more_vertWe agree with Karen Eggleston and colleagues’ (Nov 21, p 2053)1 assertion that one of the greatest challenges facing Myanmar is the optimum allocation of scarce resources, and add that evidence to inform this is needed urgently. We started working to generate such evidence shortly after the move to a nominally civilian government in 2011 opened the country up to more international collaborations. Here, we summarise the insights gained while doing one of the first multidisciplinary research programmes on the health system and tuberculosis control in Myanmar, which included two literature reviews, a mixed-methods situational assessment, a case-control study of risk factors for emergence of drug resistance, a qualitative study of barriers to accessing health services, and an economic analysis of patient costs.
Preference: Statistics, epidemiology and research design
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[Editorial] Trauma care in the UK: where is the evidence?
In 2010, a National Audit Office report cited unacceptable variation in major trauma care in England, and called for action to coordinate care between institutions. The resulting major trauma networks enabled the efficient and safe transfer of patients to major trauma centres throughout the country, and analysis by the Trauma Audit and Research Network suggested that the probability of a major trauma patient surviving in NHS England was 63% better in 2014–15 than in 2008–09.
Medicinal cannabis hits jack-pot
Medicinal cannabis will be bracketed with morphine and other restricted medicines under changes to the Poisons Schedule being made following the passage of legislation legalising and regulating its cultivation and supply.
Health Minister Sussan Ley said the Health Department and the Therapeutic Goods Administration were “well advanced” in changing the categorisation of medicinal cannabis to a Schedule 8 substance.
Ms Ley said the change would simplify arrangements regarding the legal possession of medicinal cannabis products, “placing them in the same category as restricted medicines such as morphine, rather than an illicit drug”.
The TGA is due to make an interim decision on the change in March, which will then be subject to further consultation.
The change is part of a suite of measures being undertaken after Parliament approved amendments to the Narcotic Drugs Act making it legal to cultivate and manufacture medicinal cannabis.
The legislation was passed in rapid order and without amendment, aided by support from the major political parties and across the political spectrum.
“This is an historic day for Australia and the many advocates who have fought long and hard to challenge the stigma around medicinal cannabis products so genuine patients are no longer treated as criminals,” Ms Ley said. “This is the missing piece in a patient’s treatment journey, and will now see seamless access to locally-produced medicinal cannabis products from farm to pharmacy.”
Medicinal cannabis is currently imported by individuals from overseas to treat a range of conditions including severe epilepsy and nausea and loss of appetite associated with chemotherapy.
AMA President Professor Brian Owler has said medicinal cannabis should be subject to the same sort of scrutiny and testing as any other medicine.
The Government’s legislation provides for the creation of a single, national body to regulate the cultivation and supply of medicinal cannabis.
Those wanting to cultivate cannabis for medical or research purposes will have to show that they are a “fit and proper person”, do not have ties to criminal activity, and be able to demonstrate they have the capacity to ensure the physical security of the crop before being granted a licence.
The quantities and strains of cannabis produced will be tightly controlled, and a system of permits will be used to ensure that amounts to be manufactured are planned in advance, and are in proportion to demand.
Ms Ley said the Government, through the national regulator, would closely track the development of medicinal cannabis products “from cultivation to supply, and curtail any attempts by criminals to get involved”.
Initially, the focus of the scheme will be production for domestic consumption, with any provision for exports “to be addressed at a later date”.
Adrian Rollins
[Perspectives] Weapons tests, human rights, and the question of consent
One morning in May, 1953, Ronald Maddison, a 23-year-old wireless mechanic in the UK’s Royal Air Force, entered a sealed chamber at Porton Down, a top-secret research facility in the Wiltshire countryside. At 1017 h, he received a 200 mg dose of a nerve agent administered in droplets to layers of cloth pressed against his left forearm. Within 30 minutes, he was unconscious. Soon after that, his breathing stopped. “It was like he was being electrocuted”, recounted an ambulance driver summoned to the scene: “his whole body was convulsing”.
Patchy vaccination coverage leaves some at risk
Vaccination rates in some areas are so low that they are vulnerable to the spread of potentially dangerous diseases such as measles and whopping cough.
A report detailing child vaccination rates nationwide has found that although almost 91 per cent of children were fully vaccinated in 2014-15, in more than 100 postcodes less than 85 per cent were fully immunised, including just 73.3 per cent in the Brunswick Heads area on the New South Wales north coast.
The National Health Performance Authority report indicates that the country has a considerable way to go to achieve the target set by the Commonwealth, State and Territory chief health and medical officers for 95 per cent of all children to be fully vaccinated, though there were some encouraging signs of progress.
The NHPA found immunisation rates among one-year-old Indigenous children increased significantly in 14 per cent of geographical areas, and there was a big 8 percentage point jump in the rate outback South Australia.
The report also revealed improvements in Surfer’s Paradise, and the eastern suburbs of Sydney.
The findings were released against the backdrop of concerted efforts nationwide to boost immunisation rates, most notably through the Federal Government’s No Jab, No Pay laws, which deny family tax supplements and childcare benefits and rebates to parents who refuse to have their children vaccinated.
There have been anecdotal reports of surge in vaccinations before the commencement of the school year as the new rules loomed, but public health expert Julie Leask warned the causes of low vaccination rates were complex, and it was too early to assess the effectiveness of the No Jab, No Pay laws.
In her Human Factors blog (https://julieleask.wordpress.com/), Ms Leask, a social scientist at Sydney University’s School of Public Health, said a significant percentage of the 84,571 children reported as not fully vaccinated were in fact up-to-date but there were errors in recording their status on the Australian Childhood Immunisation Register.
In other instances, parents were unaware of vaccination requirements, or encountered problems in arranging for the immunisation of their children.
Ms Leask said that without further research, it was impossible to know how many children were being denied immunisation because their parents objected to it.
She said there were encouraging accounts of some parents who were previously objectors arranging for their children to be vaccinated – including some who were “angry and resentful, feeling coerced into making the decision because they cannot afford to miss the payments”.
But Ms Leask aired concerns about the implementation of the No Jab, No Pay laws.
She said Primary Health Networks and providers including GPs, nurses and Aboriginal health workers were being forced to work “very hard to implement a complex policy in a very short timeframe,” with often inadequate resources.
Providers were in many cases being overwhelmed by demand and had not been provided with additional assistance, and were being denied access to the ACIR and so could not update patient details.
The importance of high rates of vaccination have been underlined by warnings that the world remains “significantly off-track” targets to eliminate measles, and that communities with immunisation rates below 90 per cent were at risk of fast-spreading outbreaks.
The Gavi Vaccine Alliance said that although the number of deaths from malaria worldwide had fallen substantially in the past decade, the disease still claimed 114,900 lives in 2014 – most of them children younger than five years.
Gavi said it had developed a new approach to support periodic, data-driven measles and rubella campaigns in addition to action to tackle outbreaks.
“Measles is a key indicator of the strength of a country’s immunisation systems and, all too often, it ends up being the canary in the coalmine,” Gavi Chief Executive Dr Seth Berkley said. “Where we see measles outbreaks, we can be almost certain that coverage of other vaccines is also low.”
Adrian Rollins
Films the next tobacco frontier
The World Health Organisation has called for a ratings system for films that show people smoking amid warnings that screen portrayals are luring millions of young people into the deadly habit.
While a major review has found evidence that smoking bans have delivered significant health benefits for non-smokers, the WHO is urging governments to do more to deter adolescents from trying tobacco.
Though the WHO Framework Convention on Tobacco Control, which came into effect in 2005, binds signatories to ban tobacco advertising, promotion and sponsorship, The Lancet said earlier this month that that films and television shows remain a potent way circumventing such restrictions by exposing young people to images of smoking.
Hollywood is yet to kick the tobacco habit – 44 per cent of all films it made in 2014 portrayed smoking, including 36 per cent of films rated suitable for young people.
The Lancet cited calculations by the US Centers for Disease Control and Prevention that seeing on-screen smoking would encourage more than 6 million youngsters to take up the habit in 2014 alone.
Though smoking rates among young people in Australia are low by international standards – just 3 per cent of 12- to 15-year-olds smoke, rising to 10 per cent of 16- to 17-year-olds – the WHO’s call is seen as a way to further undermine the appeal of tobacco among young people, which was a major goal of the country’s world-leading plain package legislation.
This comes against the backdrop of the rise of e-cigarettes and concerns they provide a pathway to smoking for young people.
A US study of young people who had never smoked traditional cigarettes found that almost 70 per cent who used e-cigarettes progressed to traditional smokes, compared with 19 per cent of those who had not.
Of some comfort in this regard are figures showing sales growth of e-cigarettes is slowing.
After expanding at a triple-digit pace in the past five years, sales growth in the US is expected to slow to 57 per cent this year and 34 per cent in 2017.
The latest evidence for the success of tobacco control measures has come from a group of Irish researchers who investigated the effect of smoking bans on health.
The study, published by the Cochrane Library, identified 33 observational studies showing evidence of a significant reduction in heart disease following the introduction of smoke-free workplaces and other public spaces.
The researchers found the greatest reduction in admissions for heart disease following the introduction of smoking bans was for non-smokers.
Adrian Rollins
[Correspondence] The CONFIDeNT trial – Authors’ reply
We are pleased that the CONFIDeNT study1 has attracted the interest of several correspondents. Philip Hartley and colleagues point out the discrepancy between the prespecified primary and secondary outcomes detailed on the clinical registry (ISCTRN) and those in the final Article. We have reviewed these discrepancies and concede that we failed to fully update the trial registry. Nevertheless, we can confirm that all recorded study outcomes were fully reported and that these are entirely consistent with the final (Research Ethics Committee approved) trial protocol and those prespecified in the study analysis plan before unblinding of data.
[Editorial] UK guidance on human–animal hybrid research
Last week, the Academy of Medical Sciences in the UK welcomed the publication of new guidelines by the Home Office on the use of animals containing human material (ACHM) based on the Academy’s recommendations in their report published in 2011. This research involves the introduction of human DNA sequences, cells, or tissues into animals to create animal models of human diseases to enable their study more accurately, where alternative approaches are not morally or ethically possible, or are insufficient.
[World Report] France releases interim report on drug trial disaster
A progress report into what went wrong in the clinical trial accident in Rennes has found serious failings in the way the research organisation handled the crisis. Barbara Casassus reports from Paris.
MJA chief embraces latest career twist
When the position as Editor in Chief for the Medical Journal of Australia became vacant last year, Nick Talley’s wife told him, “You should take that role”.
At the time, Professor Talley was well ensconced in his position as the University of Newcastle’s Pro Vice Chancellor (Health) and, with much already on the go, let the idea slide.
But, as has happened at other times in his life, a call out of the blue set Professor Talley’s career on a new path.
The Board of AMPCo, which publishes the MJA, approached him about becoming its Editor in Chief – an offer he happily accepted.
“My wife was right, that I would enjoy the role,” he told Australian Medicine.
Becoming the MJA Editor in Chief is not, on the face of it, an obvious move for Professor Talley, a gastroenterologist who has enjoyed a stellar career as a medical researcher and administrator, with more than 1000 publications to his name.
It is not the first time he has been head-hunted for a position that has taken his career – and life – in an unexpected direction.
In the early 1990s, while working at the Mayo Clinic in the United States, he was approached to become Foundation Professor of Medicine at Nepean Hospital in Western Sydney.
As he himself describes it, it was a significant challenge.
“I was 37 years old, had virtually no administrative experience, and was charged with the daunting task of developing teaching and research plus new clinical departments in a hospital that didn’t even yet have a physician’s training program,” he recalls.
After nine years in the position he was lured back to research and the Mayo Clinic Rochester in 2001.
Five years later, he was “tapped on the shoulder” to transform the Department of Medicine at Mayo’s Florida centre into “a cohesive academic entity”.
It was, Professor Tally says, an exhilarating experience: “I learnt more about the science of leading and management than at any other time in my career”.
This knowledge was to stand him in good stead when he was poached in 2010 to become Newcastle University’s Pro Vice Chancellor (Health), a post he has held ever since.
But, while overseeing the University’s research and education programs, Professor Talley is excited about the opportunities and demands of guiding the MJA in coming years.
It is a testing time to be assuming the helm of such a publication.
The rise of the internet has changed the way people access information, and vastly increased the amount that is available.
It has led many to question whether the days of MJA-style publications, particularly in their hard-copy format, are numbered – doubts sharpened by plunging ad revenues.
Questions are also being asked whether then process of peer review, used by the MJA to help verify the quality of the research that it publishes, is any longer suitable.
But Professor Talley looks on the task ahead of him with enthusiasm.
“We are in the middle of a digital revolution,” he says. “The way people obtain and use information is rapidly changing and evolving. It’s a very challenging and interesting time to be in the field of publishing.”
Armed with years of experience as a researcher and educator, Professor Talley has clear ideas about what the MJA needs to do.
“To provide important information and updates to clinicians at the coalface; to be a publication for first-class research of relevance to Australia; and to make clinicians aware of developments that will impact on what they do,” he says. “That is an enormously important role.”
Some believe the proliferation of open-access online journals in recent years may marginalise, if not kill off, publications like the MJA, but Professor Talley doubts this.
Though welcoming the idea that study data and results be open to all, he questions whether many such publications will survive, particularly because concerns about quality will have many doubting their usefulness.
While he is not sure that, in 10 years’ time, the journal will still be a print publication, he has no doubt that the MJA in some form has a strong future.
“There is a very important place for peer reviewed journals of high quality that act as gatekeepers for advances in science and scientific knowledge,” Professor Talley says. “There will still be a critical role for journals like the MJA, which has a pretty rigorous process of peer review, modelled on the best in the world.”
Adrian Rollins