AMA updates stance on Climate and Health

Following an extensive engagement process with members, the AMA updated its Position Statement on Climate Change and Human Health (Revised 2015), which was last revised in 2008.

The updated Position Statement takes account of the most recent scientific evidence.

AMA President Professor Brian Owler said the AMA Position Statement focuses on the health impacts of climate change, and the need for Australia to plan for the major impacts, which includes reducing greenhouse gas emissions.

“It is the AMA’s view that climate change is a significant worldwide threat to human health that requires urgent action, and that human activity has contributed to climate change,” Professor Owler said.

“The evidence is clear – we cannot sit back and do nothing.

“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.

“The AMA believes that the Australian government must show leadership on addressing climate change.

“We are urging the Government to go to the United Nations Climate Change Conference in December in Paris with emission reduction targets that represent Australia’s fair share of global greenhouse gas emissions.

“There is considerable evidence to convince governments around the world to start planning for the major impacts of climate change immediately.

“The world is facing a higher incidence of extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.

“The health effects of climate change include increased heat-related illness and deaths, increased food and water borne diseases, and changing patterns of diseases.

“The incidence of conditions such as malaria, diarrhea, and cardio-respiratory problems is likely to rise.

“Vulnerable people will suffer the most because climate change will have its greatest effect on those who have contributed least to its cause and who have the least resources to cope with it.

“The Lancet has warned that climate change will worsen global health inequity through negative effects on the social determinants of health, and may undermine the last half-century of gains in development and global health,” Professor Owler said.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) states that:

· Australia should adopt mitigation targets within an Australian carbon budget that represents Australia’s fair share of global greenhouse gas emissions, under the principle of common but differential responsibilities.

· Renewable energy presents relative benefits compared to fossil fuels with regard to air pollution and health. Therefore, active transition from fossil fuels to renewable energy sources should be considered.

· Decarbonisation of the economy can potentially result in unemployment and subsequent adverse health impacts. The transition of workers displaced from carbon intensive industries must be effectively managed.

· Regional and national collaboration across all sectors, including a comprehensive and broad-reaching adaptation plan is necessary to reduce the health impacts of climate change. This requires a National Strategy for Health and Climate Change.

· There should be greater education and awareness of the health impacts of climate change, and the public health benefits of mitigation and adaptation.

· Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.

The AMA Federal Council last month passed a policy resolution acknowledging the need for the healthcare sector to reduce its carbon footprint through improved energy efficiency, green building design, alternative energy generation, alternative transport methods, sustainable food sourcing, sustainable waste management, and water conservation.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) is available at position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

John Flannery

e-cigarettes – what is the damage?

There has been a lot of debate about whether electronic cigarettes are the best technological solution to the smoking pandemic or the biggest looming threat to public health.

E-cigarettes are battery-powered devices that deliver nicotine to the user through a vapour by heating a solution of propylene glycol or vegetable glycerin, flavouring, and other additives. Flavours range from butter rum to caramel macchiato to strawberry lemonade.

The US Centre for Disease Control and Prevention reported earlier this year that the use of e-cigarette devices among middle school and high school students tripled between 2013-2014, with around 13 per cent of students using the devices. This surpasses the number of teens who smoke conventional cigarettes in the US.

Currently, there are more than 500 e-cigarette brands and more than 7000 flavours, and they all work in different ways to deliver varying amounts of nicotine, toxins, and carcinogens. With most e-cigarette studies funded or otherwise supported, influenced by manufactures of e-cigarettes, the current evidence base on e-cigarettes is very poor.

Julia Belluz from Vox recently examined more than 60 articles, studies, and reviews, and interviewed nine researchers and health experts to try and determine whether e-cigarettes were actually safe. You can read her detailed findings at. http://www.vox.com/2015/6/26/8832337/e-cigarette-health-fda-smoking-safety

She found that the health effects of e-cigarettes were unclear because of the lack of credible research. But she said that so far the short-term exposure to e-cigarettes doesn’t appear to carry any serious side effects, however the research is still early.

She found that e-cigarettes were mostly composed of nicotine and a nicotine solvent (propylene glycol or vegetable glycerin) and that the levels of toxicants and carcinogens in e-cigarette vapour were nine to 450 times less prevalent than in conventional cigarette smoke. Though propylene glycol and glycerin are generally considered safe substances, not a lot is known about the long-term effects of daily inhalation.

Most researchers were inclined to cautiously say that e-cigarettes were safer than regular cigarettes because the immediate harms of e-cigarettes appear to be minimal compared with regular cigarettes.

Co-Director of the US Center for the Study of Tobacco Products Thoman Eissenberg said that its probably fair to say that a long term e-cigarette user is not going to die from tobacco-caused diseases, but it’s not clear whether they will die from an e-cigarette caused disease and whether their rates of death will be less than, more than, or the same as the rates of death we see from tobacco-caused diseases.

Australian law doesn’t ban e-cigarettes but we have strong regulations regarding the potential therapeutic use. E-cigarettes must be registered via the Therapeutic Googs Administration and liquid nicotine has to have a prescription.

The AMA has written to the Federal Health Minister Sussan Ley to encourage the tightening of legislation around the use of e-cigarettes, concerned that they are targeted towards younger consumers.

The AMA is asking for:

· the introduction of laws to prohibit the advertising of e-cigarettes as per the prohibition on advertising of tobacco products;

· enforcement of laws that prohibit the advertising of e-cigarettes as a therapeutic good, specifically as an aid to cessation; and

· the prohibition of marketing of e-cigarettes to people under the age of 18.

The AMA has considerable concern about the increasing control of e-cigarettes by the tobacco industry, as Big Tobacco continues to invest heavily in the development and promotion of e-cigarettes.

Kirsty Waterford

Image by Vaping360 on Flickr, used under Creative Commons licence

Tattoo-associated mycobacterial infections: an emerging public health issue

Three men aged 21–24 years presented to our dermatology clinic with a 2-week history of pruritic erythematosquamous papules coalescing into plaques within areas of recent tattooing. The tattoos were done in Thailand 4 weeks before presentation (Box, A–E). The lesions were concentrated in areas of black shading and overlapping colours, and did not involve non-tattooed skin. All patients were afebrile, systemically well with no palpable lymphadenopathy. Investigations, including a full blood count, biochemistry and inflammatory markers, returned results within the normal range. Serological tests for HIV, hepatitis B, hepatitis C and syphilis were negative. Skin biopsies were performed on all three patients. Histopathology showed a suppurative granulomatous reaction with lymphohistiocytic infiltrate in the upper and mid dermis (Box, F–H). Modified Ziehl–Neelsen staining was negative for acid-fast bacilli. However, cultures showed Mycobacterium mucogenicum in Patients 1 and 2, and M. fortuitum in Patient 3. Empiric antibiotic therapy was commenced with oral clarithromycin 500 mg twice a day for 4 weeks. Patients 1 and 2 required 7 days of intravenous amikacin 750 mg daily and cefoxitin 2 g four times a day for failure to respond based on tissue culture and sensitivities.

The surge in interest in tattoo and body art over the past decade has also led to a surge in tattoo-related complications. While the risk of blood-borne disease and secondary bacterial infection is well known, infection with other organisms has received little publicity. However, it remains a significant public health risk,1 with outbreaks of tattoo-associated mycobacterial infection documented in the United States, France and Germany. Common causative organisms include M. chelonae, M. fortuitum and M. abscessus. Infections with Mycobacterium tuberculosis2 and M. leprae3 have also been reported. Mycobacteria are ubiquitous in the environment and species such as M. chelonae are commonly found in water supplies. However, they typically only cause clinical disease in the immunosuppressed host, or when high concentrations of the organism are introduced via surgery, trauma or tattooing. Sources of mycobacteria in tattooing include tattoo inks,4 with the chemical composition of differing pigments possibly promoting or suppressing organism growth.5 Purple inks (containing manganese) may have the potential for inhibiting organism growth, similar to the action of potassium permanganate used in dermatological practice. The dilution of inks with non-sterile water to produce gradations of colour can also introduce mycobacteria. The clinical distribution of papules in the reported cases demonstrates large numbers of papules coalescing at sites of shading and the borders between colour overlaps. This distribution coincides with areas of high puncture density to give desired colour gradations.

Mycobacterial infection is an important consideration in patients with widespread papular eruption in recent tattoos. Diagnosis can only be made on skin biopsy with tissue culture, and definitive antibiotic therapy should be directed by antimicrobial sensitivities.

Box

Erythematous scaled papules on presentation, of Patient 1 (A, B); Patient 2 (C, D); and Patient 3 (E). Representative histopathology from Patient 1 demonstrating multiple granulomas in the upper to mid dermis (F, magnification x 4), with a negative Ziehl–Neelsen stain (G, magnification x 80) and suppurative granuloma formation (H, magnification x 40).

Photobacterium damselae and Vibrio harveyi hand infection from marine exposure

Clinical record

A 75-year-old man presented to the emergency department at our tertiary teaching hospital on 11 April 2014 with a 3-day history of a rapidly enlarging, painful haemorrhagic blister on his right hand. He had caught sea bream while fishing at a southern Sydney beach 3 days earlier, but did not recall any hand trauma. His past medical history was significant only for hypertension (amlodipine 10 mg daily), hypercholesterolaemia (atorvastatin 10 mg daily) and mild penicillin allergy. At presentation, he was febrile (38.3°C), with a tense, tender, 3 × 3 cm haemorrhagic bullous lesion surrounded by erythema and swelling of the hand and forearm with reduced range of wrist movement (Figure, A). Systemic examination was unremarkable. His white cell count was elevated (14.4 × 10⁹/L; reference interval [RI], 3.5–11 × 10⁹/L) with neutrophilia (10.9 × 10⁹/L; RI, 1.7–7 × 10⁹/L), and his C-reactive protein level was 30 mg/L (RI, <3 mg/L). Fluid was aseptically aspirated from the lesion, inoculated into blood culture bottles and incubated in the automated BacT/ALERT 3D system (bioMérieux). Treatment was commenced with doxycycline 100 mg orally 12-hourly and cefazolin 1 g intravenously every 8 hours.

Both aerobic and anaerobic culture bottles returned positive results within 8 hours of incubation, and direct Gram stain showed gram-negative bacilli. Subculture onto MacConkey agar incubated at 35–37°C in air, Columbia blood agar (5% defibrinated horse blood) incubated at 35–37°C anaerobically and chocolate agar incubated at 35–37°C in 5% supplemental CO₂ showed predominant growth of a slowly oxidase-positive gram-negative rod after overnight incubation on all media, with a second smaller colony type. Subsequent use of matrix-assisted laser desorption ionisation time of flight mass spectrometry (Bruker) identified Photobacterium damselae and Vibrio harveyi with spectral scores of 2.18 and 2.25, respectively (score ≥2 required for species-level identification). Antibiotic susceptibility testing was performed with the CDS method for gram-negative organisms.1 Both organisms were susceptible to doxycycline, ceftriaxone, ciprofloxacin, cefepime and ticarcillin–clavulanic acid. Photobacterium damselae but not V. harveyi was ampicillin susceptible. Considering the potential for necrotising infection in such a case, the patient was referred to a specialist hand surgeon for debridement. The lesion was deroofed and debrided, followed by hand splint immobilisation and regular dressing changes. Treatment was completed uneventfully with 7 days of oral doxycycline 100 mg 12-hourly (Figure, B).

Named after its pathogenicity for damsel fish, P. damselae (formerly V. damsela) is a marine bacterium of the Vibrionaceae family that is pathogenic to a variety of sea life including fish, crustaceans, molluscs and large sea mammals. It has been isolated from ocean and estuarine waters, seaweed and seafood, and its ability to grow at 37°C facilitates colonisation and infection of humans.2 Most reported human infections have occurred in coastal areas of the United States, Australia and Japan in wounds exposed to salt or brackish water and typically associated with fish handling. A number of case reports of P. damselae wound infection have been published, describing severe infections presenting with necrotising fasciitis with a rapidly fatal outcome.3,4 Severe infection occurs in healthy as well as immunocompromised individuals.3,5,6 Virulence is mediated by potent haemolytic toxins such as the phospholipase D damselysin.2

The role of V. harveyi, considered pathogenic only to marine animals, is unclear. This is the second reported case of dual infection with P. damselae and V. harveyi. Both cases resulted from exposure to Australian coastal water in the past 2 years. The first report described a lower limb infection in a German traveller after a boating injury on the west coast of Australia near the Murchison River estuary. On the traveller’s return to Germany, delayed presentation with progressing tibial ulceration prompted surgical debridement, with bacteriological diagnosis made from cultured wound tissue. Treatment with empirical ofloxacin, followed by doxycycline and regular debridement, resulted in a favourable outcome, although complete healing took 14 weeks.7

Vibrio spp are gram-negative rod-shaped bacteria; they inhabit warm surface waters worldwide. They preferentially grow in warm water (>18°C) of low salinity, with increasing rates of growth up to 30°C.8 Of at least 12 Vibrio spp that are pathogenic to humans, V. cholerae, V. parahaemolyticus and V. vulnificus are the most important for their associated scale of human disease and high case fatality rates, particularly in the developing world.9 The US Centers for Disease Control and Prevention have reported a threefold increase in the annual incidence of vibriosis per 100000 population, up from 0.15 in 1996 to 0.42 in 2010, despite public education and other interventional measures.10 Warming of coastal waters, which enhances growth and persistence of Vibrio spp, has been postulated as a contributor to this increase.8,10 An increased incidence of vibriosis in northern European countries during particularly hot summer months in 2006 has been associated with warming of the Baltic Sea surface temperature.11 Researchers have suggested other potential contributing factors, such as changes in precipitation and increased run-off into estuaries potentially lowering salinity, demographic changes with increasing coastal populations and recreational water activities in hotter months, and increasing host susceptibility.8,11 There appears to be sufficient public health concern in the northern hemisphere to call for enhanced surveillance and further research to increase awareness, assess health risks and guide public health action.8–11

This may apply also to the southern hemisphere. Australia’s extensive coastline is more populated within the temperate to tropical zones, regions that are also frequented by international travellers, potentially exposing many to these pathogens. Rapid global travel allows for presentation of such infections in locations very distant to the point of exposure, where vibriosis awareness and clinical experience may be limited.

Advances in diagnostic microbiology will assist with rapid identification of these organisms from appropriate culture material. A history of water exposure is essential to guide laboratory practice. Gram-negative organisms isolated from non-sterile specimens may be overlooked in the laboratory without appropriate history, and infections may therefore go unrecognised and be underreported. Greater awareness of this potentially serious emerging infectious disease is necessary to optimise detection. Improved clinical outcomes will require early targeted antibiotic therapy with doxycycline or ciprofloxacin, along with aggressive surgical management.

Lessons from practice

Soft tissue infection caused by non-cholera Vibrio spp may arise from innocuous marine exposure.
To ensure that potential pathogens are not overlooked, a history of water exposure is essential to guide appropriate microbiology laboratory diagnostic methods, particularly for gram-negative organisms. These methods may include the use of appropriate selective media such as thiosulfate–citrate–bile salts–sucrose agar for non-sterile sites.
Inoculation of aspirated fluid into blood culture bottles may enhance detection of Vibrio spp.
Doxycycline or ciprofloxacin is the treatment of choice, with consideration of early referral for surgical debridement.

Figure

A: Haemorrhagic bullous lesion on the patient’s right hand at presentation caused by Photobacterium damselae infection. B: Lesion resolution 2 weeks after treatment.

News briefs

“Post-Ebola syndrome” dogs survivors

Many survivors of the recent Ebola epidemic in West Africa are now returning to clinics complaining of mysterious symptoms: chronic headaches, debilitating joint pain, even eye problems that can progress to blindness, Wired reports. Doctors in the region have begun calling the suite of problems “post-Ebola syndrome” (PES) and they’re developing clinics devoted to caring for Ebola survivors. Until the latest epidemic, evidence of PES has been hard to find because survivors were rare. “But this most recent outbreak was unusual in the number of people who survived it — a new population to study. With 15 000 or so confirmed survivors in West Africa, epidemiologists ought to be able to nail down which symptoms are caused by Ebola infection”, rather than other suspects like Lassa fever or malaria.

Jail sentences for Bangladeshi paracetamol syrup poisoners

Six senior employees of the now-closed drug company BCI Bangladesh have been handed 10-year jail sentences for making toxic paracetamol syrup which allegedly killed hundreds of children in the 1990s, AFP reports. The men were charged in 2009 after it was found that the syrup had been adulterated with diethylene glycol, commonly used in the leather industry, and 10 times cheaper than the safe propylene glycol. Only one of the six men will go to jail, however, as the other five are still on the run. “Mohammed Hanif, a top paediatric nephrologist, has told AFP that local hospitals first started seeing children with kidney failure in late 1982. But it took another 10 years to establish the deaths were due to diethylene glycol. By then, Hanif says several thousand children had died.”

Second case of plague reported in California

Californian health officials are investigating another possible case of plague in a tourist who fell ill after visiting Yosemite National Park, the Sierra National Forest and surrounding areas — the second case in less than a month, Associated Press reports. “A child fell ill with the plague after camping with his family at Yosemite’s Crane Flat Campground in mid-July. The park reopened Crane Flat last week after treating it for four days with an insecticide. Park officials closed the Tuolumne Meadows Campground from noon Monday through noon Friday so authorities can treat the area with a flea-killing insecticide after two squirrels died of plague in the area.” A spokesperson for the Californian Department of Public Health said the risk to human health “remains low”.

Zebrafish doing their bit for diabetics

ScienceDaily reports that a group of American scientists are claiming to have identified 24 drug candidates that increase the number of insulin-producing cells in the pancreas, via experiments with 500 000 genetically modified zebrafish embryos. The transparent zebrafish embryos were modified so their insulin-producing pancreatic cells glowed yellow, and non-insulin-producing cells glowed red. Using high-throughput screening — using robotic equipment to dose tens of thousands of samples daily — researchers tested thousands of compounds from a Johns Hopkins library of drugs for ones that increased the amount of yellow glow. Originally reported in eLife, Associate Professor Jeffrey Mumm, professor of ophthalmology at the Johns Hopkins Wilmer Eye Institute, says that while more research was needed, “we think there’s potentially no limit on the diseases this screening technique could be applied to other than the human imagination”.

Pilots’ prostates can rest easier

Pilots concerned their risk of prostate cancer was elevated can breathe easier after the retraction of a recent meta-analysis that found they are at least twice as likely to develop the disease, Retraction Watch reports. The paper, recently published in Aerospace Medicine and Human Performance, was retracted for “including inappropriate data from two studies that should be ineligible”. The paper reviewed eight studies, but included two articles that reported on prostate cancer in all United States Armed Forces servicemen, and not just pilots. First author David Raslau, from the Mayo Clinic, apologised, saying: “I was at the infancy of my training in Aerospace Medicine … When I began working on this research project, the phrase ‘Air Force servicemen’ seemed equivalent to the term pilots to me. Now after having completed training in this field, I can easily see the folly of this assumption”.

[Articles] Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Ageing of the world’s population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems. The transition to non-fatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guide future health initiatives through examination of epidemiological trends and a better understanding of variation across countries.

[Correspondence] The promise of personalised medicine

I read with great interest the Viewpoint by Victor Dzau and colleagues (May 23, p 2118)1 who suggested that personalised and precision medicine would result in identification of patients at highest risk of six high-prevalence diseases (cancer, diabetes, heart disease, hypertension, lung disease, and stroke) and lead to subsequent early prophylactic intervention. The authors also suggested that personalised medicine could lead to substantial cumulative gains (expressed using US$100 000 per quality-adjusted life-year, with a $33 billion gain at a reduced disease incidence of 10% and up to a $607 billion gain at a 50% incidence reduction) in life expectancy and quality-adjusted life expectancy during the subsequent 50 years.

[Perspectives] Metaphors and medically unexplained symptoms

Her job entailed looking at diseases under a microscope in a hospital laboratory. At some point she started to have vague symptoms. Nausea, fatigue, malaise. She looked that up online. She began to obsess about food. Dizziness, ringing in the ears, back pain. She saw her doctor repeatedly and underwent scans and blood tests—the results were always normal. Jaw tightness, shortness of breath, sleep problems. She had an itch on her arm and was certain that meant pancreatic cancer. A persistent lump in her throat was suspicious for a thyroid malignancy.

[Comment] Transitioning health systems for multimorbidity

People are living longer, but with more disease and disability: an unprecedented transition from a world with communicable diseases to one with chronic disease and disability, with implications for welfare of people worldwide. Yet health systems and economies are not prepared for this transition.1,2 Instead, asymmetry between health-system responses and the growing needs is worsening,1 as are inequalities.3

[Correspondence] Rhesus disease: a major public health problem

We admire The Lancet’s Clinical Campaigns focusing the expertise of researchers and scientists to effect changes in management of diseases.1 The focus has been on major disorders that affect millions of people in high-income, low-income, and middle-income regions of the world. We believe minor issues that are immediately solvable but that need engagement with policy makers and other advocates for change likewise need attention.