Doctors get carrot, anti-vax parents the stick, in immunisation boost

Doctors will be paid a $6 incentive to chase up the parents of children who have fallen behind on their vaccinations as part of Federal Government measures aimed at boosting immunisation rates.

Health Minister Sussan Ley said an extra $26 million will be allocated in the Federal Budget to the national immunisation program to encourage doctors to identify children more than two months behind on their vaccinations, as well as to develop an Australian School Vaccination Register and upgrade efforts to educate parents.

It has been revealed last year 166,000 children were more than two months behind on their vaccinations, in addition to 39,000 whose parents had expressed a conscientious objection to immunisation, and Ms Ley said the $6 incentive, which would be in addition to the $6 paid to doctors to deliver vaccinations, was part of a “carrot and stick” approach to deepening the country’s immunity to serious diseases.

“I believe most parents have genuine concerns about those who deliberately choose not to vaccinate their children and put the wider community at risk,” the Minister said. “However, it’s important parents also understand complacency presents as a much of a threat to immunisation rates and the safety of our children as conscientious objections do. Immunisations don’t just protect your child, but others as well.”

The announcement came as the Government intensified its crackdown on anti-vaccination parents claiming childcare subsidies and other benefits.

Social Services Minister Scott Morrison has declared parents can no longer claim an exemption from welfare payment vaccination requirements on religious grounds, adding to the scrapping of exemptions for parents who make a conscientious objection.

It means that the only authorised exemption for the vaccination requirements of the Child Care and Family Tax Benefit Part A schemes, which provide childcare subsidies worth up to $205 a week, a $7500 annual childcare rebate and a tax supplement worth up to $726 a year, is on medical grounds.

Mr Morrison said only one religious group, the Church of Christ, Scientist, had a vaccination exemption, and it was not exercising it.

“The Government has…formed the view that this exemption, in place since 1998, is no longer current or necessary, and will therefore be removed,” the Minister said, adding that it will not be accepting or authorising any further applications for exemption from religious groups.

“The only authorised exemption from being required to have children immunised in order to receive benefits, is on medical grounds,” Mr Morrison said. “This will remain the sole ground for exemption.”

The Government’s tough stand has been backed by the AMA, though President Associate Professor Brian Owler said children should not be “punished” for the decisions of their parents and urged greater efforts to educate parents on the benefits of vaccination.

A/Professor Owler said a recent sharp increase in the number of parents lodging conscientious objections to immunisation meant it was “not unreasonable” for the Government to look at new ways to lift the nation’s vaccination rate.

“The number of conscientious objectors has been rising, so that’s why I think it’s not unreasonable for the Government to come up with another measure,” A/Professor Owler said. “I think it should be seen in that light, that it is really another mechanism, another lever to pull, to try and get the vaccination rates up. It’s not going to solve all of the problems, but I think it’s probably a step in the right direction.”

“The overwhelming advice and position of those in the health profession is it’s the smart thing and it’s the right thing to do to immunise your children,” Mr Morrison said.

“While parents have the right to decide not to vaccinate their children, if they are doing so as a vaccination objector, they are no longer eligible for assistance from the Australian Government.”

Child vaccination rates, particularly among pre-schoolers, are above 90 per cent in most of the country, but figures show significant pockets of much lower coverage, including affluent inner-Sydney suburbs such as Manly and Annandale, where the vaccination rate is as low as 80 per cent, as well as northern New South Wales coastal areas.

High rates of immunisation, above 90 per cent, are considered important in providing community protection against potentially deadly communicable diseases such as measles, diphtheria and whooping cough (pertussis).

Objectors regularly claim vaccination is linked to autism. But this has been scientifically disproved, most recently in a Journal of the American Medical Association study which found that the measles-mumps-rubella vaccine did not affect autism rates among children with autistic older siblings.

A/Professor Owler said there were occasional instances of adverse reactions to vaccination in some individuals, “but they are by far a minority compared to the overall benefits of vaccination. Vaccination is probably the most effective public health measure that we have.”

While he said the Government’s latest measure might help increase the immunisation rate, it was important to continue with efforts to educate parents about the importance of vaccination and encourage them to ensure their children were covered.

“The anti-vaccination lobby has been very successful in putting lots of rubbish out there on the internet in particular. Often it’s notions that have been completely discredited,” he said. “One of the things we’ve got to keep going with [is] education – encouraging parents, giving them the right messages, and getting them to go to the credible source of information, which should be their family doctor or GP.”

A/Professor Owler said often children were not vaccinated simply because it was overlooked by busy parents, and it was important to ensure people were given timely reminders.

The Government’s changes have bipartisan support and are due to come into effect from 1 January next year.

Adrian Rollins

Detecting malaria – it’s all in the breath

Diagnosing malaria may soon be as simple as undergoing a roadside breath test in what could be a major advance in the detection and treatment of a disease that kills more than 500,000 people every year and infects around 200 million.

A collaboration of Australian researchers from the CSIRO, the QIMR Berghofer Medical Research Institute and the Australian National University has discovered that the concentration of sulphur-containing chemicals in human breath varies with the onset and progression of malaria, opening up the possibility for a novel, cheap and effective method to diagnose the disease at an early stage.

The researchers found that chemicals normally virtually undetectable in human breath increased markedly among volunteers infected with a controlled dose of the disease.

The discovery arose out of two independent studies being conducted to test experimental malaria treatments. In the course of the investigation, the researchers identified four sulphur-containing compounds whose concentration varied over the course of the infection.

“The sulphur-containing chemicals had not previously been associated with any disease, and their concentrations changed in a consistent pattern over the course of the malaria infection,” Professor James McCarthy, Senior Scientist in Clinical Tropical Medicine at QIMR Berghofer, said. “Their levels were correlated with the severity of the infection and effectively disappeared after they were cured.”

CSIRO Research Group Leader Dr Stephen Trowell said what was particularly significant was that the concentration of these chemicals increased from the nascent stages of the infection, boosting the chances of very early diagnosis and treatment.

Currently, most malaria diagnoses involve drawing a blood sample and using a microscope to look for parasites – a cumbersome and invasive process that has changed little in more than 130 years.

But Dr Trowell said the discovery raised the possibility of developing a simple breath test to screen for the disease, which could make task of controlling and eventually eliminating malaria much more feasible.

The researchers have begun collaboration with colleagues in regions where malaria is endemic to see whether the technique works in the field, and work is also being undertaken to develop more cost-effective sensing equipment.

The research has been published in the Journal of Infectious Diseases.

Adrian Rollins

Hippocratic heroes

“The systematic, deliberate, physical annihilation of the European Jews” was Nazi Germany’s “Final Solution of the Jewish Question”, according to the United States Holocaust Memorial Museum (http://www.ushmm.org/wlc/en/article.php?ModuleId=10005477).

WHEN HITLER SEIZED POWER in 1933, around 9 500 000 Jews lived in Europe. Six million of these were killed by the Germans and their Polish, Lithuanian, Latvian and other collaborators, or died of starvation and epidemics in ghettos and concentration camps. A tiny number survived.

Questions have been asked about an apparent absence of resistance, especially in the military sense. There was some by the Bielski brothers and other bands of partisans, and in the Warsaw Ghetto in Poland.

Grodin, Professor of Health Law, Bioethics and Human Rights at the Boston University School of Public Health, and his coauthors have carefully documented a different kind of resistance — against the hazards of overcrowding in unhygienic conditions. The associated starvation, malnutrition and epidemics in the ghettos and holding camps killed tens of thousands of inmates. The survivors were packed into cattle trucks without food, water or toilet facilities, for days on end, until the hardiest reached the death camps.

Doctors, even the most prominent professors and researchers, were rounded up with the other Jews, and shared their privations. Many died. But while they lived, they resisted the killing of Jews. Within the limitations of captivity, they attended to public health measures, did what they could for the physically ill, and comforted those whose mental health had deteriorated. Creating a semblance of normality, they taught students, undertook surgery, did research … even making a typhus vaccine from urine.

A few dozen doctors, no longer alive, were among the 27 000 survivors of the ghettos and camps who found refuge in Australia. They included Eugenia (Ena) Hronsky, from the Auschwitz concentration camp in Poland, who became a general practitioner in Adelaide; Sydney GPs Abrasha Wajnryb and David van der Poorten, the former from the Vilna Ghetto in Lithuania and the latter a survivor of the Westerbork and Theresienstadt camps in the Netherlands and Czech Republic (formerly Bohemia), respectively; and Sydney obstetrician and gynaecologist Henryk Frant, from the Warsaw Ghetto.

The courage and achievements of our incarcerated colleagues warrant our recognition as truly Hippocratic heroes. Their stories merit the attention of doctors and students who, in the ideal surroundings of 21st century Australian medicine, cannot imagine medical practice in such deprived circumstances.

The global challenge of women’s health

Sierra Leone, a West African state of 6 million, saw 11 000 cases and over 3000 deaths during last year’s Ebola outbreak. A bitter civil war from 1991 to 2002, fuelled largely by fierce factions from neighbouring countries, led to 50 000 deaths and degradation of the country’s infrastructure and social fabric. Sierra Leone’s exports of diamonds and bauxite notwithstanding, the lack of a socially responsive polity and a largely agrarian population set the scene for the epidemic. Over 70% of its population live in extreme poverty.1

Sierra Leone also tops the 2013 chart when it comes to maternal deaths — 1100 per 100 000 live births.2 The comparable figure for Australia is six. UNICEF estimates that 88% of the women have been subject to genital mutilation.3

Improving maternal health

The Millennium Development Goals, promulgated by the United Nations in September 2000 and endorsed by 189 countries, sought to halve desperate poverty, defined as living on less than a dollar a day, by 2015. The metrics suggest that this goal has been achieved, and it is a remarkable tribute to international efforts. Among the eight goals, five concern health, and most have been achieved, including huge reductions in infant mortality.

Improving maternal health is one of the health-related goals that has proved harder to reach. Under Goal 5, countries committed to reducing maternal mortality by three-quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 45%.4

Maternal mortality — often due to blood loss and infection — has proved more resistant to efforts to substantially reduce it as a global health problem. It has been intractable in areas of poverty and social turmoil. There were 289 000 maternal deaths worldwide reported in 2013.4

The explanation for these disturbing figures has much to do with social attitudes and investment. When we encounter health disparities, the explanation is most often found outside the clinic, in society and politics. In preventing maternal death, strong investment in education for women is fundamental. Provision of the basic infrastructure necessary for safe childbirth comes next. But even more basic is a pathological view of women — that they are not a priority and that public resources should be invested elsewhere.

Broadening the focus

The World Health Organization draws our attention in 2015 to food security. Its importance is great for women’s health, before and during reproduction and throughout all adulthood, to reduce the risk of nutritional deficiencies, diabetes and heart disease.

When, in 2003–2004, my colleagues at Columbia University and I were examining cardiovascular disease in emerging economies, I was amazed to discover that it far outweighed obstetric and perinatal disorders, HIV and malaria as causes of death of women in the years of family formation and support. In seven out of nine developing countries that we studied, chronic diseases caused over 20% of deaths among women aged 15–34 years, while reproductive causes and HIV together accounted for about 10% of deaths.5 We questioned why the traditional conceptualisation of women’s health has more to do with disorders that impair their performance as reproductive machines than with the real threats to their wellbeing, including the precursors of cardiovascular catastrophe. Those who work on global programs to abate the scourge of diabetes make a major contribution to reducing deaths among women from cardiovascular disease.

Shaking stereotypic thinking

Even if our view of women’s health is restricted to an understanding of causes of death, it is clear we have a task to shake the stereotypic thinking and social relegation of women that foster a completely inadequate global response to their health needs.

There are tasks aplenty for those with advocacy in their blood at governmental, educational and individual levels. Heroic clinicians such as 91-year-old Dr Catherine Hamlin AC and her co-workers at the Addis Ababa Fistula Hospital, its five regional hospitals and the Hamlin College of Midwives set outstanding examples of other pathways.

Health at the core of closing the gap

AMA President Associate Professor Brian Owler has warned that governments need to increase their investment in health in order to close the yawning gap in life expectancy and wellbeing between Indigenous people and other Australians.

In a veiled swipe at the Federal Government’s policy focus on school attendance and employment in Indigenous communities, A/Professor Owler told a major international conference on the social determinants of health that too often the importance of wellbeing was overlooked.

“Health is the cornerstone on which education and economics are built,” the AMA President said. “If you can’t go to school because you or your family are sick, truancy officers won’t work. If you can’t hear because of otitis media, you won’t learn. If you miss training opportunities because of depression or ill health, you won’t progress to employment. You can’t hold down a job if you keep having sick days.”

His remarks to a British Medical Association symposium on the role of physicians in addressing the social determinants of health came a month after Prime Minister Tony Abbott admitted that the nation had fallen behind on meeting most of its Closing the Gap targets.

While there has been some improvement in the life expectancy of Aboriginal and Torres Strait Islander people, Indigenous men still on average 10.6 years earlier than other Australian males, and the gap for women is 9.5 years.

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said the fact that chronic and non-communicable diseases and other preventable occurrences such as suicide, trauma and injury accounted for a major proportion of the gap in life expectancy underlined the need for greater investment in health care, particularly Aboriginal community controlled health services.

“While those with chronic disease need to be cared for, prevention, particularly in the early part of life, is the key if we are going to see a generational change in health outcomes,” A/Professor Owler said.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

“There have been many examples of governments trying to address the social determinants of health – but often they have failed,” he said, referring to policies including building inappropriate housing and taking children from their families.

The AMA President said any attempt to improve Indigenous health needed to acknowledge the fundamental importance for Aboriginal and Torres Strait Islander people of their connection with the land, and understand that in many Aboriginal languages health was a concept of social and emotional wellbeing rather than a physical attribute.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

“Constitutional recognition is a vital step towards making Aboriginal and Torres Strait Islander people feel historically and integrally part of the modern Australian nation,” A/Professor Owler said. “Recognising Indigenous people in the Constitution will improve their self-esteem, their wellbeing, and their physical and mental health.”

Prime Minister Tony Abbott has taken a personal interest in Indigenous affairs, concentrating responsibility for many Indigenous policy areas within the Department of Prime Minister and Cabinet and overseeing the development of the Indigenous Advancement Strategy.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

“What is missing from the core of the IAS is a focus on health,” the AMA President said. “Health underpins many of these outcomes. We need to get the balance right and we, the AMA, need to ensure that health is seen as a foundation to these outcomes.”

He said that “spending on health is an investment. Investing in health must underpin our future policies to Close the Gap, and to address what is, for Australia, a prominent blight on our nation”.

Adrian Rollins

Not so golden times for staph

Patients at some major metropolitan hospitals are up to three times more likely to contract the potentially deadly Golden Staph bloodstream infection than those being treated at similar institutions with better infection control systems.

While the number of hospital patients catching Golden Staph (Staphylococcus aureus) in the course of their treatment has fallen nationwide, dropping from 1721 cases in 2012-13 to 1621 last financial year – a 6 per cent improvement – analysis by the National Health Performance Authority has found a wide variation in rates of infection between comparable hospitals.

Unsurprisingly, the vast majority of infections (1310) occurred in the nation’s major hospitals, and almost three-quarters (972) involved hospitals treating a relatively high proportion of patients considered vulnerable to contracting the disease.

But the ability of hospitals to curb spread of the disease varied greatly.

The NHPA reported that the rate of Golden Staph infection among major hospitals with more vulnerable patients ranged from 0.59 cases per 10,000 patient bed days at Wollongong Hospital to 2.32 at Sydney’s St Vincent’s Hospital. The average rate among such institutions was 1.28 in 2013-14.

There was a similar discrepancy among large hospitals with more vulnerable patients, from zero cases per 10,000 patient bed days at the Victorian Eye & Ear Hospital to 2.48 at Newcastle’s Calvary Mater Hospital. The average rate was 1.15.

The findings have underlined calls for renewed emphasis on the importance of infection control measures in the nation’s hospitals, particularly those with above-average rates of infection.

The Authority’s Chief Executive Officer Dr Diane Watson said the public reporting of infection rates meant hospitals that were similar in size and function could measure how they were performing relative to their peers, spurring them to address any shortcomings.

“Differences in the rate of infection suggest there is an opportunity for hospitals to continue to learn from each other to lower infection rates,” Dr Watson said.

While the number of Golden Staph infections is declining, it remains a significant killer. Between 20 and 35 per cent of patients who contract the disease in their bloodstream die from this or a related cause, while most of the remainder face a prolonged stay in hospital.

The risk is heightened by the spread of antibiotic-resistant strains of the bug, particularly methicillin-resistant Staphylococcus aureus (MRSA).

Australian National University infectious diseases expert Associate Professor Peter Collignon told the ABC the NHPA report showed there was significant scope for improvement in the infection control procedures of many hospitals.

“What it does show is that when you look at hospitals in the same groups, there are quite wide variations and to me that means that we can do better than what we are doing now,” A/Professor Collignon said, emphasising the importance of regular hand washing and tighter procedures around the use of intravenous lines.

Sydney’s St Vincent’s Hospital, shown to have the second-highest Golden Staph infection rate among the country’s major and large hospitals, said that since then it had completely overhauled its infection control procedures.

Chief executive Associate Professor Anthony Schembri told the ABC that between July last year and March this year its infection rate had virtually halved to 1.3 cases per 10,000 bed days thanks to changed protocols around central and peripheral intravenous line use, upgraded aseptic techniques and surgical site infection prevention.

A/Professor Schembri added the hospital had also launched a major campaign on hand hygiene.

A/Professor Collignon said the long-term decline in Golden Staph infection rates underlined the importance and effectiveness of hand washing and other infection control measures.

Adrian Rollins

The importance of molecular testing to confirm measles, mumps and rubella in immunised individuals

To the Editor: Despite high vaccination coverage, Australians remain at risk of measles, mumps and rubella, either while travelling to endemic countries or from domestic exposure to imported cases. Those most at risk include incompletely vaccinated adults and children whose parents choose not to have them vaccinated. Additionally, immunity generated by vaccination (rather than natural infection) may be less protective, especially if only one vaccine dose is received.1,2

When measles, mumps and rubella were commonly encountered, their clinical features were well recognised, but far fewer cases are now seen, diminishing clinical acumen and the positive predictive value of a clinical diagnosis. Further, the relative proportion of cases in previously vaccinated individuals has increased, making the clinical diagnosis more difficult as these cases may present atypically.1,3

With this clinical uncertainty, laboratory confirmation assumes greater importance.4 However, the IgM response can take several days to appear and can be attenuated or completely absent in post-vaccination infection,1,2 necessitating molecular detection methods to confirm the diagnosis.2–4 Polymerase chain reaction (PCR) testing has been shown to contribute significantly to laboratory confirmation of measles2,5 and mumps3,4 in highly vaccinated populations.

We investigated the vaccination status and mode of laboratory confirmation of notified cases of measles, mumps and rubella in Western Australia over almost 10 years, from January 2001 to September 2010. During this period, 82 cases of measles, 335 of mumps and 38 of rubella were notified to the Department of Health. Of these, eight patients (10%) with measles, 117 (35%) with mumps and four (11%) with rubella were fully vaccinated; 16 (20%), 39 (12%) and five (13%), respectively, were partially vaccinated; and 46 (56%), 53 (16%) and 22 (58%), respectively, were unvaccinated. Thirty-two per cent of measles, 49% of mumps and 89% of rubella cases were confirmed by IgM serological testing alone; 34%, 2% and 3%, respectively, were confirmed by serological testing and PCR; and 20%, 38% and 3%, respectively, were confirmed by PCR alone (IgM not detected or not requested). A further 15% of measles, 10% of mumps and 5% of rubella cases were diagnosed using clinical and epidemiological criteria, without testing. Overall, when laboratory-confirmed cases were stratified by vaccination status, the proportion confirmed by PCR alone increased from 18% in the unvaccinated to 71% in the fully vaccinated, including from 21% to 63% for measles, and 22% to 74% for mumps, respectively (Box).

These data confirm the increased number of measles and mumps cases diagnosed by PCR rather than serological testing among people who are fully vaccinated compared with the unvaccinated group. Diagnosis by PCR allows virus genotyping, which is important for epidemiological purposes2 and can distinguish wild-type measles virus from the vaccine strain when vaccine is used for post-exposure prophylaxis.5 We recommend collection of respiratory specimens, whole blood and/or urine for PCR diagnosis, in addition to serological testing, for laboratory diagnosis in suspected cases of measles, mumps and rubella.

Laboratory-confirmed cases of measles, mumps and rubella in Western Australia, January 2001 to September 2010

Vaccination status	Laboratory confirmation	Measles (n = 70)	Mumps (n = 300)	Rubella (n = 36)	Total (%)

Fully vaccinated	Serological	3	26	3	32 (28%)
	PCR	5	75	0	80 (71%)
	Both	0	1	0	1 (1%)
Partially vaccinated	Serological	5	17	4	26 (46%)
	PCR	3	15	0	18 (32%)
	Both	8	3	1	12 (21%)
Not vaccinated	Serological	13	39	20	72 (69%)
	PCR	7	11	1	19 (18%)
	Both	14	1	0	15 (14%)
Unknown	Serological	5	82	7	94 (90%)
	PCR	1	27	0	28 (24%)
	Both	6	3	0	9 (8%)

PCR = polymerase chain reaction.

AMA approves Govt jab at anti-vax parents

The AMA has backed the Federal Government’s move to rip childcare and welfare benefits from parents who refuse to have their children vaccinated, while emphasising the need for greater parent education.

AMA President Associate Professor Brian Owler said that although children should not be “punished” for the decisions of their parents, an increase in the number of people lodging conscientious objections to immunisation meant it was “not unreasonable” for the Government to look at new ways to lift the nation’s vaccination rate.

Parents who conscientiously object to the vaccination of their children could be up to $15,000 a year worse off after Social Services Minister Scott Morrison announced they would lose their entitlements to a range of Government subsidies and benefits.

Under current arrangements, parents who lodge a conscientious objection to vaccination are granted a special exemption from the immunisation requirements of the Child Care and Family Tax Benefit Part A schemes, giving them access to childcare subsidies worth up to $205 a week, a $7500 annual childcare rebate and a tax supplement worth up to $726 a year.

Mr Morrsion said there had been an alarming jump in the past decade in the number of children not immunised because their parents claimed to have a conscientious objection to vaccination, from around 15,000 to 39,000.

He said there would still be exemptions from vaccination on medical and religious grounds, (though adding there were only a “very, very small number” of religious groups that had registered an objection) but those with a conscientious objection would no longer have their choice subsidised by taxpayers.

“The overwhelming advice and position of those in the health profession is it’s the smart thing and it’s the right thing to do to immunise your children,” Mr Morrison said. “If they [conscientious objector parents] choose to not do that, well, the taxpayers aren’t going to subsidise that choice for them.”

Claims that vaccination is linked to autism have been scientifically discredited, but anti-vaccination groups continue to peddle misinformation about the safety and risks of immunisation.

A/Professor Owler said there were occasional instances of adverse reaction to vaccination in some individuals, “but they are by far a minority compared to the overall benefits of vaccination. Vaccination is probably the most effective public health measure that we have.”

A/Professor Owler said often children were not vaccinated simply because it was overlooked by busy parents, and it was important to ensure people were given timely reminders.

The Government’s changes have bipartisan support and are due to come into effect from 1 January next year.

Adrian Rollins

Health at the core of closing the gap

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

Adrian Rollins

An unusual neurological complication from a garden-variety organism: post-melioidosis parkinsonism

We report the first case of acute parkinsonism following disseminated melioidosis with multiorgan abscesses in a 62-year-old man. After 1 month of treatment with levodopa, the parkinsonism resolved completely. Melioidosis should be considered as a possible cause for parkinsonism in endemic areas.

A 62-year-old man presented to our tertiary hospital’s emergency department with a 4-week history of fever associated with lethargy and constitutional symptoms. For 9 days before admission, he had been vomiting two to three times per day. He had longstanding diabetes and hypertension and worked for the local city council as a truck driver, transporting water to local gardens and public areas. About 2 months previously, he had sustained an abrasion on his left foot that had healed completely at time of presentation.

On initial assessment, he had a blood pressure of 129/78 mmHg, a heart rate of 111 beats/min, an SpO2 of 96% in room air, and a respiratory rate of 16 breaths/min. He was clinically dehydrated and his body temperature was 38.8°C. His abdomen was soft and non-tender, with hepatomegaly of two fingers’ breadth. Respiratory examination revealed left basal lung crepitations. Results of the clinical assessment, including cardiovascular and neurological examinations, were otherwise normal.

The patient’s initial blood investigations revealed an elevated random blood glucose level (11.6 mmol/L; reference interval [RI], 4.4–6.1 mmol/L) and white cell count (12.1 × 109/L; RI, 4.0–11.0 × 109/L) with neutrophilia (93%). His haemoglobin level was low (117 g/L; RI, 130–170 g/L). His sodium concentration was low (115 mmol/L; RI, 135–145 mmol/L) and his potassium concentration was normal (3.5 mmol/L; RI, 3.5–5.0 mmol/L). His creatinine level was low (45 µmol/L; RI, 70–104 µmol/L) and C-reactive protein level was elevated (116.2 mg/L; RI, 0–100 mg/L). Platelet count (240 × 109/L; RI, 150–400 × 109/L) and urea levels (2.9 mmol/L; RI, 2.5–6.7 mmol/L) were normal. Urine analysis, including culture and sensitivity tests, yielded normal results. Leptospirosis IgG and IgM test results were negative. Results of serological testing for hepatitis B, hepatitis C, syphilis and HIV were negative. However, blood culture tested positive for Burkholderia pseudomallei.

A computed tomography (CT) scan of the thorax, abdomen and pelvis showed right pleural effusion and liver and prostate abscesses (Box). The patient was diagnosed with disseminated melioidosis with multiorgan abscesses, and he was started on intravenous imipenem for a planned duration of 6 weeks. Supportive therapy with intravenous normal saline was instituted to resolve his dehydration. Therapeutic drainage of the liver abscess and right pleural effusion was performed under ultrasound guidance.

The patient’s condition responded well to treatment, showing clinical improvement after 3 days. He became afebrile, and his blood parameters normalised with a gradual increase in his serum sodium level to 122 mmol/L over 3 days.

However, on Day 7 of admission, he started feeling weak, requiring help to ambulate. He was noted to be slow in his movements and in answering questions, with slurred speech. He complained that his upper limbs and trunk felt stiff. There were multiple new skin abscesses on his forehead. On neurological examination, he was alert, with negative Kernig’s and Brudzinski’s signs. Results of cranial nerve examination were normal. There was generalised rigidity of the neck, trunk and limbs. He had mask-like facies, bradykinesia and bradyphrenia, with monotonous speech and fine resting tremor of both hands. Medical Research Council muscle power grading of all four limbs was 4/5 with normal reflexes. Sensations were otherwise normal, and he had no cerebellar signs. He had not been given any antidopaminergic medications.

A CT scan and magnetic resonance imaging (MRI) of the brain was normal. A lumbar puncture revealed clear cerebrospinal fluid (CSF) with a cell count of 20 cells/mm3, predominantly neutrophils (RI, < 5 cells/mm3, predominantly lymphocytes). His total CSF protein level was 405 mg/L (RI, 150–450 mg/L), and CSF glucose level was 3.1 mmol/L (RI, 2.8–4.2 mmol/L) with a CSF to blood glucose ratio of > 0.5 (RI, > 0.5). CSF Ziehl–Neelsen smear and polymerase chain reaction results were negative for tuberculosis. The CSF culture was negative for B. pseudomallei.

A diagnosis of parkinsonism secondary to melioidosis was made after excluding other causes of parkinsonism, including drug-induced parkinsonism and extrapontine myelinolysis. Extrapontine myelinolysis was unlikely in our patient as the correction of hyponatraemia was gradual, and there were no supportive MRI changes.

The patient was treated symptomatically with levodopa/benserazide 50/12.5 mg twice daily for a month. The intravenous antibiotic for melioidosis was continued. After 1 month, his parkinsonism symptoms resolved and his antiparkinson medication was stopped. An ultrasound of his abdomen showed resolution of the abscess. Repeated blood culture showed no growth. He was subsequently discharged after a 1.5-month stay, and prescribed oral co-trimoxazole (trimethoprim–sulfamethoxazole 320/1600 mg) 12-hourly and oral doxycycline (100 mg 12-hourly) for 3 months.

Discussion

To our knowledge, this is the first reported case of parkinsonism secondary to melioidosis. Melioidosis is an infection caused by B. pseudomallei, a gram-negative bacterium transmitted through direct skin contact with contaminated soil. It is endemic in the Asia–Pacific region, with a reported incidence of 4.4 per 100 000 person-years in north-eastern Thailand and 50.2 per 100 000 person-years in the Top End of the Northern Territory.1,2

Neurological complications of melioidosis are rare. In the Darwin Prospective Melioidosis Study, only 14 of 540 patients (3%) developed neurological complications following melioidosis over a 20-year study period.2,3 The clinical features reported include unilateral limb weakness, cerebellar signs, brainstem signs and flaccid paraparesis.2,4 Parkinsonism and extrapyramidal signs have not been reported in previous case series.

Various infective organisms have been reported to cause post-infectious parkinsonism, including dengue virus,5 Japanese encephalitis B virus,6 West Nile virus,7 encephalitis lethargica8 and Streptococcus species.9 It is postulated that infective organisms can cause parkinsonism by three different mechanisms.

The most widely accepted mechanism is via direct infiltration of the causative organism into the central nervous system. Patients usually have pathological changes on imaging of the central nervous system and abnormal CSF findings. In the Darwin Melioidosis Prospective Study, of the 14 patients who developed neurological complications, 10 had meningoencephalitis, two had myelitis and two had cerebral abscesses.2 All were noted on MRI to have abnormal T2-weighted hyperintensities and had abnormal results of CSF analysis, with mononuclear pleocytosis and elevated protein levels.2

The second mechanism involves endotoxin lipopolysaccharide released from the gram-negative bacterial cell wall causing damage to the blood–brain barrier. There is subsequent microglia and macrophage activation, as well as the release of cytokines and oxygen radicals. This results in dopaminergic neurone damage. This pathophysiological mechanism has been postulated as a possible model for development of Parkinson disease based on animal studies.10

The final possible mechanism involves the development of antibasal ganglia antibodies with resultant insult to the basal ganglia. Antibasal ganglia antibodies are commonly implicated in many movement disorders, including chorea and tics.11 Acute parkinsonism with antibasal ganglia antibodies following streptococcal infection has been reported.9

Our patient did not have MRI changes to suggest a pathophysiological mechanism of direct invasion of the infective organism into the central nervous system. Although the CSF culture was negative and the protein level was normal, there was pleocytosis with predominant neutrophils, suggesting an ongoing inflammatory process in the central nervous system.

The onset of parkinsonism was delayed and developed when the patient was recovering from the bacteraemia, as evidenced by improving blood indices and vital signs. This suggests, at least in our patient, that the most probable mechanism for the parkinsonism was an immune-mediated process, either by liposaccharide endotoxins or antibasal ganglia antibodies. Unfortunately, we do not have a facility to test for antibasal ganglia antibodies at our centre.

The recommended treatment for neurological melioidosis includes parenteral ceftazidime or a carbapenem for 6 to 8 weeks, followed by maintenance treatment with oral doxycycline or co-trimoxazole.12 However, to date, there is no standard guideline for managing post-infectious parkinsonism. Previous cases of post-infectious parkinsonism were treated symptomatically with levodopa and other anti-parkinson agents.13 Evidence for immunotherapy for post-infectious parkinsonism is anecdotal at best.5,13

In conclusion, parkinsonism could be a neurological complication of melioidosis. Despite its rarity, melioidosis should be considered as a differential diagnosis of parkinsonism, particularly in endemic areas. In our case, the pathophysiological mechanism appears to be secondary to immunological response rather than direct CNS infiltration. Little is known about the treatment of post-infectious parkinsonism. However, at least in our patient, it was self-limiting and responded well to symptomatic treatment.

Abscesses due to melioidosis in a 62-year-old man

Liver (A) and prostate (B) abscesses.