Environmental health

A 77-year-old never-smoker presented with an abnormal screening chest x- ray

Clare Wood · Elizabeth J Silverstone · Deborah H Yates

Noise reduction, in conjunction with counselling and night-time broadband sound therapy, reduces the distress associated with tinnitus

Melville J Da Cruz

To the Editor: In August 2020, the South Eastern Sydney Public Health Unit, located in New South Wales, Australia, received a statutory laboratory notification of an elevated blood lead level of 0.34 µmol/L in a preschool‐aged child recently diagnosed with autism. This was above the 0.24 µmol/L level requiring notification under the Public Health Act 2010 (NSW). The test had been requested by the child's paediatrician due to concern about the child’s recent consumption of an oral Ayurvedic medicine prescribed by a naturopath. Our environmental health officers undertook a home lead assessment, during which a soil sample and the Ayurvedic medication sample were taken for heavy metals analysis. The soil lead concentration was 160 mg/kg. The medication was labelled Manasmithra Vatika (MV), manufactured in India (Box). Analysis revealed that it comprised 0.96% lead by weight. The naturopath indicated that they had prescribed the medication to other child and adult patients, some of whom were seeking treatment for autism. Most consultations were conducted online and the prescriptions were purchased online. We were concerned about the risk of lead toxicity in the naturopath’s other patients who had been prescribed MV, and mounted a public health investigation in order to inform patients of their risk, to advise them to cease use of the medication, and to identify the extent of the problem. The naturopath provided a list of 28 patients (13 children) to whom they had prescribed the medication. We directly followed up the 12 NSW patients (other than the index case), asking whether they had taken MV, and, if so, in what dosage and over what period. We advised those who were taking MV to immediately cease its use, and to seek blood lead level testing through their own doctors. We asked patients to provide us with any remaining MV for lead analysis. Five patients provided MV samples; analysis showed lead content of 0.74–0.96% (mean, 0.81%) by weight. Four patients had an elevated blood lead level ranging from 0.30 to 0.68 µmol/L (reference interval, < 0.24 µmol/L). A fifth patient, whose blood lead level was undetectable (< 0.1 µmol/L) had ceased taking the MV at least 3 months before measurement. Based on these findings, we initiated a multi‐agency investigation involving NSW and Australian government regulatory bodies. Action taken against the naturopath by the Australian Health Practitioner Regulation Agency and NSW Health Care Complaints Commission prohibited them from treating medical conditions, such as autism. The naturopath voluntarily ceased prescribing MV and immediately contacted their patients to inform them of the lead adulteration of the preparation. The NSW distributor of the MV medication was investigated by the NSW Health Pharmaceutical Regulatory Unit and the Therapeutic Goods Administration, leading to the distributor ceasing to import the adulterated MV. The Therapeutic Goods Administration issued a public warning regarding the presence of lead in MV preparations generally, without naming an implicated brand or source.1 Lead exposure in children can be linked to reduced intelligence, and behavioural and developmental impacts.2,3 Ayurvedic medicines are formulated and prescribed based on ancient Indian texts. Although they are herbally based, Ayurevedic texts also provide for formulation with heavy metals including lead.4 Their use has been associated with elevated blood lead levels in patients.5 The public health investigation and subsequent multi‐agency intervention we have described prevented ongoing exposure of patients to a lead‐contaminated herbal product. As a result of this investigation, we suggest: ▪ health practitioner awareness be raised regarding the risks of recommending or prescribing unregistered, imported medications; ▪ clinicians consider testing for blood lead in patients who have consumed unregistered, imported Ayurvedic medications; ▪ public health professionals be engaged in the investigation of patients with elevated blood lead levels in the absence of an occupational source; ▪ community awareness be raised regarding the risk of consuming unregistered, imported Ayurvedic medications; and ▪ a multi‐agency response is required to effectively address prescribing of unsafe complementary medications by unregistered health professionals. Box – Manismithra Vatika tablets provided by a patient with an elevated blood lead level

Mark J Ferson · Sinead Flanigan · Toni Cains

To the Editor: Self‐collected vaginal samples are as effective as clinician‐collected cervical samples for detecting underlying cervical intraepithelial neoplasia grade 2 or higher (the target lesion of cervical screening) using polymerase chain reaction‐based oncogenic human papillomavirus DNA assays.1 However, the use of self‐collection within Australia’s cervical screening program is currently restricted to women who are underscreened or never screened (at least 2 years overdue, so 4 years since their last Pap test), aged ≥ 30 years and refuse a clinician‐collected sample. This is because, at the time the current policy was developed, self‐collection was believed to result in a small loss of sensitivity. Accredited laboratories are not permitted to test samples that do not meet these requirements. VCS Pathology (part of the Australian Centre for the Prevention of Cervical Cancer) was the first laboratory to receive regulatory approval to process self‐collected samples. Here we report the reasons for rejection of samples received between February 2018 and 30 June 2021, which is important given that about one‐third (34%; 2166/6234) of samples received could not be processed (37.4% in 2018; 37.9% in 2019; 34.1% in 2020; 22.8% in 2021). The three most common reasons were that the person was not sufficiently overdue (54.1% of rejected samples; 18.5% of all samples); that the wrong type of collection device was used (17.3% of rejected samples; 5.9% of all samples); or that the person was < 30 years of age (11.2% of rejected samples; 3.8% of all samples). Other reasons included delayed sample receipt (5.2% of rejected samples; 1.8% of all samples), presence of symptoms (3.0% of rejected samples; 1.0% of all samples) and multiple reasons (combination of above factors: 6.6% of rejected samples; 2.3% of all samples) (Box). The implementation of self‐collection, while known to be highly acceptable to many women who will not accept a speculum examination for screening,1,2 has been problematic in Australia to date.3,4 The eligibility restrictions and strict laboratory requirements have created unintended barriers for practitioners and potential participants, as demonstrated by both the sample rejection rate and low overall numbers compared with the eligible population (< 1%).3 The recently announced mainstreaming of self‐collection, by making it a choice for all screening participants using on‐label tests, should overcome many of these barriers5 and improve program equity and participation. Successful implementation will depend on timely education, communication and change management. Box – Proportion of 6234 self‐collected samples received that were unable to be processed, by reason and year of receipt (VCS Pathology, February 2018 to the end of June 2021) * Incorrect collection device refers to wrong swab type or media. † Other reasons include duplicate samples, and pregnancy (which was initially an exclusion criterion).

Julia ML Brotherton · David Hawkes · Marion Saville

To the Editor: With great interest we read the article by Weise and colleagues,1 which presents the results of a retrospective cohort study that found higher age‐standardised rates of potentially preventable hospitalisation in people with intellectual disability in New South Wales compared with the general NSW population. Given the great health inequality of people with intellectual disability, we acknowledge the authors’ effort to conduct this valuable study. However, after reading the article, we were left with two questions. First, to be able to interpret the results of this study, a clear description of the population characteristics of both groups is indispensable. Information about parameters such as age and sex of both populations and about the design of the database is of crucial importance. The absence of this information makes it difficult to get a good picture of the population studied and any limitations or biases that need to be taken into account. We recognise that this type of data is not always easy to collect, especially when working with large population databases. Given its importance for interpretation purposes, we see this as a crucial point of attention for future research. Second, in this study, potentially preventable hospitalisations were identified using the definition in the National Healthcare Agreement, progress indicator 18.2 However, in addition to this definition, the circumstances and the exact reason for hospital admission have not been explored, which makes it difficult to conclude whether all hospital admissions could actually have been prevented in clinical practice. Further research would therefore be of great added value to unravel the significance of the study findings by exploring the differences in the rates of potentially preventable hospitalisations to guide possible future reforms of primary and community health care. In conclusion, the article provided us with important knowledge about the rates of potentially preventable hospitalisation of people with intellectual disability. However, the questions mentioned above need to be answered and further research should be conducted to allow a good interpretation of the results.

Karel L Wel · Lydia Kleinjan · Marleen J Leeuw

In reply

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

Retraction: Madden DL, Horton GL and McLean M. Preparing Australasian medical students to practise environmentally sustainable health care. Med J Aust 2020; https://doi.org/10.5694/mja2.50585.