Hep C drug mystery

The Federal Government has not disclosed how much it intends to spend on its goal of virtually eradicating hepatitis C from the country within a generation.

In one of the Government’s most ambitious public health measures, all adults with chronic hepatitis C have been provided subsidised access to hugely expensive frontline drugs that have a high rate of success in eliminating the disease within months.

More than 230,000 are estimated to be currently living with hepatitis C, which kills around 700 a year, but for most the drugs that could cure their ailment – Sofosbuvir, Daclatasvir and Ribavirin – were prohibitively expensive, costing as much as up to $100,000 for a course of treatment.

But hepatitis C have, since 1 March, had subsidised access to the drugs through the Pharmaceutical Benefits Scheme – an arrangement confirmed in the Budget.

Announcing the measure at the time, Health Minister Sussan Ley said it provided “great hope we can not only halt the spread of this deadly infectious virus, but eliminate it altogether in time”.

The Minister has explicitly linked the decision with the highly controversial move to axe bulk billing incentives for pathology services and cut them for diagnostic imaging – a measure expected to save $650 million over four years.

But in the Budget the Health Department said the cost of the measure was “not for publication”.

By contrast, it has announced that $57.6 million has been set aside to fund new and amended listings of drugs on the PBS and the Life Saving Drugs Program.

The Department said the PBS would cost $10.1 billion overall in 2016-17.

In addition, the Government has revealed it will spend $20.4 million to improve speed and efficiency of the system to regulate therapeutic goods, with the aim of bringing new drugs to market more quickly – in some cases up to two years sooner.

Under the plan, the number of committees advising the TGA will be cut from 11 to seven, costs and administrative burden for industry will be reduced, and the time taken to assess products will be reduced by up to three months by drawing on the work of comparable regulators overseas, such as the US Food and Drug Administration.

In addition, commercial organisations approved by the TGA will be allowed to undertake assessments of medical devices, and there will be new approval pathways for sponsors to add medicines and devices.

Adrian Rollins

[Comment] Vilanterol fluticasone and mortality in comorbid COPD GOLD B

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Due to common risk factors such as smoking and ageing, COPD often coexists with cardiovascular diseases, which have a major effect on prognosis. Cardiovascular death is the most important cause of death in patients with symptomatic moderate COPD (ie, COPD GOLD B).1,2 However, as highlighted by the GOLD guidelines, none of the current treatments of COPD, except smoking cessation, has been shown to significantly decrease all-cause mortality.

[Correspondence] Objection to chronic disease based restrictions during the Hajj

The call by Saber Yezli and colleagues (Feb 27, p 845)1 to restrict the Hajj pilgrimage based on non-communicable diseases (NCDs) is extremely disturbing to many Muslims. The Hajj is a deep, spiritual journey mandatory to financially and physically able Muslims once in their life-time. Two-thirds of the Hajj pilgrims originate from developing countries who make life-long savings to achieve their spiritual objectives. Thus, for most pilgrims, the Hajj is feasible only in older age; 43% of pilgrims are 56 years of age or older.

Flu vaccine more effective in the morning: study

Research has shown administering the flu vaccine in the morning could be more effective for immunity than in the afternoon.

The research, published in Vaccine, was conducted on 24 general practices in the UK, and involved 276 adults over the age of 65.

The adults were vaccinated for three strains of influenza in two time slots, either 9-11am or 3-5pm.

For two of the strains, there was a significantly larger increase in antibody concentration detected a month later for the group who were vaccinated in the morning compared to those who were vaccinated in the afternoon. There was no difference in antibodies for the third strain.

According to Principal Investigator of the study from the University of Birmingham, Dr Anna Phillips, “We know that there are fluctuations in immune responses throughout the day and wanted to examine whether this would extend to the antibody response to vaccination. Being able to see that morning vaccinations yield a more efficient response will not only help in strategies for flu vaccination, but might provide clues to improve vaccination strategies more generally.”

Co-investigator Professor Janet Lordsaid, “Our results suggest that by shifting the time of those vaccinations to the morning we can improve their efficiency with no extra cost to the health service.”

A larger scale study will investigate whether vaccinating in the morning would benefit people with impaired immunity, such as those with diabetes, liver and kidney disease.

Future research will also look at whether the time of day may vary for different vaccines, as they stimulate diverse immune responses for protection.

Latest news:

[Comment] No more excuses: viral hepatitis can be eliminated

The 2030 Agenda for Sustainable Development has recognised an infectious disease that the Millennium Development Goals omitted. UN Member States have now made a commitment to combat hepatitis under Goal 3.3 of the Sustainable Development Goals (SDGs),1 as a threat comparable to the “big three” communicable diseases—HIV/AIDS, tuberculosis, and malaria. Viral hepatitis is not an emerging infectious disease, but the cause of a silent epidemic of serious and often fatal liver disease, including liver cancer; the causative agents (hepatitis A, B, C, D, and E viruses) have been circulating in the human population for millennia.

Diabetes affects almost one in 10

Diabetes is rapidly emerging as one of the world’s most serious public health problems, affecting almost 500 million adults and contributing to the deaths of close to four million people a year.

An alarming report from the World Health Organization has found that incidence of diabetes, once mainly confined to high income countries, is rapidly spreading, and by 2014 422 million adults were living with the disease – almost one in every 10 adults worldwide. In 1980, its prevalence among adults was less than 5 per cent.

WHO Director-General Dr Margaret Chan said the disease’s emergence in low- and middle-income countries was particularly problematic because they often lacked the resources to adequately diagnose and manage the disease, resulting in needless complications and premature deaths.

According to the WHO’s Global Report on Diabetes, the condition was directly responsible for 1.5 million deaths in 2012 and contributed to a further 2.2 million fatalities by increasing the risk of cardiovascular and other diseases.

Diabetes takes a relatively heavy toll of younger people, particularly in less wealthy countries. Of the 3.7 million deaths linked to diabetes in 2012, 43 per cent occurred in people younger than 70 years of age, and the proportion was even higher in low- and middle-income countries.

The rise in diabetes has coincided with an increase in associated risk factors, most particularly a jump in global rates of overweight and obesity. Currently, 10.8 per cent of men and 14.9 per cent of women worldwide are considered to be obese, and on current trends that will increase to 18 per cent of men and 21 per cent of women by 2025.

While rates of obesity and diabetes are continuing to climb in rich countries, the WHO said this is being outstripped in other parts of the world, particularly middle-income nations.

The relative lack of resources to prevent, diagnose and manage diabetes in less wealthy countries is exacerbating its spread and impact.

Programs and policies to encourage physical activity, promote health diets, avoid smoking and controlling blood pressure and lipids are generally better funded in rich countries, where GPs and other frontline health services are better equipped to detect diabetes early and patients generally have good access to insulin and other treatments.

The WHO said that even though most countries have national diabetes policies in place, often they lack for funding and implementation.

“In general, primary health care practitioners in low-income countries do not have access to the basic technologies needed to help people with diabetes properly manage their disease,” the agency said. “Only one in three low- and middle-income countries report that the most basic technologies for diabetes diagnosis and management are generally available in primary health care facilities.”

In particular, it highlighted serious problems with access to treatments.

“The lack of access to affordable insulin remains a key impediment to successful treatment and results in needless complications and premature deaths,” the WHO report said. “Insulin and oral hypoglycaemic agents are reported as generally available in only a minority of low-income countries. Moreover, essential medicines critical to gaining control of diabetes, such as agents to lower blood pressure and lipid levels, are frequently unavailable in low- and middle-income countries.”

Diabetes has been identified as one of four priority non communicable diseases targeted under the 2030 Agenda for Sustainable Development, but Dr Chan said the WHO report showed there was “an enormous task at hand”.

“From the analysis it is clear we need stronger responses not only from different sectors of government, but also from civil society and people with diabetes themselves, and also producers of food and manufacturers of medicines and medical technologies,” the WHO leader said.

Adrian Rollins

Ebola outbreak in West Africa: considerations for strengthening Australia’s international health emergency response

It is time for a common vision and strategy for deploying Australian expertise to international public health emergencies

An effective response to health emergencies such as the Ebola virus disease outbreak in West Africa relies on global capacity to rapidly surge the supply of skilled workers, particularly when they are limited in affected countries and increasingly depleted during the emergency. Before the Ebola outbreak, health professionals in West Africa were already scarce; for example, in Liberia the doctor-to-population ratio was 1:70 000, compared with 1:300 in Australia.1,2 In addition to clinicians, an effective response to a large outbreak of Ebola virus disease in resource-limited settings requires international technical support across a range of public health and other disciplines, including infection prevention and control, epidemiology, laboratory diagnostics, communication, mental health, anthropology, social mobilisation, logistics, security and coordination.

Early in the Ebola virus disease outbreak in West Africa, many international non-government organisations (NGOs) and several governments established treatment centres and sent public health professionals to provide clinical care and augment control efforts. Timely public health interventions in Ebola-affected rural communities achieved crucial reductions (about 94%) in Ebola transmission.3 The Centers for Disease Control and Prevention (CDC) in the United States is a case study in how governments can deploy significant public health staff to countries affected by health emergencies. At time of writing, the CDC had effected 2206 staff deployments since July 2014 to support the public health response in Ebola-affected countries across a wide range of areas including surveillance, contact tracing, database management, laboratory testing, logistics, communication and health education.4 Most CDC public health staff were deployed into roles with a low risk of Ebola virus infection (ie, non-patient care roles) and none have become infected. In assessing the CDC’s exemplary response, it is important to note its pre-existing Global Health Strategy that clearly articulates the CDC’s vision, rationale, role, strategy, funding, partnerships, staff and areas of expertise for working in international public health, including in health emergencies such as Ebola virus disease.5

In contrast, nearly 6 months into the outbreak — when almost 5000 deaths had already been recorded — the Australian Government was being criticised by public health experts for its lack of substantive assistance to Ebola-affected countries.6 The Public Health Association of Australia called on the government to help strengthen the medical and public health capacity in the region by deploying an Australian Medical Assistance Team (AUSMAT), and by supporting Australians who wanted to volunteer their services through the World Health Organization or international NGOs by encouraging their employers to provide special leave and continuation of entitlements.6 Ultimately, the Australian Government declined to deploy AUSMAT resources, stating it would not consider sending people to Ebola-affected countries until it could get assurances from developed countries closer to West Africa that Australians would be able to be evacuated for treatment in the event they became infected.7 Instead, the Australian Government chose to fund a private contractor to staff a single treatment centre built by British army engineers in Sierra Leone. To date, anecdotal reports suggest no public health professionals have been deployed to Ebola-affected countries by the Australian Government, although the risk of infection is low.

The current and all previous Australian governments have not clearly articulated a vision for providing public health support during an international health emergency. AUSMATs are multidisciplinary health teams of doctors, nurses, paramedics, firefighters (logisticians) and allied health staff such as environmental health workers, radiographers and pharmacists8 who provide timely acute medical relief immediately after disasters in Australia and overseas. Staff of state and territory governments can be members of AUSMATs, and these agencies are reimbursed by the federal government for the salaries of staff who deploy through this mechanism. AUSMATs have a relatively small number of public health professionals on a roster largely drawn from staff of state and territory health authorities, but this list includes only a limited number with relevant outbreak response skills. While AUSMATs have a proven track record in providing emergency medical care in post-disaster settings, they are not currently designed to support the public health response required for a large outbreak.

The decision not to use AUSMAT assets and the lack of federal support for other Australian health professionals who wanted to volunteer to help contain the Ebola outbreak transferred the pressure to institute human resource policies (ie, special leave and continuation of entitlements) to state and territory health authorities. Without the type of financial arrangements that the AUSMATs afford state and territory health authorities, and with a general lack of jurisdiction-funded strategies for their staff engaging in emergency responses overseas, the environment for staff deploying independently was not always supportive.

Despite the challenges, many public health professionals from state and territory health authorities and academic institutions in Australia deployed as volunteers for NGOs or United Nations agencies, including about 15% of the Australian National University Master of Applied Epidemiology (MAE) program’s alumni since 1991 (Martyn Kirk, MAE Program Director, Australian National University, personal communication). Still, only one current Australian MAE participant was deployed, with Médecins Sans Frontières (as of January 2015), compared with 97 from a similar program in the US (the CDC’s Epidemic Intelligence Service), highlighting the missed opportunity for Australia’s next generation of outbreak control experts to get invaluable field experience while providing much needed support.

Now that the Ebola virus disease outbreak is over, Australia needs to examine how well it performed in assisting the WHO to respond to this significant threat to global health, as it was declared by the International Health Regulations Emergency Committee in August 2014.9 We believe it is time for the Australian Government, in consultation with state and territory health authorities and public health training institutions, to establish a common vision and strategy for deploying Australian expertise to international public health emergencies, including Ebola virus disease outbreaks. If AUSMATs (currently the only funded mechanism) are Australia’s preferred approach to responding to international health emergencies, their capacity to support a major public health response should be expanded by including more professionals in relevant disciplines. To maximise the impact of public health professionals deployed through AUSMAT arrangements, personnel should be made available at the beginning of future health emergencies. In addition, formalising support arrangements with members of the Australian Response MAE (ARM) Network10 (created by academic institutions in response to gaps in the coordination of Australia’s public health surge capacity) may be a way for the government to effectively mobilise skilled public health professionals for deployment overseas in response to disease outbreaks. Consideration should also be given to expanding the AUSMAT roster of public health professionals and integrating structures like the ARM Network into the response framework.

The Australian Government missed an important opportunity to contribute timely, valuable technical assistance to Ebola-affected countries; support that was essential to stopping the outbreak at its source at a time when it was needed most. In the end, many Australians stepped up as volunteers in the fight to extinguish this global threat to public health. Australian federal authorities should reflect on this experience and consider it an opportunity to strengthen Australia’s response to future health emergencies and demonstrate leadership on the global stage.

Multidrug-resistant tuberculosis in Australia and our region

MDR-TB threatens TB control programs in Australia’s region and will not diminish without concerted efforts

Tuberculosis (TB) is one of the world’s great killers, but Australia has been relatively protected because of its strong public health system. Of 1300 cases reported in Australia each year, almost 90% occur in the overseas born, although Indigenous Australians are also disproportionately affected. Most cases arise in the large immigrant communities from India, Vietnam, the Philippines, China and Nepal, but high rates are also reported from Papua New Guinea (PNG), Ethiopia, Somalia and Myanmar. These cases occur primarily in permanent residents and students, rather than in refugees or those on humanitarian visas.1

Many countries are now reporting significant rates of drug-resistant tuberculosis, with at least 480 000 cases worldwide now attributable to multidrug-resistant TB (MDR-TB; defined as resistance to the two most effective first-line agents, isoniazid and rifampicin).2 However, countries with the highest rates of drug resistance often have the poorest quality data, largely due to the lack of resistance testing. Globally, MDR-TB was estimated to constitute 3.3% of new and 20% of retreatment cases in 2014. Although the deployment of molecular diagnostics to detect resistance is progressing, only a quarter of these cases were correctly identified. For example, in PNG, MDR-TB rates are similar to those described globally, but a nationwide drug-resistance survey has not been undertaken and other data sources suggest that the rates could be underestimates.3 Extensively drug-resistant TB (XDR-TB; resistant to isoniazid, rifampicin and the most effective second-line agents, quinolones and injectables) has also been sporadically reported in Australia from PNG.4 For Australian clinicians, for whom diagnostics are widely available, the rise of MDR-TB makes definitive strain identification through culture even more important.

Traditional second-line agents to treat the handful of MDR-TB cases in Australia are generally available, but prolonged courses of toxic and expensive drug combinations are required. The agents used to treat MDR-TB depend on the remaining susceptibilities, but ototoxicity (aminogylcosides), nausea (p-aminosalicylic acid) and neuropsychiatric reactions (cycloserine) are among many common side effects. It is therefore unsurprising that globally, treatment outcomes are poor, with only about half of identified patients completing the 2-year treatment course, such that only around 10% of all incident cases complete treatment worldwide.2 Meta-analyses demonstrate that the chance of treatment success diminishes as the number of drugs to which a strain is resistant increases.5 Alarmingly, there are now data on outcomes for patients with “beyond XDR”-TB, with treatment success rates comparable to the pre-antibiotic era natural history of TB.6

There is a resurgence of interest in new treatments for TB, with the first new drugs in 40 years now proceeding through development, including bedaquiline, delamanid and pretomanid. As important as individual agents is the development of new regimens that can be deployed programmatically, such as the 9-month Bangladesh regimen (comprising gatifloxacin, clofazimine, ethambutol and pyrazinamide, with prothionamide, kanamycin and high-dose isoniazid added for the intensive phase).7 There is also interest in off-label use of existing antibiotics with anti-TB activity, such as linezolid and meropenem–clavulanate, and new strategies to minimise toxicity, such as therapeutic drug monitoring. However, even if new regimens become established, significant barriers exist to providing treatment for MDR-TB in the countries that need them most. MDR-TB is both a cause and symptom of poor communicable disease control programs, with MDR-TB regimens costing around tenfold that of drug-susceptible cases.8

MDR-TB is not a problem that will just go away. Policy makers may prefer to treat the problem they can address — focusing on improving programs for drug-susceptible TB to prevent resistance amplification. However, modelling has consistently demonstrated that cases of MDR-TB predominantly arise from community transmission rather than from resistance amplification in previously susceptible strains,9 such that only targeted control programs will achieve reduction in the disease burden attributable to MDR-TB.10

As global TB rates slowly decline, the contribution of late reactivation of latent infection to incidence is likely to increase. While this makes treatment for latent MDR-TB a key consideration, evidence for effective treatments remains scarce and clinical trials are ongoing.

The ambitious post-2015 targets for TB control, which replace the relatively modest Millennium Development Goals, present an opportunity for Australian leadership. In our setting, with most TB imported and the emergence of MDR-TB so dependent on the strength of health systems, Australia has a critical role to play in supporting developing countries of our region to improve TB control programs and their health systems generally. A vision for an expanded international response, coordinated with global partners, governments, multinational organisations, affected individuals and communities is provided by the United States National Action Plan for Combating MDR-TB.11 Given that 57% of MDR-TB cases occur in the Asia–Pacific region,2 a similar response to improve clinical diagnostics and management in our region would help keep MDR-TB from our shores.

The ASID test

The Australasian Society for Infectious Diseases view on infectious diseases challenges in 2016 and beyond

This year, 2016, is a historic year for the Australasian Society for Infectious Diseases (ASID), being the 40th anniversary of the formation of the society. It is an opportunity not only to celebrate our achievements in infectious diseases and microbiology over the past 4 decades but also to anticipate future challenges. Principal among these are antimicrobial resistance (AMR) and the emergence or re-emergence of previously controlled or unrecognised diseases.

Although infectious diseases were thought to have been conquered as public health problems 40 years ago, our complacency has been repeatedly challenged by new and re-emerging threats. In this issue of the MJA, we read about re-emergence of Ebola virus,1 preparedness for Zika virus2 and local transmission for hepatitis E3 as salient examples. Williams and colleagues also describe the diagnosis of subacute sclerosing panencephalitis in a 23-year-old man,4 a timely reminder that high levels of herd immunity are required to prevent measles outbreaks, which still occur in parts of Australia with suboptimal immunisation rates.5 But emerging infections are not only viral. In this issue, Mandrawa et al discuss carbapenem-resistant Klebsiella,6 which highlights the serious impact of AMR on clinical practice.

AMR remains a global challenge. It results in about 2000 attributable deaths per year in Australia and a projected 10 million globally by 2050.7 As antibiotics become less effective, old diseases re-emerge, many in Australia’s near neighbours. Tuberculosis (TB) remains one of the most lethal infectious diseases with a third of the world’s population being infected, and over 1.5 million annual TB-related deaths worldwide.8 In this issue, Cheng and Trauer report on the increase in multidrug-resistant TB in Australia and the region.9 Another disease from times past, gonorrhoea, is also re-emerging as increases in AMR result in treatment failures. In 2015, the National Neisseria Network reported a marked increase in rates of gonococcal disease, with the highest ever proportion of strains on record with reduced susceptibility to ceftriaxone, and high-level resistance to azithromycin recorded for the first time.10 These patterns reflect trends around the world, and as noted by Lahra and colleagues, suggest that Neisseria gonorrhoeae is emerging as a global public health threat.10 Both TB and N. gonorrhoeae emphasise our need for national, coordinated AMR surveillance in humans and animals so we can monitor and respond to these trends.

Surveillance alone will be ineffective if there is not a clear plan to reduce the AMR threat, as well as a coordinated mechanism to implement this plan across jurisdictions (which is currently lacking). The federal government released its national AMR strategy in late 2015.11 A key element is the need to develop a “one health” approach to antimicrobial stewardship, including capture of prescription data in both humans and animals, and regulation of antimicrobial use and national antimicrobial guidelines for veterinary practice and agriculture. Guideline development in animals and humans needs to be supported by implementation science to improve uptake and adherence. We also need to reduce the unnecessary use of antibiotics, which is estimated to occur in up to 75% of antibiotic prescriptions in Australia,12 the bulk of which are dispensed in primary care. There needs to be coordination of strategies to address this problem across stakeholders including professional colleges and societies. ASID, led by Professor Denis Spelman, and the Royal College of Pathologists Australasia have collaborated with the Royal Australasian College of Physicians’ EVOLVE campaign to list the top five low value interventions in infectious diseases and microbiology practice.13 These include the use of antibiotics for asymptomatic bacteriuria, leg ulcers without clinical infection, uncomplicated upper respiratory tract infections, and faecal pathogens in the absence of gastrointestinal symptoms (with some exceptions). Avoiding inappropriate diagnostic tests is one important aspect of reducing antibiotic prescribing for these conditions. For example, as Bowen et al report in this issue,14 faecal multiplex polymerase chain reaction testing results in high rates of reporting of the non-pathogenic parasites Dientamoeba fragilis and Blastocystis spp., which could lead to unnecessary antibiotic use in patients who test positive.

Another benefit of reducing unnecessary antibiotic use is reduction of adverse events. In their study of medical inpatients at a Melbourne hospital, Trubiano and colleagues found that almost one in four had a serious antibiotic allergy, most commonly associated with overuse of broad spectrum agents.15 Of particular concern was poor documentation of allergies in patient records and charts.

Over the past 40 years, members and affiliates of ASID have contributed to paradigm-shifting approaches to infectious diseases and microbiology — including the elimination of smallpox and the link between Helicobacter pylori infection and duodenal ulcers. Who knows what challenges lie ahead. We are on the cusp of personalised medicine that will predict our risk of disease, inform our likely response and guide our therapy. We must, however, remain mindful of key lessons from the past, so that history does not repeat itself. As Kurt Vonnegut, Jr wrote: “History is merely a list of surprises. It can only prepare us to be surprised yet again.”

Zika preparedness in Australia

Our comprehensive national response encompasses prevention and surveillance, as well as monitoring and controlling Aedes aegypti in Australia

The spectrum of clinical illness for Zika virus infection is generally not severe — about 80% of cases are asymptomatic1 — and the infection was not previously thought to be cause for serious public health concern. There is no specific treatment for, nor a vaccine against, a Zika infection.

Recent disquiet has been raised by emerging evidence of possible vertical transmission of Zika, the development of severe congenital abnormalities, including microcephaly,2,3 and of a possible link to fetal deaths.4 In addition, a possible link to Guillain–Barré syndrome has been reported.5,6 The World Health Organization declared the clusters of microcephaly and neurological disorders a Public Health Emergency of International Concern on 1 February 2016.7 Knowledge about any causal link between Zika virus and effects in utero is still evolving; however, given the serious implications, should there be one, Australian guidance for managing pregnant women returning from Zika-affected areas and for preventing the spread of the disease has been prepared.

In almost all cases, the Zika flavivirus is transmitted by mosquitoes (particularly by Aedes aegypti). The Zika virus was first isolated from a monkey in Uganda in 1947,8 and serological evidence of past infections in humans has been reported since 1952 in Africa and since 1981 in South-East Asia.9,10 Outbreaks in the Pacific Islands were first reported in Yap State, Micronesia, in 20071 and in French Polynesia from 2013,11 with spread to many Pacific islands between 2013 and 2016.12,13 Zika has spread rapidly across the Americas since late 2015, after being first confirmed in Brazil in 2015.14 In November 2015 the international community was alerted to the possibility of severe congenital malformations, with an International Health Regulations notification about an increase in cases of microcephaly in Brazil with geographical and temporal links to Zika.15 At that time, further information was also provided by health authorities in French Polynesia about congenital malformations, also with geographical and temporal links to Zika.15

In Australia, sporadic cases of Zika have been detected since 2012 in 35 returning travellers (to 29 February 2016), and there is a continuing risk of imported Zika infections from overseas. With the number of affected overseas areas increasing, as is greater awareness among the public and health professionals, an increase in the detection of imported cases could be expected.

The low risk of local transmission of Zika in Australia is restricted to areas of Queensland where the most suitable vector, A. aegypti, is continually present. Queensland has well developed and practised plans and resources for controlling dengue (also carried by the A. aegypti mosquito) that are also applicable to Zika. Through routine vector monitoring and control activities, and the deployment of Dengue Action Response Teams (DARTs), the Queensland government has prevented dengue from becoming endemic, despite regular importations. The Queensland government recently announced a package of measures to strengthen preparedness, including enhanced laboratory capacity in Townsville. Queensland Health remains on the alert for imported cases and subsequent local transmission.

A program of mosquito surveillance and control, coordinated by the federal Department of Agriculture and Water Resources, is in place at Australia’s air and sea ports to prevent incursions of exotic mosquitoes from overseas. While foreign mosquitoes are detected during the summer months, well established programs prevent their establishing breeding populations. There is also a specific program conducted by Queensland Health in the Torres Strait for controlling A. albopictus (a potential alternative vector for the Zika virus16), active in this area since 2005. The program has been successful in preventing its spread to the mainland and in reducing the numbers of A. albopictus and, at the same time, of A. aegypti in the transport hubs of the Torres Strait.

In February 2016, the Australian Health Protection Principal Committee issued advice on the management of pregnant women returning from Zika-affected countries and on preventing sexual transmission of Zika. A public health guideline on Zika is being finalised, and advice for travellers was issued in January 2016.17 Until more is known about the link between the virus and microcephaly, Australia recommends that women who are pregnant or planning to become pregnant should consider postponing travel to areas with ongoing transmission of Zika. If they do decide to travel, they should consistently adhere to mosquito avoidance measures. This recommendation is in line with major public health agencies around the world.

The Interim recommendations for assessment of pregnant women returning from Zika virus-affected areas18 encourage health care providers to ask all pregnant women about their recent travel history. Those who have travelled to a Zika-affected country during their pregnancy should be evaluated and tested. Any woman who tests positive for Zika virus should be referred for specialist obstetric care. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has issued guidance on the care of women with confirmed Zika virus infection during pregnancy in Australia.19

Further concerns for pregnant women and their unborn babies have been triggered by the possibility of sexual transmission of Zika virus. Initially, two instances of likely sexual transmission were reported internationally, one in 2008 and the other in 2016,20,21 and two instances of Zika virus being detected by polymerase chain reaction in semen — including one 62 days after the onset of symptoms — although virus isolation was not performed, so that it was not determined whether viable virus was present.22,23 There is evidence from the United States that sexual transmission of Zika may be more common than previously reported.23 To date, all reports of suspected or confirmed sexual transmission of Zika have involved a symptomatic man transmitting the virus to a woman. It is still unknown how long the virus can persist in semen, or how infectious this may be. Mosquitoes remain the overwhelmingly predominant mode of transmission. The Australian advice, Interim recommendations for reducing the risk of sexual transmission of Zika virus,25 recommends that men with a confirmed Zika virus infection and whose partner is pregnant should abstain from sex or consistently use a condom during sex for the duration of the pregnancy. Men with a confirmed Zika infection who do not have a pregnant partner should abstain from sex or consistently use a condom during sex for 3 months after leaving a Zika-affected country.

All recommendations about travel, testing and management require definition of the countries that have current local transmission. The list of affected countries is assessed daily by the Department of Health, based on agreed criteria. This, however, is not straightforward, and differences between overseas surveillance systems mean that a variety of sources must be checked to assess whether local transmission of Zika virus is happening in a particular country.

While unease about Zika is high, there remains a lack of high quality evidence for a causative link between infection and the development of microcephaly, and there is a general lack of data on the pathogenesis and epidemiology of the disease. Further studies are urgently required, and are underway. The need to formulate recommendations despite a paucity of data and evidence is not new in public health. However, it does pose particular challenges and risks, in that we may have to modify recommendations frequently. Expert consultations and the experiences and recommendations of other agencies internationally are important in the development of such recommendations. A key component of preparedness for communicable disease outbreaks in Australia is developing nationally consistent advice across the states and territories, and harnessing the expertise that is present throughout our country.

Australia has robust systems in place that can be adapted as required to enable a rapid response to communicable diseases such as Zika, with excellent laboratory capacity, public health response capability and communicable disease surveillance systems, as well as established vector surveillance and control programs. As the situation evolves, ongoing monitoring will continue, with information and recommendations updated as necessary. Zika is the latest communicable disease threat to challenge us. Each new threat offers an opportunity for enhancing core elements of communicable disease control and for ensuring readiness for the next emerging infectious disease.