To the Editor: The Auckland Statement on Viral Hepatitis, released in September 2012, called for action
to prevent new hepatitis B and C infections.1 Estimates suggest that more than 200 000 Australians are living with chronic hepatitis B virus (HBV) infection, with nearly half being unaware of their diagnosis.2,3 Childhood vaccination is crucial to HBV prevention, but many people from high-risk populations, including immigrants and refugees from endemic countries, are infected before arriving in Australia.4 Targeted screening of high-risk groups for susceptibility or undiagnosed infection is therefore also integral
to public health management of
HBV infection.

Although susceptible household contacts and sexual partners of all patients with HBV infection are at risk, most jurisdictions only follow up contacts for notifications of acute HBV infection and not unspecified or chronic infections, which represent over 95% of notifications.5 Contact testing therefore relies on local doctors, but contacts often do not attend the same clinic as the index patient, and incomplete contact follow-up is inevitable. Overseas data suggest that only 25% of contacts of patients with HBV are immune.6 A Victorian study found that 68% of adult household contacts were screened, but only 31% were fully vaccinated, and half the surveyed doctors were unaware of the availability of state-funded HBV vaccine for this indication.3

In 2011, a project was initiated to determine how frequently contacts of patients with chronic HBV infection seen at a tertiary referral hospital in Victoria had been tested and/or vaccinated. Ethics approval for the project was obtained from Melbourne Health. Dedicated funding was available for exploring knowledge of HBV transmission among patients with HBV, assessing their contacts’ HBV status, and determining the proportion of contacts willing to accept serological testing and free vaccination. Consent forms were delivered to contacts by the index patients. However, the study was prematurely terminated because
of poor contact response rates, suggesting tertiary care-based contact tracing is unlikely to be effective.

Instead of the current haphazard approach to HBV contact management, improved education and support for patients and general practitioners is needed. Active follow-up by health departments of all notifications would also be ideal.
If this is not feasible, a systematic approach to support contact tracing in the primary care setting might have merit, but remains unproven. Missed opportunities to diagnose infection or vaccinate susceptible contacts are public health failures.

Nosocomial influenza has been associated with significant morbidity, mortality and cost due to increased length of stay. It is likely to be under-recognised because of rapid turnover of patients and delays in diagnosis. Most previous reports of nosocomial influenza have involved known case clusters.1 We aimed to review cases of nosocomial influenza detected in a hospital-based surveillance program.

The Influenza Complications Alert Network (FluCAN) is a sentinel surveillance system that prospectively collects data on adult patients hospitalised with confirmed influenza.2 In 2010, this system involved 15 hospitals in all Australian jurisdictions and, in 2011, eight hospitals in Victoria, the Australian Capital Territory, South Australia and Western Australia. Surveillance was performed between April and November of each year.

Influenza was diagnosed using nucleic-acid detection from respiratory samples. Testing was performed at the discretion of treating clinicians but was encouraged for influenza-like illnesses because of infection prevention considerations. Seasonal influenza subtypes were not recorded, but other surveillance systems suggest that pandemic (H1N1) 2009 influenza was the major circulating strain in 2010 and 2011.3 Patients were identified by surveillance of laboratory testing logs. A nosocomial case was defined as polymerase chain reaction-confirmed influenza where the onset of symptoms was more than 2 days after the patient’s admission or, if this was not known, where the date of the positive test was more than 7 days after admission.

Continuous measures were compared using the Mann–Whitney U test, and categorical variables with the χ2 test or Fisher exact test as appropriate. We calculated crude (unadjusted) odds ratios (ORs) for characteristics of patients with nosocomial and community-acquired influenza. All statistical analysis was performed using Stata 12.1 (StataCorp). Ethics approval for the study was obtained from all sites and the Australian National University.

We found that nosocomial influenza was uncommon but may be severe. Our finding that 4.3% of hospitalised influenza patients had nosocomial influenza is similar to that from an observational cohort study in the United Kingdom in 2009–2010, which detected 30 nosocomial cases (2.0%) in 1520 hospitalised patients with influenza at 75 hospitals.4 The low numbers and high severity of illness may suggest underdiagnosis of mild cases, patients presenting after discharge, or the susceptibility of hospitalised patients with significant comorbidities, particularly malignancy and immunosuppression, reflected in the nosocomial cases reported here.2,5

Poor outcomes have been described for nosocomial influenza, particularly in neonates and in patients who are immunosuppressed.4 In our study, the proportion of patients requiring ICU admission was similar in the nosocomial and community-acquired influenza groups. This differs from the UK cohort,4 where more than half the patients with nosocomial influenza required intensive care support. Mortality in nosocomial cases was also low in our study, with only one death noted, while mortality as high as 26.7% was reported in the UK study.4 Compared with community-acquired influenza cases, we noted a significantly longer length of stay for patients with nosocomial influenza, but there are likely numerous factors confounding this observation. Nosocomial influenza has previously been associated with an increased hospitalisation duration of 8 days, as well as increased use of diagnostics and treatment.5

Strategies to reduce nosocomial transmission of influenza include vaccination of patients before the winter season, vaccination of contacts including health care workers and visitors, more effective barrier precautions including improving hand hygiene compliance, and encouraging staff to stay away from work when unwell. Although influenza vaccination is publicly funded for older people and those with chronic comorbidities, protection is incomplete. We found that vaccination failed in a third of patients and two-thirds were not vaccinated, consistent with studies estimating vaccine effectiveness against medically attended influenza6 and hospitalisation with pandemic (H1N1) 2009 influenza at 49%–59%.7 Interventions to reduce transmission from infected contacts through barrier precautions and advice not to work or visit when unwell are hampered by infectivity before symptoms appear or by minimally symptomatic infection. Prophylactic antivirals are probably only feasible to contain outbreaks in closed facilities. Less than half of the patients with nosocomial influenza in our study received treatment with antivirals within 48 hours of symptom onset. This may reflect delays in diagnosis and the lack of efficacy of antivirals after 48 hours. This proportion is lower than in the UK cohort, where 57% of 21 patients received antivirals within 48 hours of onset of symptoms.4

The proportion of health care workers known to be vaccinated in Australian hospitals has been reported at around 40%.8 Although two cluster-randomised trials found that mortality was lower in long-term care facilities where vaccination was actively promoted, the conclusions have been criticised because of methodological concerns.9 The results appeared to be internally inconsistent, with a large mortality benefit despite a lack of detection of significant influenza disease. There has been recent interest in making influenza vaccination a mandatory condition of working with patients, and this policy has been implemented with some success in the United States.10 It is not clear whether the patients identified in our study acquired infection from health care workers, from other infected patients or from visitors.

Our results suggest that a small proportion of influenza cases detected in hospitalised patients are acquired during the hospital stay, and that this may be associated with severe disease in a significant proportion of these patients. The overwhelming majority of nosocomial influenza occurs in patients with pre-existing medical illness that places them at high risk of complications.

The custodial environment poses challenges for infectious disease management.1 With close contact between inmates and high population turnover, infectious diseases can spread rapidly. Prison outbreaks of vaccine-preventable diseases including mumps,2 varicella3,4 and hepatitis B5,6 have been reported.

Health care services in New South Wales prisons are provided by Justice Health and Forensic Mental Health Network, a statutory health corporation under the Ministry of Health. In August 2010, a measles outbreak was detected in prisons on the NSW North Coast. After this outbreak was contained, it was determined that more information was needed about susceptibility to vaccine-preventable diseases among adults in custody, to inform vaccination policies and clinical practices. At present, there is no policy on vaccination of prisoners against varicella, measles, mumps or rubella in NSW prisons. It is policy that all inmates be offered hepatitis B vaccination,7 but it is unclear what proportion of inmates commence or complete the vaccination schedule.

In this study, we aimed to determine the prevalence of susceptibility to measles, mumps, rubella, varicella and hepatitis B virus (HBV) among people entering prisons in NSW. Our secondary aims were to identify sociodemographic characteristics associated with disease susceptibility and to compare the susceptibility of prison entrants with the susceptibility of a community sample.

This study was undertaken as a NSW-only add-on to the triennial National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey.8 Both studies were approved by the Justice Health Human Research and Ethics Committee.

Of 311 prison entrants approached to participate in the study, 211 (68%) completed the questionnaire and provided a blood sample. Participants were similar to non-participants in terms of Aboriginality and age. Women disproportionately declined to participate, comprising 3% of participants and 19% of non-participants.

Of the participant sample, 97% (204/211) were male, and 21% (44/211) identified as Aboriginal or Torres Strait Islander. The median age was 32 years (range, 17–79 years). Almost two-thirds of the participants (65%; 138/211) had previously been in prison, and 37% (75/202) had ever injected drugs (Box 1).

Our analysis shows that the proportion of NSW prison entrants who are susceptible to vaccine-preventable diseases varies widely with each disease. Although prisoners’ susceptibility was lower than that of the general community for some diseases, recent experience with measles in NSW has shown that there are sufficient numbers of susceptible prisoners for outbreaks to occur. Recent work suggests that vaccination coverage of more than 95% may be necessary for the prevention of measles outbreaks.11 Entry into custody is an opportune time to routinely offer vaccinations against these infectious diseases in order to ensure high levels of immunity across the prisoner population. Combination measles–mumps–rubella vaccine, varicella vaccine, and HBV vaccine are all well tolerated by individuals who have previously been infected or vaccinated; as such, all individuals with an uncertain infection and vaccination history and without contraindications can safely commence these vaccination schedules. To our knowledge, the costs and benefits of routine vaccination in correctional settings have not been evaluated — a cost–benefit analysis would be an appropriate next step in developing vaccination policies.

Birth cohort and Aboriginality were not significant predictors of susceptibility to our target diseases. Participants born outside Australia were less likely to be susceptible to mumps, likely reflecting greater exposure to wild virus in the country of birth. No history of IDU was significantly associated with susceptibility to measles, mumps and HBV. In the case of measles and mumps, it is not clear if this association is a result of higher vaccination rates or exposure to wild virus. For HBV, there was some evidence of higher levels of vaccination among inmates with a history of IDU compared with those without. Despite policies mandating that HBV vaccine be offered to all inmates, there was no association between prior incarceration and HBV vaccination. A clear opportunity exists to improve HBV vaccination coverage among NSW prisoners in general, particularly those who inject drugs. The largest increases in HBV vaccination coverage are obtained through routine vaccination of prison entrants rather than in repeated mass campaigns.12,13 Administering vaccine via an accelerated schedule (on the day of entry into prison, 7 days after entry, 21 days after entry and a 12-month booster) can increase the proportion of prisoners completing the vaccination schedule.14

Currently, the Australian immunisation handbook recommends influenza, hepatitis A and hepatitis B vaccinations for prisoners.16 Given the potential for respiratory-spread infectious diseases to spread rapidly within prisons and into the community, and the high rates of IDU and other bloodborne virus risk behaviours among prisoners, there are logical benefits to ensuring that prisoners have high rates of immunity to infectious diseases. As such, we recommend a cost–benefit and feasibility analysis of implementing routine vaccination for measles, mumps, rubella and varicella, and exploration of options for improving uptake of HBV vaccination, such as accelerated schedules.

Experience with severe acute respiratory syndrome1 and pandemic (H1N1) 2009 influenza2 has clearly shown the potential for air travel to result in the spread of emerging respiratory diseases. Similarly, countries (like Australia) that have successfully interrupted local transmission of measles virus face repeated importation of measles by travellers who are infected overseas.3 Australian residents made a record eight million short-term trips overseas in the 2011–12 financial year.4 In addition, around 6 million visitors from overseas arrive in Australia each year,4 many from countries with endemic measles transmission.

There is little published information on the risk of transmission from infectious measles cases during aeroplane travel, or the effectiveness of contact tracing in this setting. Current Australian guidelines recommend direct follow-up of contacts of all people with measles who are considered to be infectious during a flight. Contacts are defined as people seated in the same row, two rows in front of and two rows behind an infectious person.5 There were no reports of measles transmission on aeroplanes in Australia in the decade before development of these guidelines,5 which were informed by evidence from the United States that secondary transmission on aeroplanes was rare and probably related to seating proximity.6 However, since the guidelines were published, there have been multiple reports of measles transmission to passengers sitting further than two rows from the index case.3,7–9

In response to the increasing number of published reports and anecdotal evidence of measles transmission on aeroplanes, we aimed to quantify the risk of transmission of measles associated with infectious people who travelled on flights to or within Australia, to inform contact-tracing guidelines. We reviewed all cases of measles notified from January 2007 to June 2011 and known to have travelled on aeroplanes in Australia while infectious. We also collected information about any secondary cases identified among aeroplane travellers.

Measles is a notifiable disease in all Australian states and territories under local legislation, and all cases are subject to follow-up by public health authorities. Our study was undertaken under the auspices of the Communicable Diseases Network Australia (CDNA), which oversees communicable disease surveillance in Australia. The CDNA asked each jurisdiction to provide de-identified data for people who travelled on an aeroplane to or within Australia while infectious with measles. People were considered to have been infectious on the flight if they travelled during the 4 days before and the 4 days after the onset of the measles rash.

Each jurisdiction was provided with a Microsoft Excel spreadsheet on which to record details of the index case (age, vaccination history, dates of flight departure and arrival, flight number, flight duration, seat number, number of days from arrival to diagnosis and notification of the illness, and the date the flight manifest became available to public health authorities) and logistical information for contact tracing (total number of passengers and cabin crew, the numbers of passengers and staff contacted and uncontactable, and any secondary measles cases identified among the passenger cohort). For each secondary case identified, information on seating and other potential sources of measles exposure was requested. The study period was from 1 January 2007 to 30 June 2011 for all jurisdictions except Western Australia and Victoria, which provided data for longer periods (to 19 September 2011 and 30 October 2011, respectively).

All data were cleaned and collated using Microsoft Excel and analysed using SPSS, version 20 (SPSS Inc). Differences between flights on which transmission did and did not occur were compared using the independent samples t test (age in years), independent samples Mann–Whitney U test (flight times) or Fisher exact test (categorical data). Confidence intervals for transmission occurrences were calculated using the Byar approximation to the Poisson distribution.10 The level of significance was considered to be P < 0.05.

Ethics approval was not required, as our study evaluated surveillance practice using de-identified data collected during the routine public health response to measles as a notifiable disease.

A total of 327 measles cases were notified in Australia during the study period. Forty-five people (14%; 95% CI, 10%–18%) flew on a total of 49 flights while infectious, of which 13 flights were domestic and 36 were international. Where known, most index cases were Australians who acquired their infection while travelling overseas, with a minority being overseas visitors who acquired their infection before travelling to or within Australia.

Twenty secondary cases occurred among people on seven (14%; 95% CI, 6%–29%) of the 49 flights, comprising 7 of 36 international flights (19%; 95% CI, 8%–40%) and none of the 13 (0; 95% CI, 0–28%) domestic flights that carried infectious people. Nine people identified as secondary cases were seated in the same row or within two rows fore and aft of the index case; 11 were outside these rows, one of whom was a member of the cabin crew (Box 1). After index cases were diagnosed and their contacts were traced, immunoprophylaxis (measles–mumps–rubella [MMR] vaccine or normal human immunoglobulin [NHIG]) was offered to identified susceptible contacts seated within two rows fore and aft of the index case11 on three of the seven flights on which documented secondary transmission occurred (Box 2). On two of these three flights there were no secondary cases within two rows of the index case; on the third, there were five secondary cases within two rows, but none received immunoprophylaxis: three declined, one gave a verbal history of vaccination in another country and the fifth was missed during the initial contact tracing.

Secondary transmission was more likely to occur if the index case was younger (P = 0.025) or there were multiple infectious cases on board (P = 0.018) (Box 3). Two family groups with multiple infectious cases — two siblings aged 3 and 7 years, and three siblings aged 12–17 years — were associated with one and three secondary cases, respectively, on two flights. While there was a suggested association between transmission and flights of longer duration, this was not significant and transmission did occur on three flights shorter than 8 hours (4.5, 7.5 and 7.8 hours) (Box 3).

Among the 20 secondary cases, three people had been fully vaccinated (ie, had received two documented MMR vaccinations), two had one documented MMR vaccination, nine were unvaccinated and vaccination status was unknown for six. Mean age was 25 years (range, 11–47 years). Most secondary cases (11/20) were identified independently and in-flight exposure was determined after notification. The remaining cases (9/20) were identified during the contact-tracing process, with subsequent onset of illness and notification.

Fifteen of the 49 flight manifests were available to public health authorities within 5 days of the flight, 14 were available within 6–7 days and 20 after 8 or more days. The mean time to notification of public health authorities of an infectious measles case on an aeroplane was 6.5 days from the date of the flight, with an additional mean of 1.4 days (median, 1; range, 0–5 days) to obtain flight manifests and contact details for passengers. Provision of postexposure immunoprophylaxis to contacts was possible in less than one in five flights (Box 4).

Data on the number of passenger contacts followed up were available for 40 flights, for which attempts were made to contact 1082 passengers (mean, 27 per flight). Applying this mean to the 49 flights, which yielded nine secondary cases, the risk of acquiring measles if seated within the two-plus-two row range recommended by contact-tracing guidelines was estimated as 0.0068; hence, an estimated 147 (95% CI, 77–322) passengers were contacted to identify each “future” secondary case. Similarly, the risk of acquiring measles in rows 3–8 distant from an index case, assuming a wide-bodied jet with 10 passengers per row, was 0.0014, with an average of 720 (95% CI, 368–1471) passenger contacts requiring follow-up per secondary case identified.

Our analysis of people notified with measles who were likely to have been infectious or infected while travelling on aeroplanes in Australia showed that just over half of the people identified as secondary cases were seated outside the two-plus-two row distance recommended by contact-tracing guidelines in Australia5 and elsewhere.12,13 This result is consistent with other recently published literature reporting the occurrence of measles transmission on aeroplanes. Eleven reports3,6–9,14–19 (two of which refer to cases included in this study; see Appendix (pdf)) listed a total of 36 secondary cases associated with transmission in aeroplanes, with only six cases having documented seating within two rows of the index case. However, the literature is limited by publication bias favouring reporting of flights on which secondary transmission occurs, and probably of flights where cases occur outside contact-tracing guidelines. By including all people notified with measles within a defined 4.5-year period, who travelled on aeroplanes while infectious, our study overcomes the disadvantage of publication bias, and provides valuable information on the incidence of and factors associated with secondary transmission of measles on aircraft.

Aircraft cabin design is thought to limit the transmission of infectious diseases spread by droplets or aerosols, such that the greatest risk is to those seated in rows adjacent to an infected individual. Air circulation patterns are side to side, with little front to back airflow, and air exits the cabin near the floor. Recirculated air passes through high efficiency particulate (HEPA) filters which are effective against microorganisms, including viruses, before cabin redelivery.20,21 However, coughing may spread respiratory droplets in an aeroplane environment,22 and risk assessments based on seating proximity do not take into account passenger movements before (eg, at check-in), during (eg, toilet visits) and after (eg, baggage collection) the flight. Despite the designed airflow environment, transmission of measles during international aeroplane travel is not rare if there is an infectious case on board, nor is it limited to the current two-plus-two row contact-tracing recommendations, as we have shown.

The risk of measles acquisition depends on exposure to respiratory droplets, which can become aerosolised. Speculatively, younger-aged cases may have been more likely to transmit infection because children are less able to contain their respiratory secretions. Not surprisingly, risk of transmission was also increased by multiple infectious cases on board. In addition to being associated with three secondary cases in Australia, the three siblings on one flight who were infectious were associated with a further five secondary cases on a subsequent flight to New Zealand.8

European risk assessment guidelines state that no documented cases of measles transmission have occurred on flights shorter than 8 hours.12 However, transmission has been reported on short duration flights.8,9 In addition, although not stated, it could be assumed that flights from the Netherlands to England,14 Venezuela to Miami, USA,17 within Brazil7 and within the US16 would be less than 8 hours. A recent literature review13 concluded that “flight duration is not an important factor”. Our study showed transmission risk may be greater on longer duration international flights, although transmission also occurred on three flights shorter than 8 hours.

Measles contact tracing aims to provide contacts with education, counselling and, where appropriate, with immunoprophylaxis to prevent illness. Recommended prophylaxis includes MMR vaccination within 72 hours of exposure or NHIG within 144 hours after exposure.11 In our study, contact tracing generally occurred too late for provision of immunoprophylaxis, primarily because of lengthy delays in diagnosis and notification of the index case — delays in obtaining flight manifests were relatively less important. This highlights the need for medical practitioners to consider a diagnosis of measles in overseas travellers who have a clinically compatible illness, and to notify such cases to public health authorities promptly, on clinical suspicion. Unless these times can be reduced significantly, immunoprophylaxis to prevent secondary cases will rarely be feasible, let alone effective, calling into question the value of committing significant human resources to performing direct contact tracing of aeroplane contacts.

Our study has some limitations. Our methods relied on all Australian jurisdictions providing data, and it is possible there were inconsistencies in the completeness and accuracy of those data. However, all jurisdictions use national guidelines for response to and documentation of measles cases.11 Moreover, it is unlikely that identified cases (either primary or secondary) would not have been notified to public health authorities, as all cases require an urgent public health response. During the study period, endemic measles transmission had been eliminated in Australia and practically all notified cases were identified as imported cases or were linked to known imported cases, indicating that very few cases are unidentified.

While it is not possible with the data available to determine whether transmission occurred in-flight, the clustering within eight rows fore and aft of index cases suggests that in-flight transmission associated with seating proximity was the likely mechanism in most instances.

The combined delays in diagnosis, notification and acquisition of flight manifests shown in this study resulted in contact tracing being ineffective for identifying susceptible people for timely immunoprophylaxis. In addition, while 17/19 passengers who were identified as secondary cases were seated within eight rows fore and aft of the index case, these 17 rows accommodate around 170 passengers on any wide-bodied jet. This number would require the use of significant human resources to perform direct contact tracing, which is unlikely to be feasible. There are also high levels of herd immunity in Australia and transmission events are relatively infrequent.23 Therefore, we recommend that public health authorities no longer routinely perform contact tracing for infectious measles cases on aeroplanes. Other strategies, such as general media alerts that identify affected flights, and direct email or SMS text messaging of passengers (if airlines can provide such contact information), may be more timely and effective. Circumstances in which contact tracing might be justified include those where diagnosis and notification have been prompt, where flight manifests are readily available, and where there are multiple infectious people, especially children, on a flight. Authorities should also continue to document cases of measles associated with air travel, in order to provide a sounder evidence base for public health guidelines.

Ensuring measles vaccination coverage remains high, promoting predeparture measles vaccination to travellers without a documented vaccination history, and raising awareness among health practitioners of the need to consider the diagnosis of measles in returning travellers and overseas visitors with clinically compatible fever and rash illnesses will decrease the risk of measles importation and secondary transmission in Australia.

1 Aeroplane seating of secondary measles cases, by rows distant (fore or aft) from index cases, Australia 2007–2011

The red square represents index cases on flights where transmission occurred; blue squares represent seating of secondary cases according to the number of rows away (fore or aft) from index cases, not actual seating position. One secondary case in a cabin crew member is not represented.

Much has been written about antimicrobial resistance and the measures we must take to prevent an era in which infections become untreatable. Despite these longstanding concerns, there has been a steady rise in antimicrobial resistance globally, threatening the effectiveness of increasing numbers of antimicrobial classes against broadening species of microorganisms.

Do we continue on our current path until no effective antimicrobials are available, the pressure on microorganisms is slowly reduced, and resistance wanes over time? If so, we face a period during which many people will die with untreatable infections. Or do we act now?

In the spirit of optimism that action now can still make a difference, we publish in this issue several articles to be presented at this week’s combined Australasian Society for Infectious Diseases (ASID) and Communicable Disease Control conference, which address the breadth of antimicrobial resistance issues we currently face.

In their editorial, Looke and colleagues from the ASID Council (doi: 10.5694/mja13.10190) describe the growing threat of multiresistant gram-negative bacteria, a new “Red Plague”, engendered by the ability of resistance genes to move freely between bacterial species, across borders and, through global travel and trade, around the world. An example of a multiresistant gram-negative pathogen causing disseminated infection after a routine surgical procedure is described by Roberts and colleagues (doi: 10.5694/mja12.11719). This infection was caused by an organism thought to have been acquired innocuously during regular overseas travel. In the same vein, research by Kotsanas and colleagues (doi: 10.5694/mja12.11757) describes the difficulty in eliminating an environmental source of resistance-carrying plasmids that had been implicated in several clusters of infection in an intensive care unit.

The ways to deal with resistance are seemingly straightforward: halting unnecessary use of antimicrobials, limiting broad-spectrum antimicrobial use through stewardship programs, and enforcing basic preventive infection control measures that relate to hygiene, sterile technique and isolation of infectious carriers, as well as reducing antimicrobial use in veterinary and animal production sectors. As of January 2013, antimicrobial stewardship programs are a requirement for hospital accreditation in Australia, but do they actually work? Cairns and colleagues (doi: 10.5694/mja12.11683) describe an audit of antimicrobial use before and after an antimicrobial stewardship program in a tertiary hospital in Victoria. While immediately successful in reducing broad-spectrum antibiotic use, there was a trend towards a subsequent rebound, the venture has not yet been proven cost-effective, and long-term outcomes such as reductions in antimicrobial resistance cannot yet be shown. More work may be needed to convince all stakeholders of the importance of implementing these measures.

It may yet be the simplest preventive measures that have the greatest effect for the least cost. Coatsworth and colleagues (doi: 10.5694/mja12.11695) describe a case of probable iatrogenic prosthetic shoulder infection attributable to an intra-articular injection performed by a proceduralist not wearing a mask. Have we come to depend so much on the panacea of the antimicrobial that we have forgotten the lessons of Semmelweis, Pasteur and Lister? Prevention of infection must be as important as treatment, and this will require effort on a global scale. In the developing world, resistance is becoming endemic and our global interactions mean we cannot act in isolation and expect resistance to disappear.

Ghafur (doi: 10.5694/mja13.10099) urges us to behave like microbes and “unite or perish”. He calls for global, cross-border action and describes efforts in India to tackle the now very serious threat of gram-negative resistance by bringing together members from across the medical, political, industrial and community divide to create the Chennai Declaration.

We can all learn from this effort, but the real challenge is to institute the measures we know are needed and to show that they can work. If we do, we may one day write about the success story that is global collaboration, reduced resistance, better infection control and improved human health.