Letters

To the Editor: From 30 September 2009, the Australian Government began offering free pandemic (H1N1) 2009 influenza vaccine (Panvax, CSL Limited, Melbourne, VIC), using either 10-dose (5 mL) or 20-dose (10 mL) vials.1 Multidose vials are not used routinely in Australia, and are designed for high-volume vaccination clinics.2 Once pierced, a Panvax vial must be used within 24 hours or discarded.3 We investigated vaccine wastage in general practice during the first month of the vaccine’s availability. We randomly selected 300 of 697 known general practices within the Sydney South West Area Health Service. A one-page audit of vaccine vials received and consumed, and of patients vaccinated to 31 October 2009 was faxed to practices. One reminder fax was sent. Faxes were successfully delivered to 271 practices and 146 (54%) responded. Twelve responses (4%) were substantially incomplete, leaving 134 (49%) for analysis. Practices reported vaccinating 28 445 people. A median of 70% (interquartile range, 50%–90%) of people immunised belonged to a priority group. An estimated 49 130 doses were consumed, indicating that 20 685 doses (42%) were wasted. A median of 40% of doses were wasted per practice. Three practices (2%) had administered only one dose per multidose vial. There was significantly less wastage in practices with access to 5 mL vials (median wastage, 30%) than practices that had only 10 mL vials (median wastage, 50%) (P < 0.001; Wilcoxon rank-sum test). There was no significant difference in the proportion of doses wasted between the 70 practices that organised vaccination clinics and the 63 practices that did not (median wastage, 43% v 40%; P = 0.9; Wilcoxon rank-sum test). There was also no statistically significant difference in the proportion wasted between solo and multidoctor practices (median wastage, 43% v 34%; P = 0.2; Wilcoxon rank-sum test) although the absolute wastage level was lower for multidoctor practices. These results provide evidence that multidose vials (discarded within 24 hours of first use) are an inefficient method of presenting pandemic influenza vaccines for general practice use. Wastage was substantial. This study is limited to the program’s first month, so initial results may not reflect results over the whole program. However, if similar wastage occurred nationally, over 7.5 million of the 19 million doses available to Australians could be wasted. Nevertheless, the low unit cost and rapid production advantages of multidose vials may justify their use when faced with an urgent threat, and if used in mass vaccination clinics. Wastage could be reduced by increasing the availability of 5 mL multidose vials, but not (according to our data) by organising general practice vaccination clinics. Extending the vaccine shelf-life from 24 hours to 28 days, to align with licence conditions in the United States,4 could decrease wastage, as it may be that the short shelf-life results in more wastage than does supplying the vaccine in multidose vials. No rationale for the shorter shelf-life in Australia has been found, but we surmise it was set as a precaution to reduce the risk of contamination. Doses saved through reduced wastage could be used to increase Australia’s donation of vaccine to developing countries.5

Caroline E Turnour · Stephen J Conaty · Michelle A Cretikos

To the Editor: In their recent article, Beaman and Leung raised a number of important and pertinent issues about what we can learn from the influenza pandemic of 2009.1 However, we would like to correct a number of misconceptions on their part, including claims that Western Australia’s central public reference laboratory, PathWest Laboratory Medicine WA, (i) unreasonably favoured polymerase chain reaction (PCR) testing over antigen testing; (ii) rationed and prioritised testing primarily because of inability to cope with the high demand; (iii) rarely achieved the benchmark turnaround time of 48 hours; and (iv) spent excessive time processing a large number of specimens, of which 96% were reported as negative. State reference laboratories had to provide tests that would best guide individual patient management and the most effective use of hospital beds, as well as informing the public health response. The decision to avoid antigen detection tests was supported by the World Health Organization from the beginning of the pandemic2 and confirmed by subsequent published data showing that PCR testing was more reliable than antigen testing.3,4 Inaccurate test results hinder rather than help the pandemic response,5 especially in the early stages. From very early in the pandemic, we prioritised samples from hospitalised patients, health care workers, people at higher risk of severe disease and cases of special public health importance. For these urgent samples we aimed for, and largely achieved, a 48-hour turnaround time. Beaman and Leung did not allow for the substantial delays in transport and processing of samples before testing, which contributed 2–3 days to the turnaround time. A similar experience was reported in Victoria.6 This has highlighted the need to improve the way in which samples are handled at all stages between collection and testing. Rationing of services was a decision made in consultation with our public health colleagues, to ensure sustainable testing capacity for essential clinical and public health needs. In the end, PathWest tested 24 310 samples, representing 92.8% of the samples received, which included all of the high-priority and/or critical samples. It is misleading to suggest that a 96% negative rate was inefficient, and is a misunderstanding of the purpose of testing in the different phases of the pandemic. In the early phases, the yield of positive test results was expected to be low, as there was active case-finding at a time when no or very little virus was present in Australia. Across the course of the pandemic, the positive rate at our laboratory was 23% overall and 40% during the peak week. The response of public and private laboratories to the pandemic throughout Australia was impressive, and has now been the subject of state and national debriefings to identify potential improvements and the highest priorities for action. As part of that, we should all look at how we could improve our own laboratory’s performance and how we could make the best contribution to dealing with future pandemics and other emerging infectious diseases, both as individuals and as members of organisations. We would like to take this opportunity to acknowledge all the people within and outside laboratories who made a huge effort to save lives and reduce the impact of the pandemic.

David W Smith · David J Speers · Rodney A Bowman

To the Editor: We report the case of a child who presented with intussusception due to heterotopic pancreas. A 10-year-old girl presented with right iliac fossa pain and nausea. She was febrile (38.4°C) and had right iliac fossa tenderness with guarding. When she started vomiting, she was taken to theatre with a provisional diagnosis of acute appendicitis. During the diagnostic laparoscopy, her appendix did not appear inflamed and she was found to have intussusception due to a 10 mm tumour in the ileum, about 80 mm from the ileocaecal valve. The tumour was resected, and microscopic examination showed the presence of ducts and lobules of exocrine acini, with occasional foci of islet cell tissue extending into the muscularis propria. These features were consistent with heterotopic pancreas. Heterotopic pancreas is defined as the presence of pancreatic tissue outside its usual location and without anatomic relation either of continuity or of vascularisation with the pancreas.1 Its overall surgical incidence has been estimated as one case in every 500 abdominal explorations at Mayo Clinic.1 During embyrogenesis, the normal pancreas arises from several evaginations originating from the wall of the primitive duodenum. If one or more evaginations remains in the wall of the bowel, it may be carried away from the rest of the gland by the developing gastrointestinal tract and give rise to heterotopic pancreas.2 In adults, the most common locations for heterotopic pancreas, in descending order of frequency, are the stomach, duodenum and jejunum.3 However, in children, the most common location is within a Meckel diverticulum.3 Heterotopic pancreas is usually asymptomatic, and most cases have been found coincidentally at laparotomy performed for other abdominal conditions.4 However, in some people, pathological changes such as inflammation, abnormal hormone secretion and cystic degeneration within the heterotopic pancreas have been reported to cause abdominal pain and discomfort.3,4 Isolated heterotopic pancreas in the ileum is very rare and usually asymptomatic. The lesion within the wall of the ileum may act as a lead point,3,5 and this is thought to be the mechanism of intussusception. It has also been postulated that intussusception arises from local disturbance in the motility of the small intestine caused by the heterotopic pancreas.3

Narotam R Jootun · Hock P Cheah · Siddath C Fernando · William S Munro · Martin Veysey

To the Editor: The recent article by Davis and colleagues reported that the SMART-COP score underestimates the severity of pneumonia in tropical northern Australia, but can be improved by using locally relevant additions.1 The authors’ revised scoring system, SMARTACOP, increased the score for an albumin level < 35 g/L and added Aboriginal or Torres Strait Islander status as a variable. While these additions are useful, the reason for adding ethnicity was not fully clarified. A factor overlooked was low serum 25-hydroxyvitamin D [25(OH)D] levels among dark-skinned Australians.2 Smoking, identified as a marginally insignificant risk factor,1 is also associated with lower serum 25(OH)D levels.3 Vitamin D enhances the innate immune system through induction by 1,25-dihydroxyvitamin D of cathelicidin and defensins, which combat several types of bacterial and viral infections including upper respiratory tract infections.4 In the 1918–1919 influenza pandemic in the United States, many deaths were due to pneumonia that occurred as a complication of influenza infection. An ecological study found that indices for levels of vitamin D production from solar ultraviolet-B irradiance explained 50% of the variance in pandemic case-fatality rates among 12 communities.5 The mechanisms proposed for the beneficial effect of vitamin D were reduced proinflammatory cytokine production, which would reduce damage to the epithelial lining of the lungs, and induction of cathelicidin and defensins to fight the secondary bacterial pneumonia infection. If sera are available for those included in the Australian SMART-COP study,1 they could be analysed for 25(OH)D levels to test this hypothesis.

William B Grant

In reply: We thank Grant for his interest in our study on pneumonia severity assessment in tropical Australia. Our revised scoring system included increased weighting for hypoalbuminaemia, as well as adding a point for Indigenous status, because these two factors had the strongest association with the need for intensive respiratory or vasopressor support on univariate analysis.1 Unlike vitamin D status, these and the other factors included in the scoring system are readily available measures that can be used in the clinical setting to rapidly predict the need for intensive support. The scoring system was not intended to identify underlying aetiology or risk factors for severe pneumonia. For example, Indigenous status is likely to be a surrogate measure for undiagnosed comorbidities, lack of access to health care, and socioeconomic disadvantage. We agree that vitamin D is important in immune function and that the levels of insufficiency that result in impaired resistance to infection are not well defined.2 Most data on vitamin D deficiency in dark-skinned populations in Australia come from temperate areas,3,4 and the reference offered by Grant to support the concern about vitamin D deficiency does not cite any data from Australian populations north of southern Queensland.5 Further studies are needed on the prevalence of vitamin D deficiency in Indigenous Australians in tropical areas, and the additional contribution of vitamin D deficiency independent of known risk factors of severity and outcome.

Joshua S Davis · Allen C Cheng · Bart J Currie · Nicholas M Anstey

To the Editor: Newby and Robertson’s study of the effect of computerised prescribing on the frequency of repeat prescriptions for antibiotics is important in highlighting unnecessary repeat prescribing.1 However, their work has highlighted another issue — researchers’ growing habit of using the prescription of selected antibiotics to infer indication, and then to measure appropriateness of care. When using the term “upper respiratory tract infections” (URTIs), do the authors mean viral infections or all URTIs, including bacterial infections? They state: While we did not include data on the indication for treatment in our study, the antibiotics we chose are those commonly used for respiratory tract infections. Therefore, the continued high rate of repeat ordering for these antibiotics remains a concern.1 We support the latter statement wholeheartedly, but the inference that the antibiotics examined in the study were used to manage URTIs (because these antibiotics are “commonly used to treat URTIs”) is inappropriate and incorrect. A media report misguidedly described Newby and Robertson’s study as examining “how GPs’ use of computerised prescribing systems affects antibiotic prescribing for upper respiratory tract infection.”2 The study was not about prescribing of antibiotics for URTIs, but this implication is apparent in their article. From the national Bettering the Evaluation and Care of Health (BEACH) program 2006–2009,3 we examined 20 011 general practitioner prescriptions for Newby and Robertson’s selected antibiotics: amoxycillin, amoxycillin/clavulanate, roxithromycin, and cefaclor. We would usually include cephalexin, because it is prescribed as often as cefaclor for URTIs at BEACH encounters, but we have limited our comparison to the above four antibiotics. In the BEACH program, GPs link the prescription to the problem being managed so we can determine the indication for which these antibiotics have been prescribed. Over the 3-year period of the 2006–2009 BEACH program, only 21.1% of these antibiotics were prescribed for URTIs (adults [≥ 15 years], 20.6%; children [0–14 years], 22.7%). In four out of five cases, the prescriptions were for acute bronchitis, sinusitis, acute otitis media or myringitis, tonsillitis, urinary tract infections, skin infections, pneumonia, and a variety of systemic infections. It cannot be assumed that a URTI is the indication simply because these antibiotics are most commonly used for its management, and by inference, that GPs are prescribing inappropriately. Newby and Robertson are not alone — the 2010 Productivity Commission report used the number of prescriptions for “antibiotics most commonly used to treat URTI” as one indicator of the appropriateness of GP services.4 These antibiotics are, in most cases, prescribed for indications other than URTI. The appropriateness of this prescribing cannot be assessed without knowledge of the indication, and without clear guidelines as to what level of antibiotic prescribing for each indication is “best” quality.

Joan V Henderson · Christopher M Harrison · Helena C Britt

In reply: We accept the evidence presented by Henderson and colleagues that the antibiotics examined in our study are not used exclusively for upper respiratory tract infections (URTIs), and we acknowledge in our article the lack of information on indication for treatment. However, data from the Bettering the Evaluation and Care of Health (BEACH) program have been used by others to suggest that the four antibiotics represent over 60% of the prescribed antibiotics for URTIs.1 Our study does not assess the appropriateness of the antibiotic choices, focusing instead on duration of therapy as implied by the issuing of repeat prescriptions. Irrespective of indications for use of these antibiotics, our data still support our primary conclusion that computerised prescribing is associated with increased repeat ordering for these, and probably other, antibiotics. The increase in repeat ordering could possibly be explained if doctors who use computers to prescribe see “sicker” patients or a significantly different case-mix from those who write prescriptions by hand. However, the size of the difference (70% v 40% of prescriptions with repeats, respectively), the consistency across the antibiotics examined, and the identical rate of repeat ordering on handwritten prescriptions in both surveys, makes this conclusion unlikely.

David A Newby · Jane Robertson

To the Editor: In April 2009, a registered nurse at the Sydney Medically Supervised Injecting Centre (MSIC) overheard two clients warning others about the effects of injecting from a particular glass vial, believing it had given them a “dirty shot” (bacterially contaminated injection). Seeing an unlabelled, discarded vial containing cloudy fluid, the nurse was concerned that it may have contained insulin, and assessed all four clients who reported injecting from similar vials. Three clients were sweaty, nauseated, and looked unwell, while only two (who had subsequently injected heroin) showed the pin-point pupils and hypoventilation typical of opioid use. Blood glucose levels confirmed likely insulin use, with the lowest reading being 1.5 mmol/L. MSIC staff made sweet drinks available, but one client became unconscious and required intramuscular glucagon and hospital admission. She was subsequently discharged without complications. Staff were concerned that insulin from an unknown source and of unknown concentraion was for sale in the local area, and immediately informed the local police and health and social welfare agencies. Thankfully, no further cases were noted, and no permanent harm resulted from this incident. The vial found at the injecting centre was later identified as Humulin 30/70 (Eli Lilly Australia, Sydney, NSW). Insulin-induced hypoglycaemia may result in brain damage and death.1 To our knowledge, this is the first case of inadvertent insulin injection in an injecting facility reported in the scientific literature. Given the unlikely nature of the substance, and that two clients showed physical signs consistent with opioid use because of subsequent heroin injection, their presentation in another setting could well have been confused with opioid overdose. We believe the MSIC was able to avert serious morbidity and possible death because of the presence of experienced staff able to provide immediate medical attention. The MSIC opened in 2001 in Kings Cross, Sydney, the first of its kind in the English-speaking world. The centre reduces morbidity and mortality from drug overdose, enhances access to health and social welfare services, reduces transmission of blood-borne viruses and reduces the incidence of drug injecting in public places.2 The main drugs injected at the MSIC include heroin, other opioids, cocaine and methamphetamines. There are now 70 such facilities around the world; these are legally sanctioned sites where people may inject previously obtained drugs under the supervision of qualified personnel. There is growing scientific evidence internationally to show that supervised injecting facilities reduce the harms associated with illicit drug injection.3-5 This case highlights their role in preventing harm associated with more unexpected drug injections.

Marianne E Jauncey · Anita P Trevan · Richard P Sulovsky

To the Editor: Optimism about our growing ability to recognise coeliac disease (CD) is tempered by a worrying trend towards misuse of genetic testing for CD risk, as illustrated by this salutary case. A 42-year-old woman with nausea and lethargy attended her doctor, concerned that she may have CD, because her niece had the condition, and she knew it was “genetic”. A laboratory representative had told her doctor that a test for the HLA-DQ gene was the best test for CD; this test was performed, and detected genotype susceptibility for CD (HLA-DQ2 and HLA-DQ8 alleles). The patient was told she had CD and was referred to a dietitian to commence a gluten-free diet. She contacted the Coeliac Society of Australia and learned that this was an unusual way of diagnosing CD. This led to her being referred to a gastroenterologist. Further testing showed normal IgA and IgG transglutaminase antibody (TGA) levels (8 enzyme-linked immunosorbent assay [ELISA] units [reference range, 0–20 ELISA units]), and normal iron, folate and IgA levels. Mild nausea and diagnostic ambiguity prompted gastroscopy and duodenal biopsy. Findings of these tests were normal, showing no intraepithelial lymphocytosis. CD is common, affecting up to 1% of Australians,1 and causing a spectrum of complaints from classic malabsorption to more subtle problems (eg, osteoporosis and iron deficiency). It is clarified by sensitive serological detection methods (TGA levels).2 This gluten-triggered autoimmune disease represents one of the best characterised models of gene–environment interaction, in that an “at-risk” genome is needed to provide disease predisposition.3 However, CD genotyping (looking for HLA-DQ2 and HLA-DQ8 alleles) is increasingly requested under the misconception that a “genetic” test must be a more reliable detector of disease than other tools. The HLA risk genotype is necessary but not sufficient for development of CD: 20% of Australians share this risk factor, but only 5% of these express CD. Serological testing (TGA) provides approximately 90% sensitivity and specificity for CD in the appropriate clinical setting, but the diagnostic “gold standard” still involves biopsy confirmation of gluten-responsive tissue changes to justify the life-long social and financial costs of gluten avoidance. CD genotyping should be considered when: gluten challenge is not possible or acceptable; serological–histological discrepancies exist; or endoscopic biopsy is difficult or potentially non-diagnostic (eg, certain paediatric cases, or patients being treated with anticoagulants or immunotherapies [eg, prednisolone] that may normalise biopsy appearances). Our group is seeing more misuse of CD genotyping, with some practitioners using a positive result to confirm CD. As a centre of expertise in CD, we recommend that CD genotyping be confined to its negative predictive role: negative CD genotyping indicates a substantially reduced likelihood of CD (< 1%).4

Neil J Porter · Huy A Tran · Glenn E M Reeves

To the Editor: A 59-year-old woman presented with acute bilateral deafness, ataxia, and pyrexia. She had no significant past medical history and was taking no medications or antibiotics. Examination revealed normal tympanic membranes. Audiology and fundoscopy were not performed. Full blood examination results, electrolyte levels and renal function were normal. A plain chest x-ray was unremarkable, but a computed tomography scan showed lobar consolidation. The patient had microscopic haematuria but no pyuria, and negative urine culture. Blood cultures were repeatedly negative. She was commenced on a third-generation cephalosporin, as well as corticosteroids on suspicion of vasculitis. Her condition improved initially, but relapsed on weaning from the steroids. Further history-taking revealed that 3 weeks before the onset of her illness, the patient’s pet budgerigar had a prolonged diarrhoeal illness and subsequently died. On suspicion of Chlamydophila infection, she was commenced on doxycycline, and the fever resolved within 24 hours. Doxycycline was continued for 14 days, and the patient remained well thereafter. Her hearing returned to normal over 3 days. Autoimmune markers, and serological tests for Legionella species, Mycoplasma species and respiratory viruses were negative. However, her Chlamydophila psittaci IgG titre was > 512 and Chlamydophila pneumoniae IgG titre was > 2048, consistent with a recent infection with either C. psittaci or C. pneumoniae. Convalescent serological tests were not performed. To our knowledge, acute hearing loss has been reported only four times as an extrapulmonary feature of Chlamydophila infection. Puolakkainen and colleagues reported the case of a 49-year-old man who presented with otitis media in one ear and sudden deafness in the other after a severe influenza-like illness thought to be due to psittacosis.1 Crosse performed a retrospective study that looked at the clinical and epidemiological features of cases in which there was a fourfold rise in C. psittaci titre. One patient developed deafness, although no further detail was given.2 Brewis and McFerran reported the case of a 61-year-old pig farmer with sudden bilateral hearing loss associated with C. psittaci pneumonia. The hearing loss resolved with antibiotics and prednisolone.3 Finally, Darougar et al reported the case of a 15-year-old girl who presented with chronic relapsing sensorineural hearing loss, uveitis, keratitis and vertigo.4 In this case, chlamydial antibody titres were raised, and C. psittaci was isolated from the conjunctiva. She had no respiratory involvement. Her only animal exposure was to a cat with conjunctivitis, which tested negative for chlamydial and viral infections. Interestingly, Dünne et al have recently found an epidemiological association between sensorineural hearing loss and elevated C. pneumoniae IgA titres.5 This case represents further evidence that acute deafness may be a component of atypical pneumonias, and especially of Chlamydophila infection.

Andrew F Whyte · Richard Yu

To the Editor: The comments about health literacy by Adams and colleagues1 and Nutbeam2 are timely, given findings that 60% of Australians lack basic health literacy skills.2 Despite attention given to health literacy by the National Health and Hospitals Reform Commission, current discussions remain worryingly limited. In the 1990s, Nutbeam was prominent among those who recognised both the individual and the larger environmental settings of health literacy, as well as its relevance to prevention. “Health literacy and health skills” was included as a category in a landmark health goals and targets framework, as “personal health knowledge and positive attitudes towards changing behaviour demonstrably influence people’s ability to adopt healthy lifestyles”.3 Significantly, the goals of improving health literacy were expressed as enabling people to make more informed choices about their health and to take an active role in bringing about changes in environments that influence health. Since then, surprisingly scant attention has been given to health literacy in the context of coping with everyday life, including new situations4 — surprisingly, given that “nearly every choice we make throughout the day is relevant to health in some way — what we eat, how much we move, what products we buy”.5 Most discussions focus on the skills and knowledge individuals need to navigate the health system. Studies of health literacy in broader health contexts remain comparatively rare and frustratingly dispersed throughout numerous disciplines.6 It is time for greater recognition of health literacy as both a consumer issue and a public health issue relevant to disease prevention. (It is perhaps no coincidence that the Newest Vital Sign test for health literacy involves the comprehension of nutrition information about ice cream.) Nutbeam’s suggestions for building health literacy and consumer engagement in health services could easily be expanded. Why not, for example, develop a national plan with specific objectives and approaches, and definitions and indicators to measure health literacy progress? There are obvious tie-ins with the “prevention agenda” and with Australia’s new national policies on men’s and women’s health, and just bringing together the scattered articles on health literacy and gender would be a major task.7 Australian health initiatives aimed at reducing the burden of chronic and preventable disease should consider the role and challenges of health literacy beyond its application to health services use. Our growing understanding of the complex behavioural, social, systemic, and ecological forces that influence health and wellbeing should help guide these efforts.

Margo H Saunders · Anita Peerson

To the Editor: A recent editorial about health literacy and a research article on the prevalence of low health literacy in a South Australian population sample2 highlight the potential negative impact of low health literacy on treatment outcomes. Adams and colleagues also suggest a need to assess health literacy in clinical practice.2 Although calls for the introduction of screening to identify patients with low health literacy appear frequently in such articles, we urge caution in taking such a step at this time, because of a lack of sound evidence to support such a recommendation. High-level evidence related to health literacy screening is scarce. One randomised controlled trial found that making physicians aware of patients’ health literacy status led to greater use of recommended strategies, but did not translate to expected improvements in patient self-efficacy.3 An unanticipated outcome was that physicians who received advice about their patients’ health literacy status reported significantly lower satisfaction with the consultation and felt marginally less effective than those not given such information. The authors caution against health literacy screening in clinical practice unless system-wide training and support for both health practitioners and patients is in place. A fundamental principle of screening is that it should not be introduced without an effective intervention — to do so offers no advantage to patients and may be harmful.4,5 Health literacy screening raises the potential for harm due to high levels of stigma and shame that may be experienced by those with poor literacy. In Australia at this time, it is uncertain whether effective intervention strategies suitable for use in clinical settings are readily available. Moreover, we do not have reliable information about the skill levels of practitioners to address low health literacy. Published studies consistently show that 40%–60% of clinical and population samples have low or marginal levels of health literacy. This means that one of every two people attending a medical consultation can be expected to have suboptimal health literacy. Therefore, a universal approach to the assurance of comprehension in every consultation, supported by practitioner training in health literacy communication and evidence-based tools to enhance patients’ encounters with health services, may offer a more effective and efficient alternative to screening.

Robert A Bush · Frances M Boyle · Remo Ostini

To the Editor: Pregnancy following aorto-iliac bypass or replacement grafting is uncommon, as most patients requiring this operation are beyond childbearing age. However, conditions may occur at earlier ages that necessitate such a procedure and, as the case described here illustrates, the surgery is no bar to pregnancy. In 1982, a 13-year-old girl presented to hospital after two episodes of abdominal pain. Ultrasound examination showed a large dumbbell-shaped retroperitoneal tumour widely separating the aorta and vena cava. Laparotomy revealed a large tumour firmly adherent to the inferior vena cava and completely surrounding the aorta. Biopsy showed it to be a ganglioneuroma. It was possible to separate the tumour from the vena cava but not the aorta, as no plane could be defined, and during the dissection a hole was made in the vessel. The involved aorta was resected and the tumour was able to be completely removed. The removed segment was replaced with a 10 mm woven dacron tube graft (compatible with the host aorta) from the infrarenal level to the aortic bifurcation. Five years later, the aortic graft thrombosed. Exploration showed no evidence of recurrence of the tumour, and the previous graft was replaced with a 14 × 7 mm gelatin-impregnated, knitted dacron bifurcated prosthesis from the infrarenal aorta to each common iliac artery. The patient had regular follow-up, including ultrasound and magnetic resonance imaging scans. In June 2007, after I had retired from vascular surgery, I was contacted by the patient (now aged 39 years), who was seeking information about her previous operations because she was 14 weeks pregnant and her obstetrician was concerned about the uterine blood supply. She had approached the hospital, but was told that her records had been destroyed. Fortunately, I still had my personal records of her previous surgery. The patient had required in-vitro fertilisation for conception because her uterine tubes were blocked. The pregnancy proceeded normally until the 36th week, when signs of eclampsia developed. Caesarian section was performed at 37 weeks and a healthy infant was delivered. A review of the literature revealed six other reported cases of pregnancy occurring in patients who had had previous aortic grafting for aneurysmal or atherosclerotic disease.1-6 Two patients had caesarean section and the others were delivered vaginally; all infants were viable. Possible concerns expressed by clinicians in cases such as this include compromise of the pelvic circulation, affecting foetal development; compression of the graft by the fetal head during delivery; uterine contractions contributing to graft occlusion; reduction of blood flow through the graft because of the patient’s position during labour; and false aneurysm formation at the anastomotic sites, with an increased risk of rupture. With adequate assessment and supervision by obstetric and vascular surgical teams, the outcome of pregnancy in women with a history of aortic grafting should be favourable.

H Reginald Magee

To the Editor: There is generally a high level of awareness about the burden of disease associated with diabetes and its complications in Indigenous Australians.1 While high rates of renal failure, retinopathy and cardiovascular disease in Indigenous people are frequently emphasised, diabetes-related foot complications receive relatively little attention. As part of the Western Australian Department of Health’s Cardiovascular Health Network initiative (http://www.healthnetworks.health.wa.gov.au/network/cardio.cfm), we reviewed the trends in amputations for arterial disease or diabetes-related complications in Western Australia for the period 2000–2008. Discharges from hospital for any lower-limb amputations were identified using the relevant International Classification of Diseases, 10th revision, Australian modification, codes.2 Each individual was included only once, regardless of whether they had a further amputation. Age-standardised rates were calculated for Indigenous and non-Indigenous people residing in Western Australia, with and without diabetes. Toe or foot amputations were defined as “minor”, and amputations below or above the knee as “major”. Among those aged 25–49 years with diabetes, minor amputations were 27 times more likely, and major amputations 38 times more likely, in Indigenous people (Box). These data have not been validated by chart review, but there is no reason to suspect systematic bias. Nearly all (98%) of the amputations in Indigenous people were associated with diabetes. Although it is difficult to estimate the role of macrovascular arterial disease using administrative data, the literature suggests that peripheral neuropathy, ulceration and sepsis are important causal factors in these amputations.3 There is ample evidence that simple interventions such as foot screening, education and appropriate footwear are cost-effective measures to reduce amputations in patients with diabetes.4 Although there are some excellent programs and services for Indigenous people with diabetic foot problems throughout Australia, they are few in number, often fragmented and generally poorly resourced. Multidisciplinary foot clinics — considered international best practice5 — typically remain centred in capital city tertiary hospitals, requiring Indigenous people from rural and remote areas to travel long distances onto someone else’s land, with unfamiliar surroundings and devoid of family support. Although further research is required to better understand the underlying reasons for this disparity in amputation rates, there is a more urgent need to implement culturally appropriate versions of simple interventions among Indigenous people and ensure foot care is a standard component of comprehensive, multidisciplinary diabetes management. Age-standardised amputation rate* (crude number) by age group, 2000–2008 Minor amputations† Major amputations‡ 25–49 years ≥ 50 years 25–49 years ≥ 50 years Indigenous with diabetes 46.4 (93) 185.0 (118) 15.0 (30) 76.8 (49) Non-Indigenous with diabetes 1.7 (108) 28.9 (1408) 0.4 (26) 13.1 (638) Indigenous without diabetes 0.0 (0) 4.7 (3) 1.0 (2) 3.1 (2) Non-Indigenous without diabetes 0.3 (21) 6.5 (317) 0.3 (17) 12.8 (628) * Per 100 000 Indigenous and non-Indigenous people (irrespective of diabetic status) using the 2001 Census as the standard population. † Toe or foot amputations. ‡ Amputations below or above the knee.

Paul E Norman · Deborah E Schoen · Joel M Gurr · Marlene L Kolybaba

To the Editor: The advent of midurethral slings (MUSs) has revolutionised surgery for female stress urinary incontinence. An MUS is a narrow, synthetic (usually polypropylene) tape that is surgically placed beneath the middle part of the urethra, traversing either the retropubic space or the obturator foramina to provide dynamic support in order to restore urinary continence. Medicare Australia data from 1994 to 2008 (Box) show that there was a 75% increase in surgery for stress urinary incontinence over this period, from 4000 to nearly 7000 cases a year, reflecting the increasing popularity of MUSs as a result of lower morbidity and shorter hospitalisation (day surgery). The rapid uptake of MUSs since 1999 has been matched with a rapid decline, since 2001, in use of the Burch colposuspension procedure. Colposuspension is an open abdominal or laparoscopic procedure in which the bladder neck is supported by elevating the paravaginal fascia using sutures to the ipsilateral iliopectineal ligament on both sides. This operation is done via an abdominal incision or through operative laparoscopy. There has also been a decline in the use of pubovaginal fascial slings and a small increase in urethral bulking procedures. Very few needle suspensions are performed in Australia. There has been a significant increase in the number of urodynamic procedures performed (including uroflow, cystometry and urethral pressure profiles), which may also be a reflection of an increased number of women presenting for treatment. It should be noted that these Medicare data reflect trends within the private sector only, and our data are not age- or sex-specific. Nor do they distinguish between the specialties of gynaecology or urology in their use of MUSs or between different midurethral slings used in Australia. Although Burch colposuspension and autologous pubovaginal slings were for many years considered the “gold standard” operations for stress incontinence,1 recent systematic reviews have shown MUSs to be just as efficacious2,3 and possibly more cost-effective.4 Regardless of debate about which operation may be best,5 MUS surgery has become the most common operation performed for stress urinary incontinence in Australia. Data from the National Health Service in the United Kingdom show a similar trend.6 However, changes in MUS use in Australia and internationally have not always been driven by good science. The remarkable popularity of the newer single-incision slings in the United States, despite very limited availability of clinical evaluation information, is of concern. Their popularity has been attributed anecdotally to the fact that insertion of a single-incision sling is an “office” procedure that attracts greater insurance reimbursement than procedures that are performed under anaesthesia or require hospital stays. Surgery for stress urinary incontinence has moved rapidly towards a minimally invasive approach, making it more appealing to all patients, especially those who are older or medically unfit. At present, new devices to treat stress incontinence and other pelvic floor problems are being introduced and extensively used without adequate clinical evaluation by good prospective randomised trials.7 Changes in surgical practice should be driven by good scientific evidence of safety and effectiveness, rather than commercial interests or government budgets. Trends in surgery for stress urinary incontinence (SUI), based on Medicare Australia data, January 1994 to December 2008 BCS = Burch colposuspension (item no. 37044). MUS = midurethral sling (item no. 35599). * Item nos. 35602, 37042. † Item no. 37043. ‡ Item no. 37339.

Joseph K Lee · Peter L Dwyer

To the Editor: The risks of computed tomography (CT) are now well understood by radiologists and have been widely reported.1−3 Overall, the risk of fatal malignancy from a single CT scan (body, not including head) in children and young adults is about 1 in 1000 (varying from around 1 in 500 to 1 in 1500), and the high risk persists into the third decade.1,2 The risk is higher in children and young adults because there is time for malignancy to manifest (usually developing decades later), and their cells are dividing more rapidly and hence more susceptible. However, surveys of both patients and referring doctors show they have limited knowledge of the radiation risks from CT.4 Hence, most patients presenting for CT scans are not informed or aware of the risk. The High Court of Australia has determined that medical staff must inform patients of potential risks that the patient might regard as important.5 Patients, and their parents, may well consider a 1 in 1000 chance of fatal malignancy important. Most hospitals and clinics routinely recommend obtaining written, informed consent before administration of general anaesthesia or intravenous contrast agents. Some also routinely provide written information to parents or patients of the risks associated with general anaesthesia and anaphylaxis following administration of intravenous contrast agents. The risks of fatal malignancy developing later in life in children and young adults after a single CT scan are 1/500 for children aged less than 1 year, 1/1250 at 10 years, and 1/1600 at 20 years.1 This is 50–200 times greater than the risk of fatality following general anaesthesia (1/56 000)6 or administration of intravenous contrast agents (1/170 000).7 If informed consent is regularly sought before administration of general anaesthesia and intravenous contrast agents, then it is equally appropriate and consistent to seek informed consent before CT scans in children and young adults. Anything less may not be medicolegally sustainable. While patients rightly expect that referring doctors are able to balance the risks and benefits of any examination, they also rightly expect (and the High Court supports them) that any known risk will be revealed and discussed. Explicit and comparative information is best provided personally and in understandable written format by the referrer.8

John F de Campo · Margaret P de Campo

To the Editor: Sweet and Simons are right to raise concerns about the quality and reliability of the health information available on the internet in this new digital age.1 Similar to the “old media” paradigm, the driving pressure is to maximise readership, thereby maximising advertising revenue. The task of providing content of sufficient volume and quality to meet the needs of readers permanently connected to the internet appears overwhelming. As an example of the way such pressure damages the quality of health reporting, we need look no further than the way Sweet’s health blog, Croakey, and its parent publication, Crikey, dealt with the 2009 H1N1 influenza pandemic. After initially calling for a rational discussion about the merits of the population-based vaccination program,2 Croakey and Crikey published a series of articles that either trivialised the severity of the H1N1 outbreak or focused on perceived problems of the vaccine or the program. There was no corresponding focus on possible benefits of vaccination or solutions implemented to minimise perceived problems with the program. Former Minister for Health Michael Wooldridge had a piece supportive of vaccination published,3 but this was immediately followed by a response from Sweet suggesting, without supporting evidence, that he was acting as an agent of CSL.4 So effective at rallying anti-vaccination supporters has Crikey’s campaign been that members of the anti-vaccine Australian Vaccination Network now copy in Sweet and Crikey on correspondence to the federal Minister for Health denouncing H1N1 vaccines.5 Although it is unlikely this negative reporting will have a major impact on H1N1 vaccine coverage, it adds a veneer of credibility to vaccine conspiracy material widely available on the internet. Sweet and Crikey would do well to consider the wider public health implications, beyond improving readership and advertising profit, of pushing their controversial and strident anti-H1N1 vaccine message.

Stephen B Lambert

In reply: Lambert has previously raised similar concerns in comments published by Crikey and its health blog Croakey.1-3 Leading public health and medical experts contribute to Crikey and Croakey’s coverage of pandemic influenza. As has been noted in this Journal, there are many questions and controversies surrounding the pandemic and the policy response.4 It is a misrepresentation to describe Crikey and Croakey coverage as being stridently anti-H1N1 vaccination or a “campaign”. Indeed, I recently received a note of thanks from the Australian Government Department of Health and Ageing Media Unit for a “very fair report” in Crikey regarding an influenza vaccination safety issue (Department of Health and Ageing Media Unit, personal communication, 8 Dec 2009). Michael Wooldridge and CSL’s Director of Public Affairs, Rachel David, are scheduled to speak at a conference in Sydney on 24 March 2010 about their use of online media to promote pandemic vaccination.5 It cannot be controversial, in these times of heightened concern about conflicts of interest and their consequences, to suggest that if Wooldridge is publishing related comment, as in his Crikey article, any association with CSL should be declared.6 Additionally, I am regularly copied on emails or correspondence by a variety of individuals and organisations. This does not mean I am involved with these groups or necessarily support their work. Lambert is entitled to his views about the forces driving the media; my own is that an open, transparent debate about public policy, whether it relates to vaccines or other interventions, is important for the health of populations and of societies more broadly.

Melissa A Sweet

To the Editor: In their article, Couzos and Delaney Thiele raise many good points with respect to Medicare Australia’s Practice Incentives Program (PIP) Indigenous health incentive.1 The funds in question are part of the “closing the gap” spending by the Rudd government. However, the central question is whether spending many millions of dollars of this allocation to add to the income of general practitioners (through a patient enrolment program and the generation of “care plans”) will in fact convert into greater access to, and greater utilisation of, health services by the Aboriginal and Torres Strait Islander population (hereafter referred to as the “Aboriginal” population). The authors correctly point out that most practices in Australia do not treat Aboriginal patients, and that the uptake of targeted, extended-primary-care items by Aboriginal people is much lower than in the general population.1 In most areas, apart from the most remote, the problem is not a lack of services, but the red tape that blocks Aboriginal patients from taking advantage of health services. Adding further layers of red tape, such as patient enrolment, care plans, and health assessments, will only make it harder for Aboriginal patients to access extra health care. For example, an allied health service, normally accessed by walking in off the street, requires a care plan plus a team care plan. Such red tape only adds to the burden of compliance — the problem that lies at the heart of the reason why so many Aboriginal patients fail to meet basic health outcomes. From an economic viewpoint, one needs to ask what could be done with the money that will go to the health provider for administration, rather than for actual clinical care. For example, paying a GP $500 to enrol a patient could instead pay for a significant amount of dental work, speech pathology, diabetes education or physiotherapy. The Department of Veterans’ Affairs (DVA) Gold Card offers an efficient, simple and highly efficacious model that would serve the Aboriginal population a lot better.2 Under the DVA model, doctors are paid a modestly higher rebate for treating veterans (or their families). However, the real benefit for DVA Gold Card holders lies in their ability to access an expanded pharmaceuticals scheme, a comprehensive range of allied health and medical equipment, free patient transport, and private hospital care. Under the DVA, such benefits are accessed with minimal paperwork for the referring doctors and patients. Therefore, the DVA model, in contrast to the PIP Indigenous health incentive model, better targets funds towards service delivery. It is time for politicians and the Department of Health and Ageing to adopt a DVA-style model for the Aboriginal population.

Aniello Iannuzzi

To the Editor: We read with interest Walters and Dawson’s call for a clinical revolution to tackle access block1 and are heartened by the interest shown by general physicians in a problem that primarily affects the emergency department (ED). The efficient management of admitted medical patients is paramount to patient flow within the hospital, and “buy-in” from general physicians is essential. When considering any new model of care, it is important to note that longer patient assessments in ED by emergency doctors has a relatively small effect on access block; the claim that the length of assessments is a significant factor in access block has been established as a “myth” by investigators who have mapped process times.2 Therefore, it is unlikely that substituting one workforce of acute physicians for another would make any difference to overall patient flow through the ED. On the contrary, it is likely to be associated with increased costs3 and adverse effects on the emergency medicine labour supply.4 In addition, the ability and willingness of the general physician workforce to implement and sustain the newer role of “acute physician” is unknown. The root cause of access block lies in ward-bed shortages, ward processes and community capacity, which should be solved by improved flow processes across the continuum of care. Access block will not be solved by a second tier of acute physicians duplicating the role of emergency physicians. However, there are many aspects of Walters and Dawson’s model of change that would improve patient flow, in particular: improved rostering of medical staff; improved access to pathology and radiology services; and, perhaps, specific retraining of medical staff in the efficient discharge of inpatients. These aspects should be rigorously explored as we strive together to tackle access block.

Biswadev Mitra · Peter A Cameron · Pieter De Villiers Smit

To the Editor: Walters and Dawson1 correctly highlight access block (hospital overcrowding) as a whole-of-system problem. Acute medical assessment and admission units (AMAAUs), or other similar incarnations in Australia and New Zealand, are part of the solution, although the evidence presented is low-level non-Australasian data. The reduced length of stay achieved by these units and reported in papers cited by Walters and Dawson would, if replicated in Australasia, produce additional capacity, improving bed availability and patient flow. As has been repeatedly stated: it’s all about available beds!2 However, Walters and Dawson’s article stretches well beyond the evidence in its approach to emergency department (ED) roles and the interactions between AMAAUs and EDs. None of the cited studies suggested that AMAAUs provide better environments than EDs for sick undifferentiated patients. None studied effects that AMAAUs have on ED treatment and none proposed interventions specifically designed to alter ED management. They essentially examined improved patient journeys for front-loaded AMAAU versus standard (slower) general medical inpatient care. In addition, Walters and Dawson imply that these changes related to introduction of the United Kingdom’s 4-hour rule. However, many references were either non-UK or not specific to the 4-hour rule. Rigorous research in an Australasian context would be required before adopting models from a different system. The authors promote a view that undifferentiated acutely sick patients bypass the ED to be managed by “new” acute-care specialists. No evidence is presented to support this change, and it is difficult to see how this would be a sensible policy for Australia and NZ, which have mature ED systems. Emergency physicians are specialists specifically trained and skilled in early diagnosis, management and disposition of the undifferentiated, unwell patient. What is required is a system that builds on the excellent start made by the ED, removes the blocks to patient care caused by waiting for beds in the ED and then continues to emphasise rapid diagnosis, early management, disposition and flow. This is what AMAAUs can deliver and why they should be effective. Australasian EDs already provide an exemplary service in a difficult, access-blocked environment. What patients need is sufficient hospital capacity — hospitals that provide enough appropriate beds. We look forward to seeing AMAAU staff meet this need in partnership with their emergency physician colleagues. In summary, it’s all about available beds, about having enough overall capacity and optimising patient flow to maximise bed availability.2 The only revolution required is for governments to recognise this fundamental precept.

David Mountain · Daniel M Fatovich · Drew B Richardson · Sally M McCarthy

To the Editor: Although written from a United Kingdom perspective, the recent article by Walters and Dawson1 suggests a change in the clinical culture within hospitals, so that patient care and throughput can be improved. A critical factor in achieving change is the creation of an acute medical assessment and admission unit (AMAAU) within each district hospital. Characteristics of the AMAAU will “depend on local circumstances”: there is no one size that fits all.1 Because of Australia’s unique demography, and the number of communities beyond the reach of tertiary centres, many primary-care physicians (general practitioners and “rural generalists”) provide the continuum of care required by patients, both within the community and within their local hospitals (the acute admission, ongoing inpatient care and discharge planning). Twenty-first-century GPs deal daily with patients needing management of multiple comorbidities and the consequences of polypharmacy (the “sick general” and “complex elderly” clinical streams1). GP training prepares doctors for these responsibilities and could easily be expanded to include an AMAAU role for interested GPs, especially those in outer urban and major rural areas. The advent of AMAAUs is an opportunity to change the mindset in medicine: after 8 to 9 years of primarily hospital-based training, some GPs suddenly have no hospital access! This would seem to be a callous waste of talent and resources.

Frank R Jones

To the Editor: Walters and Dawson1 highlight growing interest in new models of care aimed at ameliorating hospital-bed pressures and access block. They advocate acute medical assessment and admission units (AMAAUs) as a potential solution, and claim, principally based on the United Kingdom’s experience, that these units can significantly improve clinical care and patient outcomes. A recent systematic review confirms that these units (which have attracted several different synonyms) have promise, although controlled trials have yet to be performed, and publication bias remains a potential confounder.2 Experience with such units in Australia and New Zealand is growing, with more than 30 units in operation, and up to another 15 due to open over the next few years. Several national workshops conducted during the past 12 months have allowed staff of the units to share lessons and insights, and to debate how to balance service needs with resource availability. Operating standards for AMAAUs have been developed by the Internal Medicine Society of Australia and New Zealand (IMSANZ),3 which represents consultant general physicians. A recent survey shows the operations of Australasian units concord, in the most part, with these standards.4 We caution against Walters and Dawson’s suggested separation of AMAAU physicians into two streams — acute physicians working shifts, and ward-based general physicians responsible for patients requiring transfer from the AMAAU. Given that at least half of AMAAU patients will require transfer to inpatient wards, and many may warrant ongoing outpatient care even if discharged from the AMAAU, the need for continuity of care is paramount at the interface between the AMAAU and ward or clinic. To minimise the number of handovers and their attendant hazards and inefficiency, the medical team assessing and managing the patient in the AMAAU should ideally be the same team that provides ongoing inpatient (and indeed subsequent outpatient) care. This practice also eliminates any confusion around who is ultimately responsible for decisions about individual patient care, particularly for patients who remain in the AMAAU for any length of time. General physicians can acquire and maintain skills in acute medicine by making use of professional development programs sponsored by the IMSANZ. Clinical directors are needed in AMAAUs to oversee unit operations, develop policies and procedures, and provide capacity for rapid consultant response if on-call consultants are temporarily unavailable. The real challenge, to which Walters and Dawson refer, is the need for health care professionals to recognise that whole-of-hospital redesign solutions — which include AMAAUs — are needed, if access block in emergency departments is to be successfully overcome.

Ian A Scott · John W Henley

To the Editor: The Journal took a significant step forward in publishing the three articles on access block in the 6 April 2009 issue.1-4 Walters and Dawson’s viewpoint article,4 in a later issue, touches on some ideas that will be useful in finding solutions to access block — ideas that some hospitals are implementing. However, I am not sure a microsolution aimed purely at acute medical patients can be called a whole-of-hospital revolution. The acute medical assessment and admission unit (AMAAU) is potentially a good idea. Fortunately, many hospitals all over Australia already have units that are highly efficient at the role that is proposed for it — they are called emergency departments (EDs). Most acute medical patients can be identified as needing admission after a few seconds in the ED by experienced emergency physicians. The remaining patients need some basic pathology or imaging service before a decision can be made, which should take an hour at the most. Having secondary inpatient units providing this role to the community via direct general practitioner referrals, as well as having some patients bypassing the ED by being cherry-picked by inpatient teams, may generate inefficient duplications of service. The AMAAU has merit, streaming patients to the right specialty and the right inpatient bed early in their presentation. Emergency physicians have largely known this for over a decade and these kinds of units have already been introduced in hospitals all over the country. Nepean Hospital, in western Sydney, has the PECC (Psychiatric Emergency Care Centre), AGS (Acute Gynaecological Service), MAU (Medical Assessment Unit), EDMAU (ED Medical Assessment Unit), EMU (Emergency Medical Unit) and ASU (Acute Surgical Unit), to name just a few acronyms. Unfortunately, this does not deal with the 20 patients in the ED, already admitted and sorted, waiting for an inpatient bed at 8 am on a Monday. Increased inpatient bed numbers to cope with the predicted acute ED admissions and the planned elective surgical workload must be the number-one priority. Once we have bed numbers to cope with demand, then we can plan how to use them. I propose my own revolution. We need to provide a true 7-day-a-week service to our hospital inpatients. Ward rounds should be conducted 7 days a week. All inpatient consults, including those of allied health practitioners, should be completed on the same day, including weekends. All complex imaging should be completed on the day it is ordered, not the next working day, with formal reports available the same day. Once we acknowledge that acute hospital medicine does not fit in with the 38-hour working week, then we can truly start acting as patient advocates.

James L Mallows

To the Editor: The recent article by Chang and colleagues concluded that “the clinical course and outcomes of pandemic (H1N1) 2009 influenza virus are comparable to those of the current circulating seasonal influenza”, and that: “The high number of hospital admissions reflects a high incidence of disease in the community rather than an enhanced virulence of the novel pandemic influenza virus”.1 We are concerned that these assertions underemphasise the true severity of the influenza pandemic, and have led to inappropriate reporting in the media.2 The single-centre series reported by Chang et al had a small sample size and was almost certainly underpowered to detect important differences. It is also likely that some of the five untypeable patients who were categorised in the seasonal influenza group had had false-negative test results for pandemic (H1N1) 2009 influenza. Despite the small numbers, this study suggested that patients with pandemic (H1N1) 2009 influenza were younger and less immunocompromised than those with seasonal influenza; both of these characteristics of the patients affected may indicate that the pandemic virus is a more virulent strain. However, regardless of whether its virulence was greater, our significant concern is that our community will underestimate the real burden of the pandemic, which was substantial in Australia and New Zealand during the recent winter. In recent publications, we described more than 700 people admitted to intensive care units (ICUs) throughout these two countries with pandemic (H1N1) 2009 influenza.3,4 These were often young and previously healthy people, and many were pregnant women.3 Two-thirds needed mechanical ventilation for influenza-induced respiratory failure,3 and a smaller but substantial number developed rapidly progressive acute respiratory distress syndrome and required extracorporeal membrane oxygenation (ECMO),4 the most extreme life support available. This is not the normal pattern of influenza in Australasia. In comparison to a normal winter, ICU admissions for viral pneumonitis increased 15-fold,3 and the use of ECMO for acute lung injury increased 17-fold.4 Patients infected with pandemic (H1N1) 2009 influenza required prolonged stays in both the ICU and hospital and, despite optimal care, more than 100 died. ICU bed occupancy by patients with pandemic (H1N1) 2009 influenza ran as high as 19%3 in a system that normally runs close to maximal occupancy. There is a real risk that the pandemic will affect Australia again next winter or earlier, and we feel the Australasian medical community should not be misled into believing that the pandemic (H1N1) 2009 influenza virus is not virulent and has not been responsible for significant mortality and morbidity in a population not normally affected.

Andrew R Davies · Steven A Webb · Ian M Seppelt · Rinaldo Bellomo