Victoria on measles alert as infections mount

Victorian health authorities have issued a statewide measles alert to GPs and hospitals amid fears there are “multiple” undiagnosed people who are unwittingly spreading the highly infectious disease in the community.

Warning that the number of cases are likely to mount, Victoria’s Acting Chief Health Officer Dr Finn Romanes said investigations were “strongly indicating there were now multiple undetected cases in the community potentially spreading the infection”.

There are already four confirmed cases, including a young woman who had been in Shepparton, Melbourne’s CBD, Melbourne Airport and Brisbane while infectious with the illness.

Authorities have revealed that three of the cases involved people aged between 18 to 30 years, all of whom became infected in early to mid-June, and none of whom had recently travelled overseas – the usual route by which measles is introduced to Australia.

“Because of this, our concern is that there was a person or persons who probably had travelled overseas, and have since unknowingly passed on measles to these three people in the western suburbs and Barwon area – and there may be more,” Dr Romanes said.

“There is now the potential for these three people and anyone else was has been infected to pass on the disease and create a significant outbreak.”

Dr Romanes said it was likely that the three had been infected while in Melbourne’s CBD between 10 and 13 June.

But he admitted the source of the infection had yet to be determined, and it was likely that people in outer metropolitan Melbourne, as well as in some Victorian regional areas and interstate had been exposed – one of those infected travelled to Brisbane on 1 July.

“There are many other areas across metropolitan Melbourne where infections may have been acquired, and individuals have attended a range of public settings across Melbourne and in regional Victoria whilst infectious, including Shepparton,” Dr Romanes said.

He said the infection may also have been acquired in Geelong and the Surf Coast, and warned that “it is likely there will be more cases related to this outbreak”.

Family doctors and hospital emergency department staff have been put on alert for measles in patients who present fever at rash onset, particularly if they are not fully immunised or are unaware of their vaccination status.

While measles is uncommon in Australia because of widespread vaccination, it is still prevalent in many areas overseas, and local outbreaks were usually linked to returning travellers.

Nationwide, between 90 and 92 per cent of children are vaccinated against measles, but some adults – particularly those born after 1966 – are not immunised.

Dr Romanes recommended those unsure of their vaccination status to be immunised as soon as possible, and for parents to ensure their child’s vaccinations are up-to-date.

He asked anyone unwell with a fever and rash who was not fully vaccinated for measles to ring ahead to their doctor or hospital and alert them that they may have measles.

“The doctor or hospital will then be able to immediately isolate them whilst assessing for measles, which will minimise spread to others,” he said.

Adrian Rollins

Nation’s health only partly on track

Australia is making progress in reducing rates of smoking and dangerous drinking but is losing the battle to rein in weight gain, high blood pressure, and salt and sugar consumption, according to a national snapshot of health trends.

Australia’s Health Tracker, produced by the Australian Health Policy Collaboration with the support of 50 public health organisations, shows that the nation is making good progress toward reducing drinking and smoking, with the proportion of adults drinking at risky levels trending down toward 18 per cent and the country on track to cut the number of adults who strike up on a daily basis down to 10.6 per cent by 2025.

But adults and children are continuing to put on weight, eating too much sugar (and salt) and not doing enough exercise, according to the tracker.

It shows that more than 63 per cent of adults are overweight or obese, along with more than a quarter of children, and almost a half of adults and 70 per cent of children are eating too much sugar.

The tracker found that people are not doing enough exercise, particularly in light of their energy-rich diets – just 55 per cent of adults and less than 10 per cent of teens meet physical activity recommendations.

These readings underline concerns that not enough is being done to reduce the incidence of chronic disease by changing behaviour and encouraging healthier lifestyles.

According to the authors of the Health Tracker, 50 per cent of Australians have a chronic disease, and they estimate that almost a third of such illnesses could be prevented by eliminating smoking, losing weight, cutting down on drinking, taking exercise and reducing blood pressure.

“Chronic disease is the biggest health challenge of the twenty-first century,” the authors said. “Australia lags well behind comparable countries in tackling the risk factors for preventable chronic diseases.”

But, they said, “much of Australia’s chronic disease burden is preventable or capable of significant amelioration”, and urged that there be “population-level interventions that target risk factors shared by many population groups and communities”.

There have been concerns that preventive health has been undermined in recent years by Federal Government policies and cutbacks, including the abolition of the Australian Preventive Health Agency, reducing spending on public health education campaigns, funding cuts for community organisations and programs undertaking preventive health activities and reduced policy emphasis on public health initiatives.

But both the Coalition and Labor have committed to trialling new models of chronic care in the primary health sector centred on general practice as the ‘home’ of health care and involving remuneration based not only on fee-for-service but also incorporating regular payments tied to the management of individual patients with complex and chronic illnesses.

But Public Health Association of Australia Chief Executive Officer Michael Moore said action was now needed.

“A lot of promises were made before the election to fight chronic disease,” Mr Moore said. “This research is the first of its kind, and should be taken as not only a warning, but as a call to action. What we need to see is action from the elected Government.”

Australia’s Health Tracker can be viewed at: https://www.vu.edu.au/sites/default/files/AHPC/pdfs/australias-health-tr…

Adrian Rollins

[Seminar] Systemic amyloidosis

Tissue deposition of protein fibrils causes a group of rare diseases called systemic amyloidoses. This Seminar focuses on changes in their epidemiology, the current approach to diagnosis, and advances in treatment. Systemic light chain (AL) amyloidosis is the most common of these conditions, but wild-type transthyretin cardiac amyloidosis (ATTRwt) is increasingly being diagnosed. Typing of amyloid fibrils, a critical determinant of therapy, has improved with the wide availability of laser capture and mass spectrometry from fixed histological tissue sections.

Cancer mortality to decline

The number of people dying from cancer is projected to grow, but experts predict overall cancer mortality rates will decline as the medical profession gets better at detecting and treating the life-threatening illness and dangerous behaviours like smoking and heavy drinking decline.

In an upbeat assessment of the outlook for one of the nation’s most common killers, the Australian Institute of Health and Welfare (AIHW) has used past trends in cancer deaths and mortality rates to develop projections for the next 10 years.

The Institute said that the mortality rate for all cancers combined has generally decreased over time, from 199 deaths per 100,000 in 1968 to 166 per 100,000 in 2013. AIHW said that the overall decrease is influenced by changes in both total cancer incidence and total cancer survival.

The report did not go into reasons for the decline, but initiatives including cancer screening programs, advances in diagnosis and treatment, and changes in diet and lifestyle, including a big decline in the prevalence of smoking and heavy drinking are considered to have made an important contribution.

Though cancer is a diverse group of diseases, each with its own specific risk factors, progression, treatment and prognosis, the Institute said the data pointed to a decreasing trend in cancer mortality overall.

The AIHW has projected that if current trends continue, by the middle of next decade the male mortality rate from all cancers combined will decline from 208 to 180 per 100,000 males. Nonetheless, because of population growth, the number of men dying from cancer will increase, from 25,643 I 2014, to a projected 31,555 deaths in 2025.

For women, the mortality rate from all cancers will decline from 133 to 120 deaths per 100,000 over the same period, and the AIHW predicts 24,159 women will die from cancer in 2025 – up from 19,644 in 2014, due to population growth.

The AIHW report can be found at http://www.aihw.gov.au/cancer/mortality-trends-projections/

Kirsty Waterford

Malnourished das linked to underdeveloped kids

By Caleb Radford, The Lead South Australia

Malnourished fathers could avoid passing on poor health to their children by taking vitamin supplements

and antioxidants before conceiving.

Researchers from the University of Adelaide in South Australia conducted a laboratory study using under-nourished

male mice and found a direct correlation between the health of the offspring and the father’s health at the time of

conception.

University of Adelaide researcher Nicole McPherson said previous studies had looked at the affect of malnutrition in

mothers but new evidence suggests that paternal influences could play a more direct role.

“Malnutrition is a serious issue and affects hundreds of millions of people around the world,” she said.

“The biggest issue is that people dismiss men’s health and it’s impact on the health of their children, whether that is

under-nutrition or over-nutrition.

“However, we now know that the parents’ health at the moment of conception is incredibly important. What we’re

seeing from our research is that some form of dietary supplementation may also benefit fathers-to-be.”

There are about 2 billion people in the world who suffer from various forms of malnutrition. About 2.6 million children

die from malnutrition each year, which accounts for a third of child deaths globally.

Under-nutrition is considered to be the number one risk to health worldwide and accounts for 11 per cent of the

global burden of disease.

The research study found that the offspring of malnourished male mice were born underdeveloped and showed

evidence of abnormal gene expression and metabolic markers.

These offspring were prone to health conditions including increased risk of non-communicable diseases,

cardiovascular disease and type 2 diabetes, mirroring the situation for human children born in the developing world.

Researchers responded by altering the diet of the male mice to include additional zinc, folate, iron and other vitamin

supplements.

This resulted in improved fertility rates, healthier children and normal metabolic markers.

“A father’s health at the time of conception is really important – their particular dietary quality and nutrient

sufficiency,” Dr McPherson said.

“We hope that these findings could eventually be translated into interventions, to help reduce the health burden of

under-nutrition to the world.”

“This is however a laboratory study and we still need to do more research.”

The study titled Paternal under-nutrition programs metabolic syndrome in offspring which can be reversed by

antioxidant/vitamin food fortification in fathers has been published in the Nature journal Scientific Reports.

Life expectancy up, but Africa still behind – WHO

A new report has highlighted the disturbing extent of health inequality across the globe, showing that while life expectancy has risen at its fastest rate since the 1960s, sub-Saharan Africa still lags the rest of the world by a considerable margin.

The World Health Organisation (WHO) figures show that global life expectancy increased by five years between 2000 and 2015 – the fastest increase since the 1960s.

The African region had the strongest growth, up by 9.4 years, driven by improvements in child survival, malaria control and access to retrovirals for HIV treatment.

The increase has narrowed the gap between African life expectancy and European life expectancy by 4.9 years since 2000.

But even so, a child born in Africa in 2015 can only expect to live to the age of 60, compared with the global average of 71.4 years.

A child born in Sierra Leone has a life expectancy of just 50.1 years, more than 33 years less than a child born in Switzerland (83.4). An Australian (82.8 years) can look forward to three more decades than an Angolan (52.4 years).

“The world has made great strides in reducing the needless suffering and premature deaths that arise from preventable and treatable disease,” WHO Director-General Dr Margaret Chan said.

“But the gains have been uneven. Supporting countries to move towards universal health coverage based on strong primary care is the best thing we can do to make sure no-one is left behind.”

The World Health Statistics: Monitoring Health for the SDGs report shows that the declines in life expectancy experienced in the 1990s, caused by the AIDS epidemic in Africa and the impact of the collapse of the Soviet Union on eastern Europe, have been reversed.

“The global average increase in life expectancy at birth since 2000 exceeds the overall average rate of life expectancy increase achieved by the best performing countries over the past century,” WHO said.

“The world as a whole is catching up with those countries, and improvements in outcomes for all major causes of death have contributed to these huge gains.”

WHO said it was worth considering a proposal to measure premature mortality – deaths before the age of 70 – as it was more sensitive to interventions.

“There were an estimated 30 million deaths under age 70 in 2015 and, if the Sustainable Development Goals (SDG) mortality targets had been achieved in 2015, this would have been reduced to 19 million deaths,” the report said.

“This represents a 36 per cent reduction (almost 11 million averted premature deaths) – close to the proposed 40 per cent target.”

Had those deaths been averted, five million people would not have died from infectious diseases, malnutrition, and child and maternal mortality. A further five million would not have lost their lives to non-communicable diseases, and 900,000 people would not have died from injuries.

The report found that Japan topped the life expectancy list, at 83.7 years, and Sierra Leone was the lowest (50.1).

Healthy life expectancy, a measure of the number of years of good health a 2015 newborn can expect, stands at 63.1 years globally – 64.6 years for women and 61.5 for men.

On average, women (73.8 years) live longer than men (69.1 years) in every country of the world. Scandinavian countries had the lowest male-female gaps (Iceland 3.0 years, Sweden 3.4) while some former Soviet countries were among the highest (Russia 11.6 years, Ukraine 9.8 years).

The full report can be found on the WHO website at http://www.who.int/gho/publications/world_health_statistics/2016/en/

Maria Hawthorne

Committee backs AMA on primary care

A parliamentary committee has called on the Federal Government to consider reforms to the Medicare Benefits Schedule to help GPs better manage chronic disease in patients.

The House of Representatives Standing Committee on Health handed down its report on Chronic Disease Prevention and Management in Primary Health Care last month, noting that the groundwork for improvements to the primary health care system already existed.

“It is clear, however, that this cannot occur without cooperation, coordination, evaluation and adequate data and records to support Primary Health Networks in fulfilling their important role as coordinators of care,” the committee said.

“Performance measurements, expansion of chronic disease items, improved referral and rebate claiming processes and encouraging private health insurers to manage their members in cooperation with the primary health care system is a clear goal.”

The AMA made a submission to the inquiry in August last year, noting that primary health care was critical to providing quality, effective and empowering health care for people with chronic disease.

“With more than half of all potentially preventable hospital admissions due to chronic conditions, costing more than $1.3 billion a year, there are significant benefits in ensuring access to timely, clinically necessary and well-coordinated health care,” the AMA said.

The AMA called for reform of the MBS to restructure specific chronic disease management (CDM) items to cut red tape and reflect modern clinical practice.

It also called for formal engagement protocols between Primary Health Networks (PHNs) and Local Hospital Networks (LHNs) to work together on areas such as transitioning patients out of hospitals and into aged care.

It recognised that there was scope for private health insurers to explore the potential for greater engagement with general practice, but urged caution on expanding their role into a managed care model.

The Committee picked up many of the AMA’s recommendations.

It recommended the Government investigate expanding the number of allied health treatments that can attract an MBS rebate within a year, on the proviso that the patient has the relevant General Practitioner Management Plan and Team Care Arrangements in place.

It also recommended that the Government examine reforms to the MBS to allow for a practitioner to claim a rebate for a chronic disease management consultation and a general consultation benefit, for the same person on the same day.

It recommended considering expanding the Practice Incentives Program to include programs for breast, bowel and skin cancer screening, as well as the Integrated Health Check developed by the National Vascular Disease Prevention Alliance.

“Preventive health promotion as well as expanded health checks will help to provide the awareness and early detection required to help combat these diseases,” the committee said.

“The Health Care Home trials which are expected to commence in 2017 will help to improve this outcome, and with appropriate funding, privacy considerations, capture and consolidation of data, and a focus on research and improvement, the cooperative care goals required to improve chronic disease primary care can become a reality.”

Maria Hawthorne

Global emergency call on yellow fever outbreak

The World Health Organisation has been urged to take emergency action over a rapidly spreading yellow fever epidemic that has so far infected more than 2000 people in Africa and Asia.

Health experts at Georgetown University’s Institute for National and Global Health Law, writing in the Journal of the American Medical Association, have warned that “quick and effective action” is needed to halt the spread of the disease, which has already killed more than 250 people in Angola and has appeared in Congo, Kenya and China.

The experts, Dr Daniel Lucey and Professor Lawrence Gostin, said that shortages in the supply of the yellow fever vaccine raised the risk of a “health security crisis” if the disease spreads through Africa and reaches Asia (which has never experienced a yellow fever epidemic) or the Americas (where the mosquito that can transmit yellow fever is endemic).

“The WHO should urgently convene an emergency committee to mobilise funds, coordinate an international response, and spearhead a surge in vaccine production,” they said.

Dr Lucey and Professor Gostin said delays in the international community’s response to the 2014 Ebola outbreak that eventually infected 28,646 people and claimed 11,323 lives should serve as a salutary lesson of the costs of a tardy response.

“Prior delays by the WHO in convening emergency committees for the Ebola virus, and possibly the ongoing Zika epidemic, cost lives and should not be repeated,” they said. “Acting proactively to address the evolving yellow fever epidemic is imperative.”

Yellow fever kills around 30,000 people a year, mostly in Africa, and the latest outbreak has added impetus to mass vaccination programs. More than 7 million Angolans have been immunised against yellow fever, and in May the Democratic Republic of Congo Government announced plans to vaccinate 2 million of its citizens.

Dr Lucey and Professor Gostin warned that these mass immunisation campaigns “could be a tipping point in exhausting global vaccine supplies”.

Medical experts have already advised that just one-fifth of normal vaccine dose be administered to avert the risk of an acute shortage if the disease spreads, but Dr Lucey and Professor Gostin said it was time for the WHO to step in.

They said the world health body should invoke procedures similar to those used during the Ebola epidemic to safeguard vaccine supplies.

“Stewardship of scarce vaccine supplies is essential, but requires the WHO’s Director-General to declare a public health emergency of international concern,” they wrote. “[But] it is only by convening an emergency committee that the Director-General could declare a public health emergency of international concern.

“Given the world’s vital health security interest, the WHO’s Director-General should use [the procedures] to authorise a reduced vaccine dose to control the epidemic in Angola.”

Dr Lucey and Professor Gostin said the yellow fever outbreak, combined with the experiences of the Ebola and Zika epidemics, showed that the WHO needed to have a standing emergency meeting that met regularly, rather than having to be formed each time a serious global health threat arose.

“The complexities and apparent increased frequency of emerging infectious disease threats, and the catastrophic consequences of delays in the international response, make it no longer tenable to place the sole responsibility and authority with the WHO’s Director-General to convene currently ad hoc emergency committees,” they said.

Adrian Rollins

[Comment] Tocilizumab for systemic sclerosis: implications for future trials

Systemic sclerosis is a chronic autoimmune disease that causes high morbidity and increases mortality. Although treatments have become available for some manifestations such as pulmonary arterial hypertension, there is still no approved therapy for fibrotic manifestations and the overall course of disease.1 However, following findings about the pathogenesis of fibrotic diseases, several new targeted therapies are being tested in clinical studies.2,3

[Perspectives] Malaria

In 1866 a newly qualified Aberdonian doctor, Patrick Manson, followed his older brother into the Chinese Imperial Maritime Customs Service. After a decade in the service Manson retired to Scotland, but in the early 1890s he was forced back into practice by a currency crash that wiped out his Chinese pension. Drawing on his experiences in east Asia, he began to concentrate on the study of tropical diseases, developing an ecological approach in which bacteriology and pathology were combined with entomology and geography.