News briefs

Sonic “tractor beam” could have medical uses

The tractor beam, a Star Trek staple, could be about to happen, and there could be medical applications, report The Japan Times and The Guardian. Researchers from the University of Bristol in the UK, and Spain’s Public University of Navarre say they have developed a tractor beam that “uses high-amplitude sound waves [at a frequency of 40 kilohertz] to levitate, move and rotate small objects without making contact with them”. The waves took the form of “tweezers to lift an object, a vortex to hold a levitating object in place and a cage to surround an object and hold it in place”. “Sound cannot travel through the void of space, but it can do it through water or human tissue. This potentially enables the manipulation of clots, kidney stones, drug capsules, microsurgical instruments or cells inside our body without any incision,” one of the lead researchers said.

Two-thirds of the world’s under 50s have herpes

The World Health Organization reports that more than 3.7 billion people under the age of 50 – or 67% of the population – are infected with herpes simplex virus type 1 (HSV-1). “Some 140 million people aged 15-49 years are infected with genital HSV-1 infection, primarily in the Americas, Europe and Western Pacific”, WHO says. “Fewer people in high-income countries are becoming infected with HSV-1 as children, likely due to better hygiene and living conditions, and are instead at risk of contracting it genitally through oral sex after they become sexually active.” WHO estimated that 417 million people aged 15-49 years have HSV-2 infection, which causes genital herpes. Taken together, the estimates reveal that over half a billion people between the ages of 15-49 years have genital infection caused by either HSV-1 or HSV-2.

23andMe is back in business

Two years after it was banned from distributing health information to its customers, controversial health and ancestry information provider 23andMe is back in business, reports Gizmodo Australia. In 2013, the US’s Food and Drug Administration stopped the company from providing private customers with health and ancestry information directly from their sequenced DNA, saying it was “concerned about the public health consequences of inaccurate results from the [23andMe] device … the main purpose of compliance with FDA’s regulatory requirements is to ensure that the tests work”. Now the FDA has given 23andMe the green light to resume distributing health information, albeit in a more limited way. “The new reports will provide details about what’s known as ‘carrier status’. The tests will identify genetic mutations in DNA samples that could lead to the passing of one of 36 diseases — including cystic fibrosis, sickle cell anaemia and Tay-Sachs — on to offspring. In each case, the disease would only be passed on if both parents shared the same mutation and the child inherited both mutated genes.” 23andMe has also hiked prices from USD$99 to USD$199.

Can Google Glass help autistic kids?

Wired reports that researchers at Stanford University in the US are working on software for Google’s wearable computer, Glass, which will help autistic children recognise and understand facial expressions and, through them, emotions. Lead researcher Catalin Voss has previously developed a Glass app which recognises emotions, which is now being turned into heads-up technology for cars. The new app is designed like an interactive game. “Children are asked to, say, find someone who is happy”, the researchers said. “When they look at someone who is smiling, the app recognises this and awards points. You can plot, as they wear the glasses, how they’re improving, where they’re improving. You can look at video to understand why.” The app is now being tested in a clinical trial with 100 children.

“Flakka” worse than ice, says toxicologist

A synthetic drug considered fatal has been detected in Australia and has the potential to be worse that ice, the International Business Times reports. “Flakka” is man-made, “has a similarity to cocaine and can be injected, snorted or smoked”. It can lead to a series of extreme symptoms called “excited delirium”, marked by violent behaviour, paranoia and spikes in body temperature. Reports from the United States suggest flakka, also known as “gravel” has caused several deaths there. “Flakka comes in bulk from China and is sold through gas stations, via the internet and other dealers”. Forensic toxicologist Andrew Leibie said that the drug has become so popular with people that “it will be appearing on the streets, it will be appearing in schools, it will be appearing in workplaces.”

[Correspondence] The World Bank under the leadership of Jim Kim

I read with interest the Special Report about Jim Kim by Sam Loewenberg (July 25, p 324).1 However, I thought a few points were missing. First, those who have taken up an executive position after working in a particular discipline, know how difficult it is to be fair to their own specialty of interest. For example, when Halfdan Mahler became Director-General of WHO in 1973, after many years of working in the specialty of tuberculosis, funding for tuberculosis was severely reduced. Similarly, when I became head of the Special Programme for Research and Training in Tropical Diseases in 1986, I reduced funding for my own specialty of leprosy.

Govts doing little to tackle climate health threat

More than half of governments around the world are yet to develop national plans to protect their citizens from the health effects of climate change despite increasing warnings it will cause more extreme weather, spread disease and put pressure on food and water supplies.

An international survey of 35 countries, including Australia, has found a general lack of focus and urgency around the looming threat of climate change to health, with most governments doing little work on likely effects and how to mitigate them.

The survey, coordinated by the World Federation of Public Health Associations (WFPHA), found that almost 80 per cent are yet to comprehensively assess the threat climate change poses to the health of their citizens, two-thirds had done little to identify vulnerable populations and infrastructure or examine their capacity to cope, and less than half had developed a national plan.

The result underlines the importance of repeated AMA calls for the Federal Government to do much more to prepare for the effects of climate change, which President Professor Brian Owler said were “inevitable”.

Earlier this year the AMA released an updated Position Statement on Climate Change and Human Health that warned of multiple risks including increasingly frequent and severe extreme weather events, deleterious effects on food production, increased pressure on scarce water resources, the displacement of people and an increase in health threats such as vector-borne diseases and climate-related illnesses.

“There are already significant health and social effects of climate change and extreme weather events, and these effects will worsen over time if we do not take action now,” Professor Owler said.

“Nations must start now to plan and prepare. If we do not get policies in place now, we will be doing the next generation a great disservice.

“It would be intergenerational theft of the worst kind — we would be robbing our kids of their future.”

In May, the AMA and the Australian Academy of Science jointly launched the Climate change challenges to health: Risks and opportunities report that detailed the likely health effects of climate change and called for the establishment of a National Centre of Disease Control to provide a national and coordinated approach to threat.

The WFPHA said the results of its survey, released little more than two weeks before the United Nations Climate Change Conference in Paris, should serve as a wake-up call for governments to do much more.

“The specifics of these responses provide insight into the lack of focus of national governments around the world on climate and health,” the Federation said.

Disturbingly, the survey found that Australia was one of the laggards in addressing the health effects of climate change, having done little to assess vulnerabilities and long-term impacts, develop an early warning system or adaptation responses, and yet to establish a health surveillance plan.

On many of these measures, the nation was lagging behind countries like the United States, Sweden, Taiwan, New Zealand and even Russia and China.

Climate and Health Alliance Executive Director Fiona Armstrong, who helped coordinate the survey, said the results showed the Federal Government needed to place far greater emphasis on human health in its approach to climate change.

“As a wealthy country…whose population is particularly vulnerable to the health impacts of climate change, it is very disappointing to see this lack of leadership from policymakers in Australia,” Ms Armstrong said.

Public Health Association of Australia Chief Executive Officer Mike Moore said the increasing number and ferocity of bushfires and storms underlined the urgent need for action.

“It is time to ensure that health-related climate issues are part of our national planning and budgeting if we are to pre-empt many avoidable illnesses and injuries,” Mr Moore said.

The AMA’s Position Statement on Climate Change and Human Health can be viewed at: position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

Adrian Rollins

Govt survey a smokescreen to undermine equal access: AMA

Charging smokers and the obese higher health insurance premiums is the first step toward a US-style system in which the poorest and sickest are shunted into over-stretched public health services while insurers book big profits, AMA President Professor Brian Owler has warned.

Professor Owler has launched a full-blooded attack on the Federal Government over a survey it has launched which asks consumers whether they think insurers should be given the discretion to charge different premiums according to smoking habits, obesity and other health risks.

The AMA President said the Government’s move played into the hands of health funds keen to offload customers with serious and chronic illnesses onto the public system in order to boost their profits, and would do nothing to cut down on smoking or otherwise improve health.

“We all know that non-smokers are going to say ‘Yes, I want to pay less for my premiums,” the AMA President said. “This is not the way to tackle smoking.”

He said the bigger policy question was whether people were prepared to let health funds pick and choose who they insured, taking into account that procedures like genetic screening for potentially fatal diseases would soon be a reality.

“If you’re positive for a genetic test, are you going to be denied cover? These are the sorts of questions that we need to be asking,” Professor Owler said.

Health Minister Sussan Ley seized on figures showing health insurance policies covering 500,000 people were dumped or downgraded in 2014-15 to argue insurers need to provide much better value.

Ms Ley said the Government was committed to “recalibrating” the private health system to make it value for money following a succession of premium increases that have outstripped inflation and the proliferation of junk policies that offer nothing more than a public hospital bed.

“Consumers are angry, confused, and I’m concerned that simply shopping around is no longer enough to get the best value for money,” she said, inviting them to take part in an online survey being run by the Health Department.

Premium increases outstrip costs

The private health insurance market is dominated by five big funds and the industry recorded an after-tax profit of $1.1 billion in 2014-15. Premium revenue surged by 7.3 per cent, leading the regulator to note that “the increasing cost of health services and growing utilisation rates have been more than offset by higher premiums”.

But the Minister has been forced on to the defensive amid criticism that her approach to put the interests of insurers ahead of patients, particularly the sickest and most vulnerable.

Shadow Health Minister Catherine King said suggestions in the survey that insurers be allowed to charge different premiums according to age and gender as well as lifestyle habits like smoking showed that women and the elderly were in the Government’s sights.

Ms King said it was alarming that the survey highlighted the higher benefits paid out to patients 75 years or older, while asking about gender was a “clear sign” that women of child bearing age would be required to pay higher premiums.

Community rating under attack

Professor Owler said the private funds wanted to undermine community rating, the principle under which insurers must offer the same price of health cover to all, regardless of their health risk, in order to boost their bottom line.

This was the intention behind the push to have smokers charged a higher premium, he said, warning the idea would eventually be extended to policyholders with other health risks.

“Where does it stop, because we know that genetic testing is coming down the track. You know that obesity and all sorts of other issues are going to be brought into play in the future, and…the insurers are only going to want to insure those people that are fit and healthy and don’t need anything done to them,” Professor Owler said. “That is all about maintaining their bottom line and…improving their margins.”

His concerns were given added weight when Mark Fitzgibbon, Chief Executive of insurer NIB, told Fairfax Media that although higher premiums for smokers would be the first move, insurers might eventually monitor the habits of policyholders to reward healthy behaviour like exercise (and, by implication, to punish unhealthy activity).

But Ms Ley said it was not the Government’s intention to impair access to health care, and its starting point was that Medicare and public hospital system remain universally accessible.

“It’s important we’re able to ask consumers what they expect from their private health insurance, and there’s plenty of room to do that without moving towards US or UK models that exclude sick people, or make it only available to rich people, which we don’t support,” she said.

But the Minister flagged changes to industry regulation, remarking that a succession of the above-inflation premium increases suggested there was “something wrong” with its regulatory foundations.

Professor Owler said this was worrying.

“I find it very concerning when the Health Minister makes statements like she’s concerned that the health insurers are wrapped up in regulation or being restricted by regulation,” he said. “Those regulations are there to protect the public health system, and they’re there for a good reason.”

Adrian Rollins

Latest news:

[Editorial] Advancing China’s health and medical science

The Lancet and the Chinese Academy of Medical Sciences (CAMS) held the first of what will become their annual Health Summit in Beijing last week. More than 500 delegates, most from China, participated. 30 research abstracts were selected from among 600 submissions for oral presentation, together with around 100 posters. Four keynote speeches highlighted critical aspects of China’s endeavour to achieve universal health coverage by 2020: Nanshan Zhong spoke about the continuing threat of air pollution and chronic airway diseases; Wang Yu described the neglected challenge of hepatitis B and C; Richard Peto set out a comprehensive strategy to halve premature mortality; and Xuetao Cao presented a manifesto for strengthening the scientific capacity of China to meet the needs of its 1·3 billion people.

[Comment] A Commission on obesity

The global pandemic of obesity continues unabated: 2·7 billion adults are projected to be overweight or have obesity by 2025.1 Obesity is driving global increases in type 2 diabetes, cardiovascular diseases, and several types of cancer, yet the implementation of recommended policies to reduce obesity has been slow and patchy.2 Therefore, WHO targets for 20253 to “halt the rise of obesity and diabetes” from the 2010 baseline will not be met without major global action. In addition, obesity is a visible marker of serious, underlying, systemic problems in food systems and in urban design and transport systems.

[Comment] Respiratory medicine and critical care: a call for papers

As health care becomes ever more complex and the approach to treatment more personalised, research is a vital component in our mission to help improve the lives of patients living with respiratory diseases. From understanding the genetic links to disease to cutting-edge treatments, high-quality research helps us to navigate the intricate path to optimum care for patients.

Freedom of choice a weighty problem

Governments will have little choice but to tighten food and marketing regulations and possibly increase taxes on unhealthy products if the nation’s waistline continues to bulge, the AMA has warned.

The peak medical representative organisation told a Senate inquiry into so-called “nanny state” laws that unless Australians improved their diets and increased physical activity, rates of overweight and obesity would continue to climb and the consequent social and economic costs could force governments to act.

While not calling for a sugar tax, the AMA warned that simply giving people information for them to make informed choices may not, by itself, be enough.

“If people continue to make poor choices, and the number of adults who are overweight or obese continues to increase, Government will have little choice but to regulate,” it said, suggesting this might extend to include “restricting…advertising, increasing price, and reducing access, to products known to have a negative impact on health”.

Its views were echoed by ACT Chief Health Officer Dr Paul Kelly, who told The Canberra Times that although he did not advocate a sugar tax, government needed to be “part of the solution” to obesity.

“Just telling people [about healthy food choices], and asking them to make their own decision, is insufficient,” Dr Kelly said. “We know that the majority of the work we do in the hospital system is related to chronic diseases, many of which, if not caused by, are at least made worse by people being overweight or obese. And that’s a real cost to the whole community.”

The AMA made its warning in a submission to the Senate inquiry being led by Liberal Democratic Party Senator David Leyonhjelm, who objects to what he sees as unwarranted Government constraints on freedom of choice, and has taken particular aim at public health measures such as tobacco controls, alcohol restrictions and bicycle helmet laws.

“It’s not the government’s business, unless you are likely to harm another person. Harming yourself is your business, but it’s not the government’s business,” Senator Leyonhjelm said. “So bicycle helmets, for example, it’s not a threat to other people if you don’t wear a helmet; you’re not going to bang your bare head into someone else.”

Poor choices can hurt many

But the AMA argued this was a narrow view that ignored the society-wide consequences of individual choices.

The Association said that often people failed to appreciate the effect of their choices on those around them.

“All too often it is family members and governments who are left to provide support and care for poor individual decision-making,” the AMA said. “More tragically, sometimes innocent victims have to bear the consequences. As doctors, we see too many innocent victims, victims of road traffic accidents caused by drunk or speeding drivers, victims of alcohol and drug-induced violence.”

The Association said that millions were alive today because of public health initiatives such as vaccination programs, road safety laws, smoking restrictions and air and water standards that initially encountered resistance, but which are now widely accepted and supported as reducing the risk to individuals and enhancing the common good.

For example, smoking is a leading cause of preventable deaths, and dealing with its health and economic consequences costs the country billions of dollars each year. For this reason, the community accepts and expects measures to control tobacco marketing and use.

Similarly, compulsory bicycle helmets laws introduced in the early 1990s have been found to have greatly reduced the risk of head injury for cyclists, to the benefit of individuals, their families and the community.

Sydney University philosopher Professor Paul Griffiths and Sydney Law School Professor Roger Magnusson said Senator Leyonhjelm’s critique of public health measures missed the mark.

“Australia’s health legislation is a poor candidate for Libertarian criticism,” they wrote in The Age. “Accurate information about the risks and harms posed by consumer products increases freedom by helping people understand their options.”

In its submission, the AMA rejected the view that these and similar regulations were an unwarranted intrusion on individual liberty.

It said that even with such public health measures in place, “people in Australia are largely able to do as they wish, even when it is likely to cause harm to themselves or others – some people continue to smoke or consumer excessive amounts of alcohol”.

But the AMA asserted governments had a responsibility to protect people from harm caused by others, and to regulate behaviour to improve individual health and promote the greater good.

“Government does have a role to play in making this country a safer and healthier society,” it argued, “…in regulating and modifying the behaviour of individuals so that the rest of us can be confident that we won’t be affected by the poor decisions of others, such as being run off the road by a drunk driver.”

“We need all those who have a responsibility for prevention, including governments at all levels, to live up to their responsibilities for public health and prevention.”

Adrian Rollins

Post-artesunate delayed haemolysis in severe imported Plasmodium falciparum malaria

We report a case of post-artesunate delayed haemolysis (PADH) in severe Plasmodium falciparum malaria.

A female wildlife conservation worker based in South Africa presented with severe malaria (hypotensive shock and 30% parasitaemia level). She had not been on malaria prophylaxis. Six months earlier she had a febrile illness after a tick bite, which was treated with doxycycline with complete resolution. Blood tests revealed renal impairment, abnormal liver function tests with coagulopathy and thrombocytopenia without intravascular haemolysis. Systemic examination was unremarkable.

In the intensive care unit she was given intravenous artesunate for 5 days and supportive platelet transfusion. Blood cultures and serologies for dengue, leptospirosis, schistosomiasis, rickettsia and HIV were negative. Oral artemether-lumefantrine was prescribed to complete malaria treatment. Recurrence of haemolysis was observed on Day 10 of admission (1 week after artesunate treatment). Extravascular haemolysis was confirmed by low haptoglobin and elevated lactate dehydrogenase (LDH) levels. Other causes of haemolysis such as viral haemorrhagic fever (Rift Valley and Crimean–Congo fevers), drugs and viral infections were excluded.

A literature search of haemolytic causes alluded to the possibility of PADH.1 Proposed criteria by the United States Centers for Disease Control and Prevention (CDC) for PADH (a decline in haemoglobin levels of ≥ 10%, haptoglobin levels of ≤ 0.1 g/L and an increase in LDH levels of > 390 U/L) were present.1 Supportive therapy with blood transfusion led to restabilisation of haemoglobin. Convalescent serological testing found an increase in Rickettsia typhi titre from < 128 to 256 before discharge. This was consistent with murine typhus likely caused by flea bites when cleaning her room. Empirical therapy with doxycycline given earlier in the current admission would have treated this.

Artesunate is the drug of choice to treat severe P. falciparum infection due to concerns of drug resistance and mortality benefit.2 PADH is a rare but significant complication of artesunate, with 23 confirmed and 15 probable cases.3 Although there has been heterogeneity in the criteria for diagnosis of PADH in the past, the CDC optimised the definition in 2014.1,4 PADH typically occurs 1 to 3 weeks after administration of intravenous artesunate treatment.1 Artesunate supplied in Australia is manufactured overseas (China) and sourced by a local company. Although controversy remains around artesunate manufactured overseas due to non-adherence to Good Manufacturing Practice (GMP) guidelines, whether PADH is caused by direct toxicity from the drug in non-GMP settings remains speculative as it has also been described in three patients who received the drug made in the US and Canada.4,5 There are two proposed mechanisms of PADH: (i) rapid clearance of parasite from the infected red blood cells causes them to “pit”, which causes haemolysis; and (ii) activation of the pro-inflammatory cytokines.3,4 Higher parasitaemia levels in non-immune patients are more frequently associated with PADH.1,4 PADH is also known to occur with oral artemisinin derivatives.1

Clinicians using artesunate to treat patients diagnosed with falciparum malaria need to be aware of the risk of PADH, especially if haemolysis develops after treatment. Based on the current literature, we recommend a follow-up of at least 1 month after treatment.1,2

[Comment] Long working hours: an avoidable cause of stroke?

William Osler, in an article about atherosclerosis published 100 years ago, wrote that the main cause of myocardial infarction was “wear and tear of life”.1 Although we now have more detailed theories regarding the causal mechanisms, there is still some kinship between modern studies of work-related determinants of cardiovascular diseases and Osler’s broad approach to the cause of disease.2