[Correspondence] Neglected tropical diseases in the Sustainable Development Goals

Neglected tropical diseases (NTDs) have been formally recognised as a target for global action towards the Sustainable Development Goals. So can we now get rid of the word neglected? Not yet. Strangely, the NTDs were only a late addition by the Inter-Agency and Expert Group on Sustainable Development Goal Indicators to target 3.3—to “end the epidemics of HIV, tuberculosis, malaria and neglected tropical diseases” by 2030.1

[Perspectives] Mary Bassett: trailblazer for health in New York City

Mary Bassett, Commissioner of the New York City Department of Health and Mental Hygiene, spent 17 years of her early career in Zimbabwe as the AIDS epidemic, of which she had seen the beginnings in her native Harlem, engulfed sub-Saharan Africa. Returning to New York, the most urgent need was a different one: to tackle non-communicable diseases (NCDs) caused by smoking and poor diets. But on both continents, she identified the same underlying issue that she has fought all her life—health inequalities.

[Comment] The historian will see you now: introducing Case Histories

“I hope that Lord Grey and you are well”, wrote the Regency wit and clergyman Sydney Smith to his confidante Lady Mary Grey in February, 1836, “no easy thing, seeing that there are about fifteen hundred diseases to which man is subject”. Last year the editors of the Lancet journals announced the launch of The Lancet Clinic, a major online initiative which draws together an overview Seminar with the best current research from across the Lancet journals on 135 of the most globally important diseases.

Wollongong academics disown anti-vax views

Health academics at the University of Wollongong have affirmed the lifesaving benefits of immunisation after their institution become embroiled in controversy over the decision to award a doctorate for a thesis questioning the safety and efficacy of mass vaccination programs.

Sixty-five senior medical and health researchers including Professor of Public Health Dr Heather Yeatman, Dean of Medicine Professor Ian Wilson, and Professor Alison Jones, Executive Dean of the Faculty of Science, Medicine and Health, have jointly signed a public statement backing the evidence supporting vaccination and its importance in preventing disease.

“The evidence is clear,” the statement said. “Immunisation protects children and saves lives.

“While individuals may express opinions, the international scientific evidence overwhelmingly supports immunisation to protect children from infectious diseases.”

A series of reports in The Australian newspaper revealed that Dr Judy Wilyman, described as an “anti-vaccination campaigner”, had been accepted for a PhD after submitting a thesis in which she criticised the National Immunisation Program (NIP).

In her thesis, Dr Wilyman argued that the implementation of mass vaccination programs like the NIP coincided with “the development of partnerships between academic institutions and industry” and notes the involvement of organisations including the World Bank, the International Monetary Fund, the Bill and Melinda Gates Foundation and UNICEF in urging population-wide immunisation.

“Whilst the Government claims serious adverse events to vaccines are rare this is not supported by adequate scientific evidence due to the shortcomings in clinical trials and long-term surveillance of health outcomes of recipients,” she argues. “A close examination of the ‘Swine Flu’ 2009 vaccine and the vaccine for human papillomavirus (HPV), intended to prevent cervical cancer, shows shortcomings in the evidence base and rationale for the vaccines. This investigation demonstrates that not all vaccines have been demonstrated to be safe, effective or necessary.”

The social sciences researcher called for “independent research” into the safety and efficacy of current vaccines, and added that it was important to have “comprehensive evidence that it is safe to combine multiple vaccines in the developing bodies of infants”.

Dr Yeatman said large-scale immunisation programs began in the 1930s and “immunisation provides an important safeguard against infectious disease when children go to school or play with others”.

According to Immunise Australia, mass immunisation had led to a 99 per cent plunge in deaths from vaccine-preventable disease.

“For more than 50 years, children have been immunised and it is one of our best success stories in public health,” she said.

Wollongong University has staunchly defended its decision to grant Dr Wilyman a PhD, on the grounds of academic freedom.

But, following sustained criticism, it has launched a review of the process involved in awarding PhDs – though it will not include that presented to Dr Wilyman.

Adrian Rollins

[Comment] Trends in cause-specific mortality in Chinese provinces

China’s extraordinary economic development has brought with it huge improvements in public health. Children born in China today are expected to live almost a decade longer on average than are individuals born in 1990.1 The country now has more people aged 65 years and older than any other country in the world, placing enormous pressures on its health-care infrastructure.2 As average incomes have increased, lifestyles have changed, and access to health care has improved, the country has experienced a rapid transition away from infectious diseases and towards non-communicable diseases as causes of mortality.

[Comment] A roadmap for better mental health in New York City

New York City is frequently at the forefront of public health policy. Aggressive action to combat the dangers of tobacco use, including the 2003 Smoke-Free Air Act, tax policy, and educational campaigns, led to steep declines in smoking rates.1,2 Regulations to improve the food environment, such as labelling about calories in 20063 and sodium in 20154 and bans on trans fats in 2008,5 continue to be implemented as a way to tackle a growing obesity epidemic and rise in non-communicable diseases.

News briefs

Touchbase website for LGBTI health

A new website has been developed to provide targeted information on drugs, alcohol, and mental and sexual health to Australia’s lesbian, gay, bisexual, transgendered and intersex communities, BuzzFeed Australia reports. TouchBase (www.touchbase.org.au) is a joint initiative between the Victorian AIDS Council, the Australian Federation of AIDS Organisations and the Australian Drug Foundation. A unique aspect of TouchBase is its focus on drug interactions with HIV medication and hormones. “We’ve created TouchBase to address gaps in existing information for LGBTI people,” said Victorian AIDS Council CEO Simon Ruth. “It’s a unique website, because LGBTI people have different drug-using norms — we use drugs in different patterns, we have different concerns, people have been dealing with different issues throughout their lives.”

New Surgeon-General for ADF

Air Vice-Marshal Tracy Smart has been named as the new Commander of Joint Health Command and Surgeon-General of the Australian Defence Force (ADF), taking over from Rear-Admiral Robyn Walker, who served in the role from 2011. Air Vice-Marshal Smart became the highest ranked lesbian officer in the ADF in 2009 when she was made Air Commodore in 2009. Her latest promotion will see her responsible for the delivery of health services and medical readiness of all ADF members, and will also provide strategic health advice and technical oversight of operational health services. She has publicly led the ADF contingent at the Sydney Gay and Lesbian Mardi Gras three times since 2008, the Star Observer reports. “One of the things that matter to me is to say gay men and lesbians are in every walk of life, including what in Australia now is a highly respected profession, like medicine and defence. The more people who do it the stronger that message is.”

Google searches track infectious diseases

The United States’ National Public Radio (NPR) reports that researchers from the University of Illinois in Chicago have teamed up with internet search giant Google to track sexually transmitted diseases. Google has given the researchers and the Centers for Disease Control and Prevention access to its search data. “Researchers can mine Google data to identify search terms that spiked during previous upticks in a particular disease. Then, researchers can measure the frequency of those searches in real time to estimate the number of emerging cases. For instance, a jump in gonorrhea might coincide with more people searching ‘painful urination’ or other symptoms. Search trends can be broken down by city and state, weighted by significance and combined with other data to produce a snapshot of where disease is spreading well before public health agencies report the number of verified cases.”

Vaccine for dengue fever approved in Mexico

The New York Times reports that Mexico has become the first country to approve the use of a vaccine to protect people aged 9–45 years against dengue fever. Clinical trials showed the vaccine reduced the risk of developing dengue by about 60%, the NYT reported. There is no treatment for dengue, a viral disease transmitted by mosquitoes. It can cause high temperature and intense joint and muscle pain. In severe cases, it can be fatal. Estimates about the number of people sickened by dengue each year range from 50 million to 400 million. In recent years, the disease has spread out of its traditional location in developing countries in tropical areas.

Almost two-thirds of Aussies overweight or obese

Australian Bureau of Statistics data released in the 2014–15 National Health Survey showed that 63.4% of Australians are classified as overweight or obese, totalling 11.2 million people. A quarter of children aged 5–17 years are overweight or obese. Nevertheless, 56.2% of Australians aged 15 years and over consider themselves to be in excellent or very good health. One in nine adults experienced high or very high levels of psychological stress. “The percentage of adults consuming more alcohol than the recommended guidelines — two standard drinks per day — dropped by 2% from 2011–12 to 17.4%”, the Huffington Post reports. “One in four men exceeded the lifetime risk guidelines compared to one in 10 women. Smoking rates among 18–44 year olds have declined by 12 percent since 2001. Rates of smoking are higher in outer regional and remote areas. Mental and behavioural conditions topped the major long-term health conditions list, with four million sufferers identified in 2014–15.”

Anti-vax dodge a dubious legal ploy

Doctors are being urged not to sign a form being circulated by anti-vaccination campaigners attempting to circumvent new ‘No Jab, No Pay’ laws.

The AMA’s senior legal advisor John Alati said the form, which asks doctors to acknowledge the ‘involuntary consent’ of a parent to the vaccination of their children, used unusual, confusing and misleading wording, and was of dubious legal status.

“This is not a Government-issued form, and there is no legal obligation whatsoever on a doctor to sign it, or even consider it,” Mr Alati said. “It is likely to be meaningless in the legal sense.”

The form has been circulated among anti-vaccination groups ahead of the 2016 school year following Federal Government welfare changes aimed at denying certain welfare payments to parents who refuse to vaccinate their child.

Under the No Jab, No Pay laws, from 1 January this year parents of children whose vaccination is not up-to-date will not be eligible for the Family Tax Benefit Part A end-of-year supplement, or for Child Care Benefit and Child Care Rebate payments. The only exemption will be for children who cannot be vaccinated for medical reasons.

The new laws are aimed at penalising parents who claim a conscientious objection to vaccination, and to provide an incentive for parents who have neglected their child’s vaccination to bring it up-to-date.

The new laws were introduced amid mounting concern that vaccination rates in some areas were slipping to dangerously low levels, increasing the risk of a sustained outbreak of potentially deadly diseases such as measles.

The Australian Childhood Immunisation Register shows there has been a sharp increase in the proportion of parents registering a conscientious objection to the vaccination of their child, from just 0.23 per cent in late 1999 to 1.77 per cent by the end of 2014.

In all, around a fifth of all young children who are not fully immunised are that way because of the conscientious objection of their parents.

The form being circulated by anti-vaccination groups, headed “Acknowledgement of involuntary consent to vaccination”, is intended to circumvent the No Jab, No Pay laws and allow conscientious objectors to receive Government benefits without allowing the vaccination of their children.

But Mr Alati said the dubious nature of the document made it highly unlikely it would be effective in achieving its goal.

He said the very claim of ‘involuntary consent’ in the form’s title was muddled.

“[Consent] may be grudging or doubtful, but if it is given by a person with capacity, apprised of relevant facts, it is consent,” Mr Alati said. “If it is not voluntary, it is presumably not consent.”

In the form, the doctor is asked to sign a statement that “consent provided by (name of parent) is not given ‘voluntarily in the absence of undue pressure, coercion or manipulation’, and hence that, according to Section 2.1.3 Valid Consent of the Australian Immunisation Handbook 10^th edition, the consent is not legally valid. Given the absence of valid consent, I am/am not willing to proceed with the vaccination of (name of child).”

Mr Alati said the wording of the acknowledgment was “confusing, to say the least”.

But he warned that although the form was likely to be legally meaningless, its wording was concerning.

He said the fact that it did not include a statement that the doctor had outlined the risks and benefits of vaccination may be used as evidence that the patient was not properly informed of the implications of not being immunised.

And he said the wording of the line “I am/am not willing to proceed with the vaccination of…”, created the false impression that the choice of whether or not to proceed with the vaccination lay with the doctor, not the parent.

Mr Alati said where there was no medical reason for exemption, the doctor’s job was to outline the relevant facts about immunisation and to provide vaccination where consent was given. Where it was withheld, “the doctor should not perform the procedure as it might constitute trespass to the person”.

The AMA legal expert advised doctors presented with the form not to sign it.

“Given the unusual, confusing and misleading wording of the form and its dubious legal status, we do not recommend that any doctor sign it,” he said. “Doctors should explain to the parent or carer that it is their choice whether to proceed with the vaccination, based on what they have been told, and note the situation on the patient’s health record.”

He said any doctor considering signing the form should “carefully weigh up the potential risks of doing so”.

Adrian Rollins

[Comment] Genetics and phenotypes in inflammatory bowel disease

Inflammatory bowel diseases, encompassing Crohn’s disease and ulcerative colitis, have long been recognised as very heterogeneous diseases at the clinical level. Farmer and colleagues1 were among the first to report that location of disease was a major driver for disease presentation, complications, and rates of surgery. More recently, the Montreal and Paris classifications (ie, modified Montreal classification for use in paediatric inflammatory bowel disease) have tried to standardise clinical phenotypes further, acknowledging that age at diagnosis, and location and extent of disease in Crohn’s disease and ulcerative colitis, and disease behaviour in Crohn’s disease, are the main factors affecting disease course and prognosis.

[Comment] Coronary artery disease: a dam in the river for ranolazine

Coronary artery disease is the largest contributor to cardiovascular diseases and the number one cause of death in western countries. Percutaneous coronary intervention (PCI) has become the most commonly done interventional procedure in medicine, and coronary artery bypass grafting (CABG) has become one of the most commonly done forms of major surgery.1,2 The number of CABG operations done each year has remained constant, whereas the number of PCI procedures has increased and now accounts for an increasing proportion of revascularisation procedures.