.

Julia M L Brotherton · John Kaldor · Marion Saville

To the Editor: Givney’s recent letter restated the case for a national centre for disease control.1 His arguments for national planning, and particularly for a non-politicised approach to coordination and modification of responses to public health threats based on evidence, will be welcomed by many. A clear example of the validity of his case is provided by the recent pandemic (H1N1) 2009 influenza. In hindsight, despite certain risk groups being severely affected,2 the 2009 influenza season was generally mild.3,4 However, the public health response, based on the agreed pre-pandemic plans, was personnel-intensive and long-lasting.5 Crucially, there was a need for a well trained, flexible epidemiological workforce to rapidly analyse data to inform any response. Here, we highlight the contributions of Master of Applied Epidemiology (MAE) staff and students to this component of the response. The MAE program has operated as Australia’s only field-based epidemiology training program since 1991. MAE staff and students were enlisted to the response within days of the pandemic alert, as they constitute the only readily available epidemiological capacity in Australia. A survey conducted in February 2010 indicated that between April and December 2009, 18 students and five MAE staff members contributed 1159 person-days (3.2 person-years) to the response at local, state and national levels and internationally in New Zealand and with the World Health Organization. Contributions included establishing and evaluating surveillance systems, data analysis and reporting, training and supervision, rapid assessment and longer-term research projects. Areas covered included: border screening; investigation of clusters of cases related to air arrivals; school, prison and household transmission studies; analysis of state and national data; and establishment of a hospital-based sentinel surveillance system. Research findings have been disseminated widely via government reports, seminars, conference presentations and peer-reviewed publications. During the pandemic, the MAE program provided epidemiological “surge capacity”. This vital technical input to higher-level analysis allowed policy responses to changing evidence, a contribution that needs to be maintained and strengthened if Australia is to respond appropriately to future emerging disease threats. A logical home for a field epidemiology training program such as the MAE would be a national centre for disease control, with strong linkages to one or more academic institutions. We therefore echo Givney’s call for the establishment of an Australian centre, providing independent, evidence-based advice to governments, and incorporating a strong commitment to workforce capacity building and sustainability.

Paul M Kelly · Kamalini Lokuge · Hassan Vally · Alexander S Cameron

To the Editor: We report the use of nebulised frusemide for the symptomatic treatment of end-stage congestive heart failure (CHF). An 84-year-old man with New York Heart Association class IV CHF was referred to the Community Heart Failure Team at St Vincent’s Hospital, Sydney, for ongoing management after a hospital admission for acute pulmonary oedema. His medical history included aortic stenosis, pulmonary hypertension, type 2 diabetes, chronic renal failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD) and hypercholesterolaemia. The patient’s medications were home oxygen via a concentrator at 2–4 L/minute; digoxin 62.5 μg three times a week; warfarin 5 mg daily; glyceryl trinitrate 25 mg daily (delivered via a patch); simvastatin 40 mg nightly; spironolactone 12.5 mg daily; frusemide 80 mg orally twice daily (flexible regimen); insulin/isophane (Protaphane; Novo Nordisk) variable dose twice daily; fluticasone 250 μg/salmeterol 50 μg (Seretide; GlaxoSmithKline) one dose twice daily; and omeprazole 20 mg daily. Previous trials of a β-blocker and angiotensin-converting enzyme inhibitor were not tolerated. Two days after the patient was discharged, a home visit by the clinical nurse consultant (CNC) found him with grossly oedematous legs, jugular venous pressure (JVP) elevated above his ears, and crepitations from the bases to the upper mid zones of his lungs. On Day 1 and 2 of CNC care at home, the patient received intravenous bolus doses of frusemide 80 mg, resulting in good diuresis. On Day 3, the CNC was unable to gain intravenous access and, after consulting the Community Heart Failure Team cardiologist and pharmacist, administered frusemide 80 mg via a nebuliser. The patient reported immediate improvement. Oxygen saturation increased from 88% to 97% on room air and his chest was clearer on auscultation. Increased diuresis occurred, with weight loss of 1 kg. Because the patient’s JVP and leg oedema were unchanged, the dose was repeated daily for 5 days until respite admission (for social reasons and intravenous frusemide administration). Nebulised frusemide had provided symptomatic relief from dyspnoea for about 5 hours with no adverse effects for the patient, but did not provide sufficient diuresis to reduce his fluid overload symptoms. Ultimately, a central catheter (“long line”) was inserted to enable the CNC to administer frusemide intravenously at the patient’s home. CHF-associated dyspnoea causes significant morbidity and distress for patients and carers. Nebulised frusemide has been used for relief of dyspnoea associated with asthma, COPD and malignancy.1 Its precise mechanism of action is unknown, but is believed to be through local lung rather than renal effects.1 Our searches of MEDLINE, EMBASE, CINAHL and the internet found no reports of the use of nebulised frusemide for dyspnoea resulting from pulmonary oedema or CHF. Patients with CHF receiving palliative care have limited options for diuresis when oral administration is ineffective and intravenous access is unavailable. The use of nebulised frusemide could have potential in this setting, but requires further research.

Kate A Towers · Kimberley A Bardsley · Peter S Macdonald

To the Editor: We report a case of ischaemic stroke in a 34-year-old man with severe vitamin C deficiency caused by poor nutrition. The patient was a lifelong non-smoker with no history of hypertension or hypercholesterolaemia, and no family history of stroke, although he had recently been diagnosed with type 2 diabetes mellitus. At presentation, neurological examination showed profound left-sided hemiparesis, with normal sensory examination and visual fields. Cardiovascular examination was normal, and there were no carotid bruits. The patient’s body mass index was 25.5 kg/m2. Magnetic resonance imaging of of his brain showed acute infarction in the right posterior corona radiata (Box, A). Coagulation and lipid profiles were normal. Glycosylated haemoglobin was 7.1%. Comprehensive testing for underlying thrombophilia, vasculitides and Fabry disease all returned negative results. Computed tomography angiography and carotid ultrasonography confirmed normal carotid and vertebral arteries. Transoesophageal echocardiography showed a structurally normal heart without a source of embolus. The patient had poor dentition, with calculus deposition, scorbutic gums and gingival inflammation (Box, B), and reported easy bruising in recent months. Suspecting a diagnosis of scurvy, we conducted a nutritional assessment of the patient. His diet consisted mainly of fast food, with negligible vegetable and fruit intake, and no vitamin supplementation. For the week before admission, we determined that his average vitamin C intake was 4 mg/day. This corresponded to a > 99% probability of inadequate intake when compared with the estimated average requirement of 30 mg/day for adults1 (z = − 4.33; P = 0.0015). Laboratory testing confirmed the presence of severe vitamin C deficiency (< 5 μmol/L; reference range, 40–100 µmol/L). The patient was admitted to a stroke unit, commenced on aspirin, ramipril and atorvastatin, and received dietary counselling. Vitamin C 1000 mg daily was prescribed for one month. Subsequent testing confirmed normalisation of his plasma vitamin C. Following inpatient rehabilitation, he regained motor function and returned to independent living. There is growing evidence that vitamin C deficiency is an important, but largely unrecognised, risk factor for modification in patients with cerebrovascular disease.2 Vitamin C is a water-soluble antioxidant that inhibits oxidation of low-density lipoprotein and protects against endothelial dysfunction. Primate models have confirmed that cerebral infarct size is inversely related to cerebral vitamin C content.3 Although scurvy is now relatively rare, subclinical vitamin C deficiency is not uncommon, being present in about 10% of the general population.4 Alcoholics, institutionalised and elderly people are particularly at risk. In this case, we hypothesise that an unhealthy diet resulted in deficiencies in antioxidants (including vitamin C), and that this contributed to stroke pathogenesis. The marked prematurity of disease onset may have resulted from effect modification of antioxidant deficiency on conventional atherosclerotic risk factors (such as diabetes). A cohort study previously observed the modifying effect of vitamin C deficiency on the association between stroke and hypertension.5 However, it is unlikely that a direct causal link will ever be established. Since malnutrition and unhealthy eating practices continue to be serious public health problems, we suggest attention to nutritional status should be incorporated into the new standard of stroke care. Perhaps a new adage should be considered: an orange a day keeps stroke away? A: Diffusion-weighted magnetic resonance image of the patient’s brain showing an acute infarction in the posterior limb of the right corona radiata. B: The patient’s mouth showing scorbutic gums consistent with scurvy.

Emily Y-J He · Louis W Wang · Matthew C Kiernan

To the Editor: Burger and colleagues reported the limitations of pre-August 2010 Pharmaceutical Benefits Scheme (PBS) criteria for subsidised anti-tumour necrosis factor-α (anti-TNF-α) treatment of perianal Crohn’s disease (CD).1 PBS-subsidised infliximab is now available for CD patients with a Crohn’s Disease Activity Index (CDAI) > 300 who have failed to achieve an adequate response to minimum doses of steroids and immunomodulators, and for patients with fistulising CD.2,4 In contrast with some Australian centres, our hospital has given infliximab to patients who fell outside these restrictions for indications for which clinical efficacy has been shown.1 We report on infliximab use and patient outcomes in patients with CD and ulcerative colitis (UC) since local PBS-subsidised use commenced in October 2008. Between October 2008 and February 2010, 57 patients at our hospital (44 with CD and 13 with UC) commenced infliximab treatment. Patients were assessed for remission status at 6–8 weeks after commencement of infliximab therapy (ie, after the induction course of three infusions). Twenty-four CD patients met PBS criteria. Of these, 12 achieved remission (CDAI < 150 [n = 8] or clinical remission on symptomatic grounds [n = 4]), eight showed clinical or endoscopic improvement justifying continued infliximab treatment, and four had no treatment response. Twenty CD patients did not meet PBS criteria. Of these, nine achieved remission (CDAI < 150 [n = 7] or clinical remission on symptomatic grounds [n = 2]), nine showed clinical or endoscopic improvement, and two had no treatment response. Reasons for not meeting PBS criteria were as follows: insufficient trial of prednisolone and an immunomodulator (10 patients, of whom 1 had no treatment response to infliximab); insufficient trial of an immunomodulator alone (7 patients, of whom 1 had no treatment response to infliximab); insufficient trial of prednisolone alone (2 patients); and CDAI < 300 (1 patient, who subsequently achieved clinical remission). Fourteen patients had perianal disease, of whom five did not meet PBS criteria. Of the 13 patients with UC, none were eligible for PBS-subsidised infliximab treatment. Six achieved, and remained in, clinical remission after a full infliximab induction course of three 5 mg/kg doses. Of the seven patients who did not, two initially responded but failed on reintroduction of treatment after an infliximab-free period. The other five had no response; three required colectomy. Our audit showed that less than half of patients receiving infliximab for inflammatory bowel disease fulfilled PBS guidelines for subsidised prescription, mostly because of relatively strict requirements for prior steroid and immunomodulator therapy, and the absence of UC as a listed indication. Furthermore, our CD patients who did not meet PBS criteria had similar treatment outcomes to those who did. Thus infliximab treatment can be of major benefit to patients with refractory disease whose only other treatment alternatives are experimental therapies or major surgery. Further revisions to PBS criteria for anti-TNF-α therapy, including relaxing restrictions for CD and providing access for patients with severe UC, are required.

Nicholas A Biehl · Janina Pawlik · Geoffrey M Forbes

To the Editor: I cannot argue with the push by Hickie and McGorry for services for young people from 12 to 25 years of age who suffer from “depression”.1 But I question their sequencing of treatments model that pervades the beyondblue draft clinical practice guidelines about which they editorialise. Their model presupposes a unitary entity of “major depression” that varies in severity, with milder conditions being treated by psychotherapy and more severe conditions being treated with antidepressant medication. Consider the following case to show how the guidelines get it wrong. A 16-year-old girl presents with her first episode of moderately severe major depression. She is treated as per the guidelines for depression with a selective serotonin reuptake inhibitor (SSRI) and rapidly develops a severe psychotic mania. She is certified to a psychiatric facility and requires a prolonged admission. For the next 2 years she remains chronically hypomanic, refusing to try better treatment. Eventually, following a severe depressive episode, her treatment is reorganised and her condition stabilises. However, the trauma and psychosocial damage from the hospitalisation and prolonged period of illness are significant. In the guidelines, bipolar disorder — arguably the only “biological” kind of depression in this age group — is separated from the body of recommendations for managing depression. The possibility that this episode of depression may be part of an as-yet-undeclared bipolar disorder needs to be thoroughly integrated into the understanding and management of “depression”.2 Features that would suggest possible bipolar disorder include psychomotor retardation and cognitive impairment,3 psychosis, reverse neurovegetative features (hyper-somnia or hyperphagia),4 a few manic symptoms mixed with depression5 (racing thoughts, distractibility, flight of ideas, increased energy or psychomotor agitation), or the depression not making sense psychologically. Past episodes of depression, brief hypomania, anti-depressant-induced hypomania, or a family history of bipolar disorder also need to be documented. Doctors should then routinely discuss with patients and families the possibility that bipolar disorder could be diagnosed, and warn that the patient may experience a manic switch. If the likelihood is high, as part of a proper process of informed consent, the patient should be offered concurrent lithium or antipsychotic medication. The patient and family can be assured that expert clinical observation over time will clarify the diagnosis and what treatment is appropriate. This approach not only involves the patient and family in decision making, giving knowledge and choices, but, importantly, incorporates the reality of diagnostic uncertainty.

Norman P Zimmerman

In reply: Zimmerman correctly highlights the intrinsic limitations of applying the current “evidence base” for managing severe depression in young people. In part, our critique of the new guidelines1 stems from our shared concern about their real utility in clinical practice. As we have outlined elsewhere, we do not favour a simple “sequencing of treatments” model or recognise a clear separation between early phases of severe unipolar or bipolar depression.2 The real difficulty for clinicians is that young people presenting with severe depression are not only at high risk of immediate harm, but may also be on the path to a range of different psychiatric (and neurobiological) outcomes, including bipolar disorder, psychotic disorders and comorbid alcohol and substance misuse.2,3 Unfortunately, there are no clear clinical, neuropsychological or biomedical predictors of the relative risks of developing these adverse outcomes.2,3 Consequently, we have recommended the development of a broader clinical trials network that recognises this complexity and seeks to develop a more relevant evidence base in the future.4 For now, we need to continue to develop clinical service initiatives that not only engage young people but can provide the longitudinal and more specialised care that may be required for those who develop more complex disorders.5

Ian B Hickie · Patrick D McGorry

To the Editor: In their recent letter, Colquhoun and Jenkins1 correctly note that the external jugular venous pressure is as reliable as the internal jugular venous pressure in estimating right atrial pressure. Furthermore, the external jugular vein is more readily visible and accessible for cannulation should accurate measurement be required. While routine clinical observation is important, direct invasive measurement of right atrial pressure may be required in patients who are critically ill or experiencing rapid fluid shifts, as when undergoing major surgery. Potential serious complications of central venous cannulation are a significant barrier to direct measurement, but it has been suggested that cannulation of a central vein may not be required to assess right ventricular filling pressures.2 Indeed, the early observations of direct measures of venous pressure by Berger3 and others in the 1930s were performed in peripheral veins. A more recent study by Amar et al2 showed a reliable correlation between peripheral venous pressure (PVP) and central venous pressure (CVP) in 150 patients without cardiac disease undergoing major non-cardiac surgery. PVP, measured in either the hand or forearm, was found to be 2–3 mmHg higher, on average, than CVP, with similar changes when fluid boluses were administered. Further studies have shown similar utility of PVP measurement in cardiac surgery,4 neurosurgery and paediatrics.5 The insertion of central venous catheters for pressure monitoring alone may not be warranted if connecting a pressure transducer to a simple cannula in a peripheral vein can attain the same information. Using peripheral venous pressure measurement, the risks of arterial puncture, pneumothorax and central venous catheter-related bloodstream infections can easily be avoided.

Stuart D Marshall

To the Editor: The article on home haemodialysis by Agar and colleagues describes a changing pattern of practice that has seen many patients enjoy the freedom of dialysing at night in their home environment.1 One consideration not mentioned is the need for appropriate vascular access. For a patient to engage in self-cannulation, a fistula needs to be created for ease of use. This requires a few imperatives in fistula design to be met. In my practice, an attempt is made to create an autogenous fistula for vascular access whenever possible. It is well documented that an autogenous arteriovenous fistula (AVF) is superior to prosthetic graft or catheter access in terms of access longevity and patient-related complications.2-4 In the past 11 years, I have found it necessary to create a new AVF with prosthetic material in no more than 1% of cases. For some patients, however, a fistula may be positioned where it is accessible to renal nursing staff but not for self-cannulation. This would make nocturnal home dialysis difficult and underpins the importance of surgical access design to facilitate it. For self-cannulating patients, great effort is made to create vascular access in the non-dominant arm, in the forearm rather than the upper arm, and with cephalic rather than basilic vein run-off. The cephalic vein lies on the upper outer aspect of the forearm with the limb in a neutral position, and a needle in it remains fairly secure when a patient is asleep. Guidelines on surgical placement of an AVF from the Society for Vascular Surgery, while not specifically prescriptive for patients wanting to self-cannulate, include the same recommendations.5 Use of a long saphenous vein loop fistula in the forearm, positioned appropriately, also provides ready access for a patient who may otherwise struggle with the dexterity required for venepuncture. A thigh loop is an alternative but less desirable option, as patients with chronic renal disease are likely to have lower-extremity occlusive disease, an increased incidence of groin infection, and a greater likelihood of vascular steal.5 I applaud efforts to facilitate nocturnal home dialysis, and enjoy the challenge of surgically creating vascular access to make this endeavour successful.

David N McClure

To the Editor: I applaud Leach and colleagues for their recent article examining lost opportunities with Australia’s health workforce.1 There are many lost opportunities in the area of rural health. National and international studies have documented that a health professional with rural origins is more likely to return to a rural area to work than a colleague who grew up in the city.2,3 My research over the past 4 years looks predominantly at primary school students and their parents, teachers and governesses who reside over 800 000 km2 of outback Australia and study by distance education. My research is mainly into primary school-aged students because it is generally agreed among career development theorists that students start to shape ideas about occupations long before they reach high school.4 The students I studied initially had little knowledge or interest in health careers (relevant educational activities were subsequently provided to the school community in 2008). I identified five main factors inhibiting their knowledge and interest in health careers: the severe chronic shortage of health professionals in rural and remote Australia (and therefore a shortage of positive health professional role models); the limited career pool of their parents (most of whom are involved in the agricultural industry); the isolation in which they live; the limited information about the health professions provided by the school (their window to the outside world, which did not make up for their environmental shortfall); and parental perceptions. Two factors influencing parental perceptions deserve mention: awareness of the unhealthy workloads and the high degree of burnout among rural medical practitioners (they didn’t want this for their children); and the negative images portrayed in the media (eg, reports about health workers’ pay). My research focused solely on developing an awareness of the health professions as possible career options for these students.5 However, other factors also prevent students who live in rural and remote Australia becoming health professionals: inequality of primary and secondary educational opportunities;6 falling access, participation, retention and success rates in tertiary education;7 and the financial, emotional, family and social costs of attending tertiary courses a long way from home.8 We are all aware of the hardships of urban-raised health professionals undertaking rural medical placements, but do we understand equally the hardships of rural and remote students studying in the city? If Australia is genuine about wishing to solve the rural health workforce crisis, students from rural and remote areas must be provided with real opportunities to become rural health professionals, because the evidence suggests that the long-term survival of rural health services may depend on the recruitment of rural students.

Susan M Gorton

To the Editor: In response to Hall and colleagues,1 the Royal Australasian College of Surgeons supports any measures that have been proven to successfully reduce death and injury in young drivers. Raising the minimum legal drinking age (MLDA) to 21 years has been shown to significantly decrease road crash deaths in the United States.1 The College agrees with these authors that there would be major political obstacles and very little public support in Australia to increasing the MLDA; however, should the politicians and the public see first hand the devastating effects of alcohol on young people that our surgeons see on an all-too-regular basis, the mindset might change significantly. Hall and colleagues state other ways that we can achieve further reductions in road crash deaths — extending the zero-tolerance laws for young drivers until age 22 years, as it is in Victoria, or until 25 years for even further reductions.1 The College certainly supports this, particularly as evidence is building that the physical maturation of the part of the human brain that assesses risk and controls impulsive behaviour is not complete until age 25 years in men.2-4 The Trauma Committee is most concerned about alcohol-related trauma and will explore this issue at the annual Trauma Committee workshop, during the College’s Trauma Week. The workshop, entitled “Alcohol and injury”, will be held at the College in Melbourne on 18 November 2010.

Daryl R Wall

To the Editor: Nelson and colleagues1 referred to the limited community data from the Melbourne Medical Deputising Service (MMDS) that was analysed by Carville et al.2 MMDS consultations also represent general practice consultations, although the majority of MMDS consultations occur after hours. We can now provide an update on MMDS consultations from January 1998 to June 2010, stratified by age. De-identified data were extracted from the MMDS database for diagnoses that included the terms “chicken pox” or “varicella” and “shingles” or “zoster”, and patient age. Using the total consultations as the denominator, we calculated the crude and age-specific rates of varicella (chickenpox) and herpes zoster (HZ [shingles]) per 1000 consultations by week, and present the results here by year. These updated data support the conclusions reached by both groups of researchers that there has been a decrease in varicella cases and a rise in HZ cases in Australian general practice consultations since the introduction of a varicella vaccine in 2000. We had previously shown a decrease in hospitalisations and MMDS consultations for varicella and an uncertain effect on HZ up to 2007 after the introduction of varicella vaccine.2 The overall rate of varicella-related MMDS consultations continued to decline from 2007 to 2010, with an annual average rate of 3.3/1000 consultations in 2000 decreasing to 1.5/1000 consultations in 2007 (P < 0.001, 2000–2007) and to 1.0/1000 consultations for the first half of 2010 (P = 0.043, 2007–2010). Decreasing rates of varicella-related consultation were seen in all age groups, although an apparent increase in the consultation rate for children aged less than 5 years in 2010 might be explained by a summer peak in varicella infection and incomplete annual data (Box 1).3 The trend in HZ-related MMDS consultations showed an increase in the annual average rate from 1.7/1000 consultations in 2000 to 2.7/1000 consultations in 2007 (P < 0.001, 2000–2007) and to 3.4/1000 consultations for the first half of 2010 (P = 0.020, 2007–2010). There was a substantial increase in the HZ-related consultation rates for people aged 70–79 years and 80+ years (Box 2). Our updated data support the recommendation for adding vaccination against HZ to the vaccine schedule for older Australians,1 although the optimal age at which this should occur remains to be determined. 1 Varicella (chickenpox)-related consultation rates, by age group, 1998 to June 2010* * Data from the Melbourne Medical Deputising Service database. 2 Herpes zoster (HZ [shingles])-related consultation rates, by age group, 1998 to June 2010* * Data from the Melbourne Medical Deputising Service database.

Kristina A Grant · Kylie S Carville · Heath A Kelly

To the Editor: The article in the Journal by Leach and colleagues highlights workforce shortages in the Australian health care sectors.1 The authors identify 12 clinical professions for which data from the 2006 Australian Bureau of Statistics census show poor retention rates, and warn of the implications for the Australian population of these future shortfalls in the health workforce. However, in our opinion, the imminent workforce shortage in the pathology sector (rather than that in the higher profile specialties) is likely to represent the vulnerable point of first failure of the health care system in Australia. Pathology and diagnostic laboratory medicine are major areas in the health system, with about 70% of medical decisions being based on laboratory test results.2 About 13% of Australia’s federal health budget is allocated to pathology testing, and a similar percentage is allocated from state health budgets. Within pathology laboratories, medical scientists form the single largest professional group, although they are usually unrecognised and overlooked in workforce surveys, as is the case in the article by Leach and colleagues. Medical scientists face these same problems of poor retention within the health workforce, leading to the risk of future shortfalls in laboratory capacity and an inability to provide adequate diagnostic support for the medical system. The potential laboratory capacity shortfall has been accelerated by government policies leading to reduced funding for pathology, and the consequent failure to invest in workforce recruitment, training and development. Such an approach may deliver short-term savings, but is leading to an unsustainable environment due to the lack of an appropriately qualified and trained workforce.3 This problem is not restricted to Australia, but highlights the need for a sustainable and long-term approach to ensuring access to relevant health resources for all Australians.

Tony Badrick · Leslie Burnett · Peter E Graham · Peter P Vervaart

To the Editor: We read with interest the article by Seed and colleagues1 about the collection and distribution of blood from two donors diagnosed with Plasmodium vivax malaria following travel to Papua New Guinea (PNG). Although the potentially infectious blood components were recalled before transfusion, this case underscores the complexity of managing the risk of transfusion-transmitted malaria (TTM). Three points in particular are worth noting. First, the donors were asymptomatically harbouring infection at donation following routine foreign travel. (Between 1963 and 1999 in the United States, only one donor was implicated in TTM following routine travel, compared with more than 30 donors with lengthy residence in Sub-Saharan Africa.2) Second, both donors acquired malaria despite observing Australian guidelines for chemoprophylaxis. Finally, both were non-reactive on the enzyme immunoassay (EIA) used to screen their donations (Malaria EIA, NewLabs, Newmarket, United Kingdom) after intervals of 4 and 13 months between return from PNG and their donations. Interestingly, chemoprophylaxis for these donors was both the cause and a potential solution for the “near-miss” event. The primary prophylactic regimens used were sufficient to modify the primary infection such that antibody response to the blood-stage antigens, on which the EIA is based, occurred only after relapse months later. Had the donors taken primaquine following their travel, the parasitaemia triggered by the hepatic hypnozoite forms that characterize P. vivax infections might well have been prevented. Although primaquine is not universally recommended for terminal prophylaxis, it is consensually recommended for terminal prophylaxis for travellers who have had “intense” or “significant” exposure to P. vivax or Plasmodium ovale, such as PNG would offer.3 Seed and colleagues suggest the need for an exception to blood service management practices for donors who have recently visited a geographic area with distinct epidemiological risk for malaria. Noting the disproportionate risk associated with travel to PNG, they suggest excluding donors with a history of recent visits to PNG from routine testing for malaria (and excluding their donations from fresh component production for an appropriate period). In the United States, regulators are similarly considering carving out an exception for travellers to Mexico,4 a low-risk country where the areas associated with most (approximately 75%) malaria deferrals report near-zero malaria risk (our unpublished data). US data suggest that more than 45 000 donors will be recovered annually if the Mexican state of Quintana Roo is exempted from the deferral requirements, and regulators are weighing this benefit against the exquisitely low added risk. The outcome of this deliberation is pending, but the fact that risk gradients within a given risk category are prompting consideration of differentiated management in two countries is notable.

Bryan R Spencer · Louis M Katz

To the Editor: Children have been seen as a key priority group for pandemic (H1N1) 2009 influenza (“swine flu”) vaccination. In Australia and New Zealand, children aged 0–4 years had the highest population rate of intensive care unit admissions for swine flu.1 From 3 December 2009, the Australian Government provided free H1N1-specific influenza vaccine for all Australians aged 6 months and older. However, it was not known how parents and other caregivers would respond to the offer of vaccination. We sought to determine caregivers’ intentions regarding whether their child would receive the pandemic vaccine. The study was approved by the human research ethics committee of the Children’s Hospital at Westmead and was conducted in November and December 2009, immediately before, and alongside, the commencement of the pandemic vaccination program for children. A paper-based questionnaire (with an alternative web-based option) was sent to caregivers of children aged 6 months to 5 years who were attending 16 long-day-care centres across metropolitan Sydney. It included questions about attitudes, behaviour, intentions and beliefs regarding swine flu, seasonal influenza and vaccines. We analysed responses using SPSS, version 17 (SPSS Inc, Chicago, Ill, USA) and conducted univariate analysis (as factors had high collinearity) to search for factors associated with caregivers’ intention for their child to receive the pandemic vaccine. The response rate was 44% (431/972). Most respondents had families of two children (47%) or one child (41%); 90% were mothers; and 48% had a postgraduate education. Caregivers were asked to report in relation to their eldest child attending the day-care centre (mean age, 38 months). Three children (out of 427 responses; 0.7%) had already received the pandemic vaccine; 23% of caregivers (92/400) said they would have their child vaccinated; 54% (217/400) were unsure; and 22% (87/400) would not. Intentions regarding seasonal influenza vaccination were similar. Factors associated with caregivers’ intention to have their child vaccinated with pandemic vaccine are shown in the Box. Those with the strongest associations included caregivers’ intention to have their child vaccinated against seasonal influenza in 2010 and belief that seasonal influenza vaccine is completely safe or only a slight risk. Factors not significantly associated with respondents’ intention to have their child vaccinated with the pandemic vaccine were the respondent’s age group, sex, education level, language spoken at home, and number of children in the household. The study indicated that at the commencement of the Australian pandemic influenza vaccination program for children, there was significant uncertainty among this sample of relatively highly educated respondents. The proportion of respondents intending to have their children vaccinated was far lower than recent Australian estimates (6% of children aged 4 years and under).2 Our findings suggest that, despite the acknowledged severity of pandemic influenza, respondents’ concerns about vaccine safety were influencing their intentions. Indeed, the program commenced in a context of public debate about the response to the influenza pandemic and the vaccination program, including concerns about the safety of using multi-dose vials for vaccine delivery.3,4 Among respondents intending for their child to have the pandemic vaccine, the association with the child having had a previous influenza vaccination suggests that, having once taken up vaccination, respondents were more likely to intend to do so again. More recent events in Australia leading to suspension of use of all three 2010 seasonal influenza vaccines for children under 5 years of age are likely to further increase safety concerns.5 While two vaccines have since been reinstated, these events present a significant challenge for future influenza vaccination programs. Providers are likely to have an important role in communicating recommendations and addressing caregivers’ concerns. Factors associated with caregivers’ intentions for their child to receive the pandemic (H1N1) 2009 influenza vaccine Survey responses Intention “yes” (n = 92) Number OR (95% CI) Would you have your child vaccinated against seasonal flu in 2010? (n = 396) No 8 1.00 Unsure 33 2.29* (1.11–5.15) Yes 51 17.49* (7.55–40.50) How safe do you think the seasonal flu vaccine is for children aged 1 to 5 years? (n = 396) Moderate/high risk 7 1.00 Don’t know 19 2.04 (0.82–5.07) Completely safe/slight risk 66 6.64* (3.00–15.22) How safe do you think the seasonal flu vaccine is for babies aged 6 to 11 months? (n = 395) Moderate/high risk 21 1.00 Don’t know 36 1.35 (0.75–2.44) Completely safe/slight risk 35 4.32* (2.27–8.22) Did your child receive seasonal flu vaccination in 2009? (n = 394) No 77 1.00 Yes 15 3.48* (1.65–7.36) How concerned do you feel about your child catching the flu? (n = 396) Not at all/ a little/ moderately 31 1.00 Very/extremely 61 2.46* (1.46–4.17) Does your child have any medical conditions requiring ongoing visits to a health care professional? (n = 396) No 76 1.00 Yes 16 2.00† (1.03–3.87) The flu vaccine can give you the flu. (n = 396) Agree 24 1.00 Don’t know 23 1.18 (0.62–2.23) Disagree 45 1.82† (1.04–3.20) OR = odds ratio. * P ≤ 0.01. † P ≤ 0.05.

Julie Leask · Maria Yui Kwan Chow · Catherine King · Robert Booy

To the Editor: The World Health Organization Surgical Safety Checklist (Checklist) has recently been editorialised by Merry and Barraclough.1 We are all keen to see perioperative mortality and morbidity reduced to a minimum, and one cannot disagree with the intent of the Checklist, which was tested in a pilot study2 involving almost 8000 patients in eight hospitals (in disparate developed and developing countries). The study showed a reduction in the death rate associated with surgery from 1.5% to 0.8% (or 15 per 1000 down to eight per 1000). Impressive indeed! My concerns are firstly with process. One hospital in Brisbane has already introduced the Checklist without the constructive engagement of those at the clinical coalface, contrary to what proponents of the Checklist advocate, and it is being used in a way which distracts personnel during the induction of anaesthesia. To those familiar with accident analysis, this is a good example of poor process implementation by a hospital administration and its managers. Secondly, I am concerned by the use of the study of Haynes and colleagues2 to underwrite the Checklist. Results of the study would be more meaningful if the reduction rates in mortality in the hospitals in the developed countries (Canada, United States, United Kingdom and New Zealand) were separated from those in the developing countries. Or would this have shown the developed countries’ reduction rate to be statistically non-significant? Are we to believe that use of the Checklist could save seven lives per 1000 procedures in Australia, or 15 000 to 21 000 lives across the three million procedures undertaken here annually? Total figures for perioperative mortality across all procedures in all operative categories remain a matter for conjecture. However, in looking at the high-risk group of cardiac surgical operations in Victorian public hospitals,3 we can see a published mortality rate of 10 per 1000 for coronary artery bypass or isolated valve surgery, only a little higher than that seen after the introduction of the Checklist across a broad surgical population. We should be careful to see that spin does not become embedded within medicine, even where it is associated with what is probably a good idea.

James P Bradley

In reply: Thank you for the opportunity to respond to Bradley’s letter. We agree that constructive engagement of clinicians is essential in adoption of the World Health Organization Surgical Safety Checklist (the Checklist) — that point is clearly made in our editorial.1 Bradley’s anecdotal comment about use of the Checklist causing distraction during the induction of anaesthesia is difficult to evaluate in the absence of more detail. Surely any competent anaesthetist committed to patient safety could liaise with other team members to find an acceptable time to fulfil the entirely reasonable expectation of ensuring that relevant safety checks have been done? Furthermore, the study of Haynes and colleagues2 provides considerable reassurance about the possibility of unintended harm from use of the Checklist. Justification for the Checklist does not depend on the above-mentioned study alone: the Checklist was developed by an extensive process of literature review and consultation. It reflects expert consensus, and its endorsement by the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Surgeons and many other organisations adds to this consensus. There is no suggestion that the Checklist will save any particular number of lives in any given country — rather, its use is likely to reduce the number of patients harmed during surgery, and this is surely worthwhile.

Alan F Merry · Bruce H Barraclough

To the Editor: The editorial by Runciman in the Journal was cogent and timely.1 The Garling report on acute care services in New South Wales public hospitals highlights areas where critical changes need to be made in order to improve patient safety.2 It is widely recognised that junior doctors play a vital role at the coalface in many key areas, including assessment and escalation of care for deteriorating patients and the handover of patient care, both in hospital between shifts and also from hospital to the community. In NSW, these processes are currently receiving much needed attention in order to ensure patient safety within hospital settings. As Runciman so rightly identifies, junior doctors also play a critical role in “transformational” cultural change. In public hospitals such as my own, it has been fascinating to observe the small ways in which a junior doctor can influence senior clinicians in fields such as compliance with hand hygiene protocols, and in querying transfusion requests which do not conform to National Health and Medical Research Council clinical guidelines. We need to continue to mentor junior doctors so their messages about change and improvement are well delivered and well received. With the move of junior doctor pre-vocational training into community settings (the Prevocational General Practice Placements Program) there are increasing opportunities for change on a larger scale. In the future, patients will not be the only agents who move from community to hospital settings and back again. Junior doctors will be employed across both settings and will be an important vector for change and improvement. We will also need to encourage supervision by senior doctors who engage with and understand the health system, not just the hospital system. Providing junior doctors with appropriate tools to drive change (eg, training in graded assertiveness and situational awareness), encouraging them to view their role in health system improvement at the whole-of-community level, and providing leadership across the system, give us every reason to believe that Runciman’s vision of transformational change is possible, and indeed likely.

Joanna R Sutherland

To the Editor: I read, with encouragement and hope, Runciman’s timely editorial concerning the pressing need for patient safety education to become an integral part of medical undergraduate curricula.1 I also support his plea for patient safety to now be treated as a full-blooded science. His description of medicine as “islands of excellence in a sea of mediocrity” is both apt and perhaps still somewhat generous. In many health care ranks (in common with the rest of the human race) there continues to be a reluctance at the personal level to admit the natural and ever-present human tendency to err.2 Consequently, opportunities continue to be lost to learn from analysis of these mistakes by reporting their mechanisms honestly in detail, either anonymously or openly in a trusting work environment. Sadly, the ongoing barriers of a blame culture (often accompanied by outcome bias), misplaced ego and lack of understanding of such fundamental issues as error cascades and latent errors work against these simple and powerful safety improvement steps. The preoccupation of sections of our medicolegal system with blaming and shaming usually innocent health care individuals for system failures is also a barrier to such reporting. While Runciman suggests a gradual awakening of appreciation of such system faults, lip service still abounds and basic human error concepts continue to be uncomprehended or overlooked, even by some of the more senior and influential members of our profession. This works against the education of junior doctors. As Runciman urges, the only way to deal with this now is to give the young, fertile medical undergraduate minds the opportunity to grasp these fundamental concepts at the beginning of their clinical lives. It is their patients who will benefit as well as their own peace of mind and, importantly, their own humility, throughout their years ahead. The repeated objection that undergraduate curricula are already overloaded is not acceptable. The science of patient safety is no longer an optional or minor subject for medicine. It should be woven intimately throughout the undergraduate curriculum.

John A H Williamson

To the Editor: The pace of improvement in the safety and quality of health care has been disappointing. However, the recent enthusiasm for medical education providing a new solution is troubling.1,2 The safety and quality movement has been regrettably dismissive of the need for creation of evidence.3 Indeed, it now seems that the focus on “dramatic” errors has been a distraction from the major volume of harm due to the poor care of patients with chronic disease.4 There is substantial literature on the development of professionalism, which attests to the difficulty of teaching medical students non-technical skills (or of selecting students with “appropriate” attitudes). There are three major reasons for this difficulty. The first is the problem of defining the desirable standard — whether of safety or professionalism.5,6 The second is the so called “hidden curriculum” — the ubiquity of error, unsafe practice and unprofessional behaviour that students are exposed to in clinical environments. Third, many of the safety and quality issues and skills just do not seem relevant to the students, despite the care that has been taken in the development of safety and quality curricula. To provide “experience that is arranged to be both motivating in the moment and consequential for capabilities in the long run”7 will require a new and more pragmatic approach to education. We need to select safety and quality issues that all doctors can influence by exercise of their personal knowledge and skills. This is the stuff of medical education. Errors in clinical reasoning8 form an excellent teaching topic, but many safety problems are simply too hard for medical students (neither do we expect medical students to learn the details of intensive care or casemix funding). Provision of appropriate experiential learning requires links to the people who understand and manage governance and safety in the clinical workplace. Rather than a stand-alone communication syllabus, the medical students in Queensland, for example, should receive the same teaching about clinical handover as the junior (and senior) medical staff of Queensland Health. Handover is then perceived as a highly relevant skill. If competencies in safety for medical stu-dents are to be required they must be linked to both fuller competencies for graduate training and the introduction of safer workplace practices. Without these parallel and more important activities, the proposed reform in medical education is likely to be disappointing in its impact.

Christine M Jorm

To the Editor: We report a case of measles in a 24-year-old man who returned from the Fédération Internationale de Football Association (FIFA) World Cup in South Africa in July 2010. Despite Australian health alerts about measles in South Africa,1 the patient had received no pretravel medical advice or vaccinations. Six days after returning home to the Northern Territory, the patient developed fever, headache and myalgia. The following day he developed vomiting, diarrhoea, and productive cough, with a widespread rash appearing the subsequent day. He visited two general practitioners, was prescribed doxycycline and then admitted to hospital on Day 6 of his illness. On examination, his temperature was 38.9ºC; pulse, 112 beats per minute; blood pressure, 133/72 mmHg; and oxygen saturation, 96% on room air. He had conjunctivitis, a widespread blanching maculopapular rash involving his face, trunk, limbs, hands and feet (Box) and cervical lymphadenopathy. He had bilateral basal lung crackles and tender hepatomegaly. Investigations showed thrombocytopenia (platelet count, 148 × 109/L; reference range, 150–450 × 109/L); hyponatraemia (sodium concentration, 131 mmol/L; reference range, 132–142 mmol/L); and abnormal liver function test results (alanine transaminase concentration, 417 U/L [reference range, < 40 U/L]; alkaline phosphatase concentration, 236 U/L [reference range, 39–117 U/L]). His chest x-ray was normal. The following day, measles virus RNA was detected from a throat swab, and the patient was put into respiratory isolation and therapy with doxycycline ceased. He made a full recovery. The patient reported receiving childhood vaccinations, and while he thought he may have received one measles, mumps and rubella vaccination, he had not had two. Follow-up was required for 84 identified contacts, with no measles cases subsequently notified in the NT. The FIFA World Cup is the world’s largest single-sport event, with an attendance this year of over 3 million people. Mass gatherings may be associated with outbreaks of communicable diseases such as meningococcal disease, measles and pandemic (H1N1) 2009 influenza, in addition to an increased risk of sexually transmitted diseases.2 These risks should be considered when seeing patients who have travelled to such events, in addition to country-specific health risks. Recent data from the GeoSentinal surveillance network showed that a systemic febrile illness was the most common presenting syndrome among travellers returning from South Africa. Most of these cases of illness (54.5%) were due to spotted fever group rickettsiosis.3 The risk of acquiring rickettsiosis increases among travellers visiting game parks, with an incidence of African tick bite fever (Rickettsia africae) among short-term safari tourists of 4.0%–5.3%.4 Measles has rarely been reported in travellers returning from South Africa,2 but the country is in the midst of a measles epidemic, with 17 354 confirmed cases between January 2009 and 12 August 2010.5 Measles presents with fever, cough, rhinorrhoea and conjunctivitis, followed by a widespread rash. The incubation period is usually 7–10 days, but may be up to 18 days. The virus is highly infectious, from 5 days before to 4 days after the onset of rash. Young adults from non-endemic countries such as Australia are at particular risk, as they may only have had one childhood vaccination for measles, with consequent inadequate protection. Although measles has been eliminated in Australia,6 sporadic outbreaks continue to occur,7 and travellers returning from overseas create an ongoing potential for the re-establishment of endemic measles. Given the public health implications of a delayed diagnosis, doctors must be alert to possible cases of measles in travellers returning from endemic countries. The patient’s widespread maculopapular blanching rash

Bridget E Barber · Krispin M Hajkowicz · Vicki L Krause · Kevin G Freeman · Bart J Currie

To the Editor: Allergen avoidance is the mainstay of food allergy management. Consumers with food allergies rely on accurate labelling of foods to avoid ingestion of allergens and subsequent allergic reactions. Current Australian legislation states that ingredients derived from common allergens (peanuts, tree nuts, eggs, wheat, cows milk, soy, fish, shellfish and sesame) must be clearly labelled.1 However, use of shared processing facilities can result in cross-contamination of other ingredients with these allergens. This has led to the use of advisory statements such as “may contain traces of” by manufacturers. A recent Food Standards Australia New Zealand survey found that consumers with food allergies are frustrated by such labelling.2 There is also confusion among the medical profession about whether to advise patients with food allergies to avoid all foods with allergen avoidance advisory statements. The perception by some in the general population and in the medical community is that these statements are so widely used that avoidance would be overly prohibitive. However, there are currently no published data on the extent of advisory labelling use in Australia. We aimed to assess the prevalence of advisory labelling for three common food allergens — peanuts, tree nuts and eggs — on the packages of products for which these allergens were not listed as ingredients. Products containing one type of tree nut (eg, macadamia nut) could still have advisory labelling for other tree nuts (eg, almond). All products were therefore examined for advisory labelling for any tree nut which was not listed as an ingredient. Packages of non-refrigerated processed foods were examined between August and September 2008 at a large supermarket in Melbourne. All product types were examined within each category (eg, for the savoury biscuits category, we examined rice crackers, flavoured wheat crackers and water crackers) and, for each product type, one flavour per brand was selected for examination. Single-ingredient foods, such as flour, sugar, fruit and vegetables, were excluded. Advisory statements included, but were not limited to, “may contain traces of”, “processed on the same line as” and “made on equipment that also processes”. Overall, 761 products were examined. Of these, 384 (50%) carried an advisory statement for one or more tree nuts. Of 737 products that did not list peanut as an ingredient, 348 (47%) carried an advisory statement regarding peanut. Of 641 products that did not list egg as an ingredient, 146 (23%) carried an advisory label for egg. The presence of advisory statements varied between categories of food, with sweet biscuits most likely to carry labelling for peanut and tree nuts and bakery items most likely to carry labelling for egg (Box). Advisory statements have been widely adopted by manufacturers across a range of products, and are likely to limit food choices for consumers with food allergies who avoid all foods labelled with advisory statements. Unfortunately, there is no evidence on the frequency of trace allergen contamination in Australian products, although studies in the United States found that only 10% of 179 products with advisory labelling for peanut contained detectable levels3 and that, as for Australia, this labelling was widely used for some product categories.4 There is also no evidence regarding the proportion of consumers with food allergies who will develop an allergic reaction (including anaphylaxis) to trace contamination of food. Scientific assessment of the risks posed to consumers with food allergies by trace contamination is urgently required. This evidence would allow the development of informative labelling guidelines, including changes to legislation where required, to allow consumers with food allergies to safely manage their allergies, hopefully without the need to avoid entire categories of common foods. Allergen avoidance advisory statements on packaged processed foods at a large supermarket in Melbourne, August–September 2008 Number (%) of products with an advisory statement* Category of food Peanut Tree nuts Egg Sweet biscuits (n = 130) 117 (93%) 120 (92%) 48 (70%) Chocolates (n = 60) 43 (80%) 49 (82%) 2 (4%) Bakery items (eg, cakes) (n = 35) 24 (71%) 30 (86%) 10 (71%) Muesli bars and snack bars (n = 27) 13 (67%) 20 (74%) 4 (15%) Dinner bases and stocks (n = 32) 19 (59%) 9 (28%) 5 (17%) Savoury biscuits (n = 41) 23 (56%) 23 (56%) 20 (51%) Lollies (n = 55) 29 (56%) 25 (45%) 1 (2%) Breakfast cereals (n = 63) 25 (41%) 37 (59%) 3 (5%) Instant noodles (n = 18) 7 (39%) 6 (33%) 8 (50%) Pasta sauces (n = 15) 5 (33%) 4 (27%) 0 Bread (n = 16) 5 (31%) 5 (31%) 5 (31%) Soups (n = 20) 3 (15%) 3 (15%) 4 (21%) Cake mixes (n = 30) 4 (13%) 20 (67%) 11 (58%) Tinned meals (n = 17) 2 (12%) 2 (12%) 1 (7%) Baby foods (n = 30) 3 (10%) 3 (10%) 1 (4%) Pasta (n = 13) 0 0 4 (39%) Chips (n = 20) 0 0 0 Other (eg, tinned fish, breadcrumbs, sauces, custard powder) (n = 139) 26 (19%) 28 (20%) 19 (14%) * Number of products that had an advisory statement but did not have the allergen of interest listed as an ingredient. The denominators used to calculate percentages were the numbers of products within each category of food that did not have the allergen of interest listed as an ingredient.

Jennifer J Koplin · Nicholas J Osborne · Katrina J Allen