Pertussis control: where to now?

Improving protection against pertussis requires sorting the facts from the artefacts

Pertussis is a disease of significant morbidity and, in infants, mortality. Regrettably, even though there is greater than 20-fold reduction in pertussis burden with immunisation,1 it persists globally as a significant public health problem. For more than two decades, Australia has had the highest reported rates of pertussis in the world.2 In the 1990s, this was driven by the introduction of mandatory reporting by laboratories of positive test results for vaccine-preventable diseases to the National Notifiable Diseases Surveillance System and extensive use of serological tests for diagnosis, primarily in adults.3 Unlike many other countries, all positive test results in Australia are included in national data. Also, testing for pertussis by polymerase chain reaction (PCR) has qualified for reimbursement since 2008, after which a sevenfold increase in testing of children in general practice was documented.4 Pertussis epidemics occurred sequentially across Australia from 2008 to 2012 and, unlike previous epidemics, the highest notification rates were for children under 10 years of age. This raises the question of whether Australia’s “pertussis problem” is related to vaccines with poor effectiveness or is an artefact of testing.

Observational methods are used to measure vaccine effectiveness (VE) (also known as “field efficacy”). The screening method enables estimation of VE if the vaccination status of patients with a case of the disease and population vaccine coverage are known — the more effective the vaccine, the lower the likelihood of patients with a case of the disease having been vaccinated compared with the source population.5 The screening method performs best when about 50% of the population is vaccinated. When vaccine coverage is over 90%, estimates of VE change substantially with small changes in population coverage estimates. In this issue of the Journal, Sheridan and colleagues use the screening method to estimate VE for acellular pertussis vaccine in Queensland children during an epidemic in 2009 and 2010.6 They found that VE for three doses in children aged from 1 to < 4 years was over 80%. However, similar to studies in the United States,7,8 VE fell significantly and progressively in children over 5 years of age, whether they had received four or five doses. It was previously reported that among Queensland children born in 1998, those who had received one or more doses of whole-cell pertussis vaccine were significantly better protected than those who had received only acellular vaccine, especially after 6 years of age.9 A national study, which included Queensland data from 2009, took a different approach — cases were individually matched by birth date to children on the Australian Childhood Immunisation Register and were limited to children younger than 4 years.10 Similar VE estimates were obtained for the first 2 years of life, but, in contrast to findings from the Queensland study, there was a significant and progressive fall in VE between ages 2 years and 4 years (the latter being the age at which children were eligible for the fourth dose).

Importantly, Sheridan et al were also able to evaluate testing patterns by age, showing that the overall number of PCR tests increased in the second year of the Queensland epidemic.6 Also, in children aged over 5 years, although PCR tests were less commonly performed, the results were more commonly positive.6 This is probably due to older children with cough being less likely to present to general practice and less likely to be tested, suggesting that notification rates of pertussis would have been even higher if more testing had been done. Disease severity is also an important consideration: assessing the disease burden from pertussis cases in older children is valuable, and VE is expected to be lower for less severe illness.5 Apart from the requirement for hospitalisation, against which VE was high for children younger than 1 year3 and 1–4 years,10 few data on severity are available. In a recent New South Wales study using linked hospitalisation and pertussis notification data, it was found that only 2% of children over 5 years who had pertussis were hospitalised, but 8% had been taken to an emergency department.11

What conclusions can we draw from these studies? First, the current acellular vaccines are highly effective in preventing severe pertussis, especially in the first 2 years of life, but effectiveness progressively wanes from 2 years after the last dose. Such rapid waning was not expected when the decision to forego the 18-month booster in favour of a booster for adolescents was made in 2003. This decision was based on favourable results from modelling this change using the only available data at the time12 — data which suggested that three doses provided protection up to 7 years of age,13 which contrasts with more recent findings. Australian data showing low levels of population antibody to pertussis toxin preceding the recent epidemic support the idea that the schedule change had a negative impact.14 Second, high levels of laboratory testing inflated Australian case numbers disproportionately to other countries, through identifying more ambulatory cases in children and adults. Third, pertussis vaccine coverage has increased dramatically in Australia since the epidemic in the late 1990s, with better acceptance by parents and doctors of the acellular vaccines compared with more reactogenic whole-cell vaccines. Notably, the national epidemic from 2008 to 2012 was associated with fewer deaths than the late 1990s epidemic, despite much higher numbers of cases.

Where does the future lie for pertussis vaccines in terms of improving disease control, especially death and severe morbidity? A vaccine that effectively reduces transmission and disease is an important objective for herd immunity. In this regard, there is promise from research on live attenuated vaccines,15 and the potential for acellular vaccines with improved adjuvants and less reactogenic whole-cell vaccines, but all are some years away. Immunising mothers during the last 8 weeks of pregnancy with adult-formulated acellular pertussis vaccine could prevent early infant mortality and morbidity. Reinstalling the 18-month booster in the National Immunisation Program could improve control in early childhood, if cost-effectiveness criteria can be met. For all vaccines on the National Immunisation Program, ongoing monitoring of VE is crucial and greater use of Australia’s high-quality data systems can support this, as recommended in the National Immunisation Strategy.16

Where have all the Bilneys gone?

As with nuclear testing controversies, we should not shy away from advocating on climate change

I did not go to Gordon Bilney’s funeral. But then why should I be invited? At one time we inhabited different sides of the political divide — although in our case the divide was often razor thin.

Bilney was Minister for Development Cooperation and Pacific Island Affairs in the Keating government from 1993 to 1996. Before that, in the early 1960s, I always greatly admired him as a fellow student politician, when we were all radicals. Conscious of “the Bomb” then, we had considerable sympathy for the Campaign for Nuclear Disarmament and the daguerreotype grainy images of endless duffle coats and miserable faces of protesters marching from London to the Aldermaston Atomic Weapons Research Establishment. However, the push for a nuclear-powered Australia was secondary for Australian youth as Australia was increasingly sucked into the conflict in Vietnam.

When I was a Victorian medical student, Bilney was a South Australian dental student. He went from teeth pulling to jawboning, entering the world of diplomacy, which readied him for politics when he became the federal member for Kingston in South Australia and served five terms from 1983.

For a brief period in the nineties, Bilney contributed significantly to public health. The 1996 federal election came, and unfortunately, Bilney went — not only as a government Minister, but also from his electorate — a casualty of an electoral intercession Australia “had to have”.

At the time Bilney was Minister, I was President of the Australasian Faculty of Public Health Medicine (AFPHM), a faculty of the Royal Australasian College of Physicians (RACP). There was a strong push — led by Sue Morey, who had been to Papua New Guinea in the 1960s and 1970s — for public health physicians to be more involved with the South Pacific nations. As a result of her legacy, Bilney and I renewed our relationship.

Whenever I entered his ministerial office, he would greet me with the salutation “comrade”. The idea that the government could help the public health physicians bring representatives of small Pacific nations to the AFPHM annual meeting appealed to him and he supported funding for this. A number of potential initiatives came from his attendance at one of the AFPHM’s meetings but, sadly, these initiatives lapsed with the change of government.

The single factor that unified most South Pacific nations was nuclear testing at the Mururoa and Fangataufa atolls. In June 1995, the then French President Jacques Chirac announced that France would conduct a nuclear test series there beginning in September 1995 — just one year before the signing of the Comprehensive Nuclear-Test-Ban Treaty — precipitating great outrage.

Having persuaded the RACP to participate, and with advertising agency Saatchi and Saatchi’s considerable assistance, the AFPHM spearheaded an antinuclear-testing campaign based around full-page advertisements, not only
in Australia but also in France. Le Figaro refused to run them, but both Le Monde and Libération accepted them. Sackfuls of antitesting letters arrived at both the Australian Embassy and the presidential palace in Paris.

The advertisements coincided with Bastille Day 1995, and The Australian summed up the situation by saying that France’s total indifference to South Pacific feeling about nuclear tests was disgraceful.1 There were numerous protests around Australia. As a sidelight, the Australian fencing team, off
to an international competition in The Hague, wore T-shirts featuring a nuclear explosion and the pointed wording “Club Med Mururoa”. Despite such confrontational behaviour,
the T-shirts proved very popular at the competition!

Meanwhile, in an expression of solidarity, Cook Islands doctors wrote an open letter condemning the ongoing testing, which was published in Australian newspapers — an indication that seed funding for public health interaction with our Pacific nations colleagues instituted by Bilney had stimulated a spirit of cooperation — at least in this one important public health issue.

After a sixth nuclear test in January 1996, France ended its program. We had all stirred the controversy; who knows how much had penetrated thinking at the presidential palace.

Fast-forward to the present, and public health physicians have tried to take on the problem of climate change; a particularly relevant topic for the island nations of the South Pacific, where rising sea levels are inevitable. The College has baulked.

The difference between then and now is that, although
there were elements in the College then who did not want involvement in the nuclear protests, the majority realised that the college had an obligation not only to make statements
but also to actively lead in areas where the health of the environment was a vital community issue. It is easy to put out a media release on a Sunday evening, but it is another matter to set out a plan of action and prosecute it without fear or favour. Presumably, climate change should loom large in such considerations. Where has the concern for our colleagues
in the South Pacific and their work gone over the past two decades?

The problem is that the Bilneys of this world are a rare commodity. After the nuclear tests stopped and the Australian Government changed in 1996, Bilney went fishing. For the AFPHM now, the antinuclear stand, distant as it may be, should serve as an example for intervening in the climate change policy debate and inspire hope that there is a champion like Gordon Bilney willing to assist.

Finally . . . an evidence-based tool to find primary health care evidence

To the Editor: If primary health care is to maximise its contributions to population-based outcomes, there must be optimal capacity to retrieve the evidence so critical to informing Australian policy and practice.1 We report a tool called the PHC (Primary Health Care) Search Filter, which retrieves the underlying corpus of relevant published literature in MEDLINE. The PHC search filter was developed using established research methods, incorporating a gold standard comparison approach.2 This useful and simple search tool offers a sophisticated mechanism for retrieving relevant documents pending the development of operational machine-based filtering.

A dual independent review of references of 10 systematic reviews commissioned by the Australian Primary Health Care Research Institute and deemed relevant to primary health care by the Expert Advisory Group (EAG) provided a gold standard set of MEDLINE-indexed articles for testing. These citations were randomly divided into three sets: the term identification set (TIS), filter development set (FDS) and filter validation set (FVS). The TIS was used to generate a list of candidate MeSH (Medical Subject Headings) and text word search terms based on frequency analyses. The highest frequency terms were individually and collectively tested for retrieval effectiveness in the FDS. The best performing search string was then tested in the FVS. This search, comprising 12 terms known as the PHC search filter, successfully retrieved 154/200 citations (77.0%) in the FVS and 415/529 citations (78.4%) from the full gold standard set.

The filter was then translated
for use in PubMed through the Primary Health Care Research
and Information Service website
(http://www.phcris.org.au) to facilitate quick, real-time and free access to relevant citations. A post-hoc relevance test of 500 items retrieved by the search filter in PubMed, dual-reviewed by the EAG, demonstrated 88.4% relevance. Testing in a mixed set of known relevant and non-relevant records could provide a further estimate of the filter’s precision and sensitivity. The PubMed version comprises the terms listed in the Box and is articulated in full in an unpublished report available on request. Readers can access the search filter at http://www.phcris.org.au/phcsearchfilter. The filter can be run alone or combined with other useful search topics such as chronic disease management, continuity of care
and heart failure.

This filter was developed to support policy and practice with respect to primary health care in Australia, and builds on earlier work in relation to palliative care as part
of the federally funded CareSearch project (http://www.caresearch. com.au). Collectively these strategies demonstrate how evidence-based approaches to finding the evidence can be implemented into online knowledge networks.

Top 12 performing search terms in the Primary Health Care Search Filter tool

Term type: MeSH

Community mental health services

Family practice

Home care services

Family physicians

Community health services

Community health nursing

Community pharmacy services

Community health workers

Preventive health services

Term type: text word

Primary care

General practi$

Primary health care

$ = truncation: a truncated search finds all terms beginning with that word stem.

February Calendar 2014

Sun	Mon	Tue	Wed	Thu	Fri	Sat
26	27	28	29	30	31	1 Heart Kids National Awareness Month, Ovarian Cancer Awareness Month, National Red Feb Month, National Raynaud’s Awareness Month, FebFest 2014
2 National Neuroblastoma Awareness Day	3	4 World Cancer Day	5	6	7	8
9	10	11	12 Duchenne Awareness Week	13	14 National Condom Day National Heart Research Day- Nationwide	15
16	17 Australia’s Health Weight Week	18 International Asperger’s Day	19	20	21	22
23 Ovarian Cancer Australia’s Teal Ribbon DayNational DonateLife Week	24 National Sunnies for Sight Day	25	26 Teal Ribbon Day	27	28 International Rare Disease Day	1

Impact of pneumococcal polysaccharide vaccine in people aged 65 years or older

Invasive pneumococcal disease (IPD) is a major cause of morbidity in very young children and older adults.1 The 23-valent polysaccharide pneumococcal vaccine (23vPPV) has been available in Australia since 1986, and use of it has increased progressively since then. It was recommended and subsidised under the Pharmaceutical Benefits Scheme for Australians aged ≥ 65 years in 1997, provided free of charge for this group in Victoria from 1998, and included in the nationally funded National Immunisation Program from 2005.2 The vaccine’s effectiveness against IPD in immunocompetent older people has been estimated as about 70%,3 but it is generally regarded as not effective in preventing carriage of pneumococcal serotypes against which it is targeted.1,3

Australia is the only country to have introduced nationally funded programs for the 7-valent pneumococcal conjugate vaccine (7vPCV) for infants and the 23vPPV for older people in the same year (2005).4 Unlike the 23vPPV, the 7vPCV has been shown to prevent carriage of vaccine serotypes,1 resulting in herd immunity impacts. Reductions in IPD due to 7vPCV serotypes, in vaccinated and unvaccinated age groups, have been observed in many countries. Increases in non-7vPCV serotypes (referred to as serotype replacement) have also been observed in vaccinated and unvaccinated age groups, with the net impact on total IPD incidence varying from country to country.5

In Victoria, a 36% decrease in IPD incidence occurred in people over 65 years of age following the introduction of funded 23vPPV in that state in 1998;6 this was before widespread use of the 7vPCV in children. 7vPCV coverage among infants rose rapidly to 90% in Australia in the first year of the nationally funded program.7 As all 7vPCV serotypes are also present in 23vPPV, any herd immunity effect from 7vPCV would complicate interpretation of the impact of 23vPPV in older people. Studies from two regions on IPD incidence in Australian adults in the post-7vPCV era have provided conflicting evidence on the changes in total IPD incidence in older people.8,9

In July 2011, the 13-valent pneumococcal conjugate vaccine (13vPCV) was introduced for all Australian infants, replacing the 7vPCV and (in the Northern Territory) the 10-valent pneumococcal conjugate vaccine.10 Unlike the 7vPCV, the 13vPCV has been licensed for use in adults aged ≥ 50 years in the United States and Australia, but has not yet been included in the National Immunisation Program.

To inform policy decisions relating to the use of the 13vPCV and the 23vPPV in Australian adults, we aimed to answer three questions:

Can herd immunity effects in older Australians be observed from 7vPCV use in infants?
Can a direct effect of 23vPPV on IPD incidence in older people be shown in the post-7vPCV era?
Irrespective of ecological trends, has the 23vPPV been effective in preventing IPD in older Australians?

Methods

Notifications of IPD were obtained from the National Notifiable Diseases Surveillance System (NNDSS), which notionally captures all laboratory-confirmed cases of IPD. To distinguish the impact of the 7vPCV and the 23vPPV, notifications were aggregated by serotype category: serotypes contained in both vaccines (7vPCV serotype), those contained in the 23vPPV but not in the 7vPCV (23vPPV–non-7vPCV serotype) and those not contained in either vaccine (non-23vPPV serotype). Notifications for people in Victoria and people recorded as Indigenous were excluded, as funded programs for these populations commenced earlier than the national program (in 1998 and 1999, respectively). The proportion of notifications for which specimens were serotyped increased from 70% in 2002–2003 to 87% in 2006. To ensure that time trends in serotype categories were not distorted by this change, the serotype distribution among untyped cases was inferred from the serotype distribution among typed cases, by jurisdiction and by year.

This study was exempt from the requirement for ethics approval as it was conducted as a quality assurance exercise pertaining to the National Immunisation Program, under the auspices of the Australian Technical Advisory Group on Immunisation. De-identified data were provided for this purpose by the Communicable Diseases Network Australia.

Trends in IPD and vaccination coverage

Population rates of IPD by serotype category in people aged ≥ 65 years by year from 1 January 2002 to 31 December 2011 were plotted with 95% confidence intervals, which were calculated using the Poisson distribution of notification numbers. The estimated residential populations, minus Indigenous population estimates from the 2006 Australian census, were used as denominators for calculations of rates in the non-Indigenous population.11

Vaccination coverage estimates for people aged ≥ 65 years, by jurisdiction, were available from adult vaccination surveys conducted by the Australian Institute of Health and Welfare in 2004, 2006 and 2009.12–14 These were based on respondents’ report in telephone interviews regarding receipt of pneumococcal or pneumonia vaccine within the previous 5 years, without reference to written vaccination records.

IPD rate changes in vaccinated and unvaccinated age groups

Changes in rates from the pre-7vPCV era (2002–2004) to the recent post-7vPCV era (2010–2011) periods by serotype category were measured using incidence rate ratios (IRRs) with 95% confidence intervals. IRRs for the vaccinated age group (≥ 65 years) were compared with those for the unvaccinated age group (50–64 years), in which 23vPPV coverage was low (< 5%).7

Vaccine effectiveness estimates

Estimates of vaccine effectiveness (VE) in the ≥ 65-year age group were calculated using the screening method, a form of case–cohort study. It compares the likelihood of prior vaccination in 23vPPV serotype IPD cases with that for the total population. It uses the formula VE=1−[CV÷(1−CV)]×[(1−PV)÷PV], where CV is the proportion of cases that occurred in vaccinated people, and PV is the proportion of the population that had been vaccinated.15

The proportion of the population vaccinated was obtained from the adult vaccination surveys conducted in 2004, 2006 and 2009.12–14 Separate estimates for the 65–74-year and ≥ 75-year age groups by jurisdiction were available from the 2004 and 2006 surveys.

The proportion of 23vPPV-type IPD cases that were recorded as being in “fully vaccinated” people (ie, those vaccinated within 5 years, according to national recommendations at the time) who were aged ≥ 65 years was derived from the NNDSS for each year that population coverage data were available (2004, 2006 and 2009). For these VE calculations, cases recorded on the NNDSS as having occurred in people in Victoria or Indigenous people were not excluded, as their different dates of 23vPPV funding do not influence VE estimates. In addition, cases that occurred in Indigenous people were included in population coverage data, so the method required their inclusion in the study population.

A logistic regression model was fitted using the GENMOD procedure in SAS 9.1 (SAS Institute) as described previously.16 Data were stratified by year, age group and, for 2004 and 2006, by jurisdiction. A sensitivity analysis of the VE estimates was conducted, recalculating VE using a deviance of ± 10% of the total population in coverage estimates. Statistical analysis was carried out in SAS 9.1.3. Statistical significance was established by non-overlapping 95% confidence intervals, of rates and rate ratios.

Results

From 2002 to 2011, there were 3978 IPD notifications for Australians aged ≥ 65 years who were not in Victoria and were not Indigenous.

Trends in IPD rates and vaccination coverage

Annual IPD notification rates in people aged ≥ 65 years by serotype category are shown in Box 1. There was a substantial and statistically significant decrease in 7vPCV serotype IPD during the post-7vPCV era (2005–2011), as well as significant increases in 23vPPV–non-7vPCV and non-23vPPV serotypes, based on non-overlapping confidence intervals of annual rates.

The serotype most associated with replacement following 7vPCV introduction internationally — 19A — increased from 3% of isolates in 2002–2004 to 22% in 2010–2011.

The range of self-reported vaccination coverage (percentage vaccinated in the previous 5 years) estimates for those aged ≥ 65 years are also shown in Box 1, for all jurisdictions except Victoria. Coverage ranged from 41% to 53% in individual jurisdictions in 2004, increased to 51%–64% in 2006 and decreased to 48%–56% in 2009.

IPD rates in vaccinated and unvaccinated age groups

Pre-7vPCV (2002–2004) to post-7vPCV (2010–2011) changes in IPD rates in the ≥ 65-year age group and the 50–64-year age group are shown in Box 2. In both age groups there were substantial, statistically significant decreases for 7vPCV serotypes and increases for 23vPPV-non-7vPCV and non-23vPPV serotypes, based on IRRs not overlapping 1.0. The magnitude of these changes did not differ significantly between the two age groups. For all serotypes, the IRR point estimate was lower in the ≥ 65-year age group, but confidence intervals for the two age groups overlapped.

Vaccine effectiveness estimates

Numbers of IPD cases and VE estimates for 23vPPV against 23vPPV-type IPD are shown in Box 3. All VE estimates were statistically significantly above zero. The point estimate for 2009 was lower than for 2004, but was compatible with it, as confidence intervals overlapped. A sensitivity analysis to evaluate the impact of varying population coverage estimates for 23vPPV yielded an upper VE estimate of 75.8% (95% CI, 72.1%–79.9%) if true population coverage was 10% higher than estimated in the adult vaccination survey and a lower VE estimate of 40.5% (95% CI, 31.1%–49.9%) if true population coverage was 10% lower than estimated.

Discussion

Changes in IPD rates over time by serotype category presented here provide evidence of a substantial herd immunity impact in older people due to 7vPCV use in infants. However, an impact on IPD rates directly resulting from 23vPPV use in older people, by comparing changes in vaccinated and unvaccinated age groups, was not clearly shown. The VE estimate for 23vPPV against 23vPPV-type IPD was 61.1%. An overall decrease of 35% was observed in total IPD rates in ≥ 65-year-olds 6–7 years after the commencement of the nationally funded programs for 7vPCV and 23vPPV (25.2 notifications/100 000 population/year in 2002–2004 v 16.4 in 2010–2011).

Herd immunity impacts in adults from use of the 7vPCV in children have been shown in many countries. Herd immunity impacts on total IPD rates are heavily dependent on the pre-vaccination serotype distribution in adults and the length of time since 7vPCV introduction, as serotype replacement increases over time.5 Australian non-Indigenous people had one of the highest proportions of 7vPCV-type IPD out of total IPD in the world, similar to that in the US, and these are the only two countries with net decreases in IPD reported for older people following 7vPCV introduction.17

Trends in IPD rates by year in Australia in our study did not show clear evidence of a reduction of disease incidence due to use of 23vPPV in people aged ≥ 65 years. However interpretation of this finding is complicated by two factors: an overall modest level of 23vPPV coverage and a relatively small increase in coverage after national funding began in 2005; and the apparent indirect effects of introducing the 7vPCV for infants at the same time. The comparison of rates in vaccinated and unvaccinated age groups, both subject to herd immunity impacts from infant vaccination, allows the possibility of some impact from the 23vPPV. The absence of impacts on population IPD rates following publicly funded 23vPPV for ≥ 65-year-olds has also been reported in the US18 and United Kingdom.19 Gradual increases in coverage also occurred in those settings, and formal VE assessments in adults have consistently shown significant VE.20–22

All observational methods used to estimate VE are subject to bias. For our application of the screening method, different methods were used to ascertain the vaccination status of the general population (telephone survey) and the vaccination status of 23vPPV-type IPD cases (general practitioner and/or patient interview). However, our sensitivity analysis showed that the VE estimate remained statistically significant even if the true population coverage was 10% lower than the adult vaccination survey estimates. A study of 23vPPV vaccination status in older people in Victoria found that patient recall underestimated vaccination status by 6% compared with medical records.23

During the period of our study, a single revaccination was recommended for people first vaccinated at ≥ 65 years of age. As of December 2011, this is no longer recommended.10 The latest national estimate of the proportion of people aged ≥ 65 years who have ever received 23vPPV is a modest 59%.13 Given the evidence of the vaccine’s effectiveness, higher coverage would be expected to increase the impact of the vaccine in reducing IPD incidence.

Data are yet to emerge on the herd immunity impact from 13vPCV use in Australian children. However, if similar effects are seen from the additional six serotypes as from the 7vPCV, there would be a further reduction in IPD in older people and, therefore, less potential benefit from the 23vPPV.

The appeal of a conjugate vaccine used in older people includes potential, although unproven, benefits such as a superior response to booster doses and impacts on carriage and non-invasive pneumonia. Herd immunity impacts of 7vPCV on non-invasive pneumonia in older people have been reported as being non-existent, very small or extensive.24–26 A randomised controlled trial assessing the impact of 13vPCV use in older people on pneumonia is currently underway.27 However, this trial is not being conducted alongside concurrent use of 13vPCV in infants. The incremental benefits of 13vPCV use in older people in addition to an infant program would be more difficult to evaluate.

In conclusion, our data show moderate effectiveness of the 23vPPV against IPD in older Australians, consistent with that shown in comparable populations elsewhere. In combination with herd immunity impacts from 7vPCV in children, this resulted in a 35% decrease in IPD in those aged ≥ 65 years. Further benefits could be expected if an increase in 23vPPV coverage in older people could be achieved.

1 IPD notification rates by serotype category for ≥ 65-year-old Australians and pneumococcal vaccination coverage, 2002–2011*

IPD = invasive pneumococcal disease. 7vPCV = serotypes contained in the 7-valent pneumococcal conjugate vaccine and 23-valent polysaccharide pneumococcal vaccine. 23vPPV–non-7vPCV = serotypes contained in the 23-valent polysaccharide pneumococcal vaccine but not the 7-valent pneumococcal conjugate vaccine. Non-23vPPV = serotypes not contained in either vaccine. * IPD notification rates do not include people in Victoria or Indigenous people; serotype categories are adjusted for untyped cases; error bars for IPD notification rates are 95% confidence intervals; and error bars for vaccination coverage are ranges of self-reported vaccination coverage for individual jurisdictions excluding Victoria.

2 Invasive pneumococcal disease notifications and notification rates for unvaccinated (50–64 years) and vaccinated (≥ 65 years) age groups of older Australians by serotype group, 2002–2004 versus 2010–2011*

	Number of notifications		Notifications per 100 000 population per year
Age and serotype group†	2002–2004	2010–2011	2002–2004	2010–2011	Incidence rate ratio (95% CI)‡

50–64-year-olds
7vPCV	490	45	6.59	0.76	0.12 (0.08–0.15)
23vPPV–non-7vPCV	180	311	2.42	5.34	2.21 (1.83–2.67)
Non-23vPPV	53	95	0.71	1.64	2.31 (1.62–3.27)
All	723	451	9.71	7.74	0.80 (0.71–0.90)
≥ 65-year-olds
7vPCV	954	80	17.00	1.84	0.11 (0.09–0.14)
23vPPV–non-7vPCV	317	401	5.65	9.27	1.64 (1.41–1.91)
Non-23vPPV	144	230	2.56	5.30	2.07 (1.67–2.57)
All	1415	711	25.21	16.41	0.65 (0.59–0.71)

7vPCV = serotypes contained in the 7-valent pneumococcal conjugate vaccine and 23-valent polysaccharide pneumococcal vaccine. 23vPPV–non-7vPCV = serotypes contained in the 23-valent polysaccharide pneumococcal vaccine but not the 7-valent pneumococcal conjugate vaccine. Non-23vPPV = serotypes not contained in either vaccine. * Data on people in Victoria and Indigenous people are excluded. † Adjusted for untyped cases. ‡ 2010–2011 : 2002–2004.

3 Numbers of IPD cases and VE estimates for 23vPPV against 23vPPV-type IPD in Australians aged ≥ 65 years*

Year

Cases in people vaccinated with 23vPPV/total cases (%)

Proportion of population vaccinated with 23vPPV†

VE estimate (95% CI)‡

2004

106/339 (31.3%)

51.1%

63.3% (53.1%–71.9%)

2006

132/320 (41.3%)

62.2%

65.6% (56.1%–73.9%)

2009

90/241 (37.3%)

56.0%

50.4% (35.1%–62.9%)

Total

328/900 (36.4%)

61.1% (55.1%–66.9%)

IPD = invasive pneumococcal disease. VE = vaccine effectiveness. 23vPPV = 23-valent pneumococcal polysaccharide vaccine. na = not applicable. * Data include people in Victoria and Indigenous people. † Values are summary proportions of Australians who received the vaccine within the previous 5 years. ‡ VE estimates were calculated using data stratified by jurisdiction, year and age group.

Detecting undiagnosed diabetes using glycated haemoglobin: an automated screening test in hospitalised patients

Error in author name: In “Detecting undiagnosed diabetes using glycated haemoglobin: an automated screening test in hospitalised patients” in the 21 February 2011 issue of the Journal (Med J Aust 2011; 194: 160-164), an author’s name was incorrectly spelled. The correct spelling of the fourth author’s name is Parind P Vora.

headspace — Australia’s innovation in youth mental health: who are the clients and why are they presenting?

headspace National Youth Mental Health Foundation is the Australian Government’s major investment in the area of youth mental health.1 The National Survey of Mental Health and Wellbeing (NSMHW) revealed that one in four young people experience a clinically relevant mental health problem within any 12-month period, compared with one in five in the general population.2 Half of a cohort of young people were shown to suffer diagnosable mental ill health at some point during the transition from childhood to adulthood, which reduces fulfilment of their potential and increases likelihood of disability and premature death.3 Australian data are consistent with international trends and the adolescent and early adult years are periods of peak prevalence and incidence for most mental disorders.4,5 Yet, despite having the highest prevalence, young people have the lowest level of professional help-seeking for mental health problems across the lifespan.2

headspace was initiated in 2006 to address the concerning mismatch between level of need and amount of mental health service use among adolescents and young adults.1 The initiative is innovative in targeting the age range from early adolescence through early adulthood, maintaining that the traditional child and adolescent versus adult service divide creates a disjunction at precisely the time when there is greatest need for continuity.6 There are now 55 headspace centres across Australia, scaling up to 100 centres in 2016.

The approach to service delivery has been described elsewhere,1,7 but briefly, headspace centres aim to create highly accessible, youth-friendly, integrated service hubs that provide evidence-based interventions and support to young people aged 12–25 years around their mental health, health and wellbeing needs. Each centre is directed by a lead agency on behalf of a local partnership of organisations responsible for the delivery of services, comprising mental health, alcohol and other drug, primary care, and vocational services. The main aim is to improve outcomes for young people by addressing the major barriers to service use for young people,8,9 and enabling better access to and engagement in early intervention services that provide holistic and integrated care.

The current study provides the first comprehensive profile of headspace clients across the entire national network of the current 55 centres. It is timely to investigate the demographic characteristics of young people presenting to headspace centres and their reasons for presentation to determine whether headspace is providing early service access for adolescents and young adults with emerging mental health problems.

Method

Participants and procedure

Participants were all headspace clients who received a centre-based service between 1 January and 30 June 2013. This comprised data from 21 274 clients across the 55 current headspace centres. The centres have been operational for varying periods of time, including 10 round 1 centres (established in 2007), 20 round 2 centres (2009), 10 round 3 centres (2011), and 15 round 4 centres established in the past 12 months.

A major review in 2012 of routine data collected by headspace found that beyond basic demographics, the information was generally of poor quality. Consequently, a new minimum dataset was implemented from the beginning of 2013. This requires young people accessing headspace centres and their service providers to enter data into an electronic form about each occasion of service. Data are de-identified by encryption and extracted to the headspace national office data warehouse.

Measures

Client demographic characteristics comprised age in years, sex, Aboriginal and Torres Strait Islander background, country of birth, living situation and current occupation.

Client clinical presentation characteristics were measured through self-reported reason for presentation, as well as by clinician diagnosis according to relevant World Health Organization ICD-10 classifications of mental and behavioural disorders. Level of psychological distress was measured by self-report using the 10-item Kessler Psychological Distress Scale (K10),10 while stage of illness was estimated by clinicians using the categories of no mental disorder, mild to moderate symptoms, subthreshold symptoms not reaching full diagnosis, diagnosed disorder, periods of remission, or serious and ongoing disorder without periods of remission.11 Days out of role were self-reported,12 and overall functioning was assessed by clinicians using the Social and Occupational Functioning Assessment Scale (SOFAS).13

Results

Client demographic characteristics

The proportion of male and female clients in each age group is shown in Box 1. The peak age of presentation was 15–17 years, and relatively more males presented in the youngest (12–14 years) and oldest (21–25 years) age groups. Overall, 63.7% of clients were female and 35.6% were male, with only 0.7% reporting that they were intersex, transgender or transsexual. The NSMHW showed that 30% of young women and 23% of young men had experienced mental disorder in the past 12 months.14

There were 7.7% of clients who identified as Aboriginal or Torres Strait Islander, compared with 2011 census data showing that 4.0% of Australians aged 12–25 years identify as Aboriginal or Torres Strait Islander.15

Clients who reported being born outside Australia comprised 7%, compared with 15% of the population aged 10–24 years in 2007–2008.16 Consistent with population trends, the most common places of birth outside Australia for headspace clients were England and New Zealand. Ninety-four per cent reported speaking only English at home, which compares with 80.3% in the general population aged over 5 years.17

Over half the clients (57.1%) lived in major cities, while 31.2% lived in inner regional areas, 9.6% in outer regional, and 2.1% in remote or very remote areas. This compares with 2012 estimates from the Australian Bureau of Statistics that 70% of the youth population lived in major cities, 18% in inner regional areas, 9% in outer regional and 2% in remote or very remote areas.18

Most headspace clients had stable accommodation (86.6%), but there were 10.3% for whom accommodation was an issue, 2.4% who reported that they were at risk of being homeless, and 0.7% who were currently homeless. This compares to 0.7% of the Australian population aged 12–24 years who were estimated as being homeless or in marginal housing in the 2011 census.19 Security of housing decreased markedly with age among headspace clients, from 94.0% of those aged 12–14 years to 81.5% of those aged 21–25 years.

Many clients were currently engaged in education, with 46.7% at school and 21.0% in higher education. Among those aged 18–25 years, 29.0% were not engaged in employment, education or training, which compares with 27.3% in the population.20

Presentation characteristics

Overwhelmingly, the main self-reported reason for young people presenting at headspace centres was having problems with how they felt (71.6%); specifically, almost a quarter first presented feeling sad or depressed (24.9%) and 12.7% were feeling anxious. The next most common reason was having relationship problems (11.4%), followed by physical health issues (6.6%), school/work problems (6.0%), alcohol or other drug problems (1.7%), sexual health issues (1.6%) and vocational concerns (1.0%). Reasons for presenting varied by age and sex (Box 1). Relationship and school issues decreased with age, while problems with feelings increased, especially for males. For females, health and sexual health reasons for presentation increased with age, while alcohol and other drug and vocational issues become more pressing for males.

Over half (69.3%) of the young people attending headspace did so with high or very high levels of psychological distress (Box 2). This compares with only 9% in the general community aged 16–24 years, and 21% of young people diagnosed with mental disorder in the NSMHW.14 Males aged 12–14 years were most likely to present with the lowest levels of psychological distress, while females aged 15–20 years were most likely to present at the highest level of distress. By early adulthood, the distress levels of males and females converged. These patterns were reflected in the mean K10 scores. For males, these increased from 20.7 (standard deviation [SD], 8.2) for those aged 12–14 years to 26.9 (SD, 9.0) for those aged 21–25 years. The increase for females was less pronounced, from 25.7 (SD, 9.4) to 27.7 (SD, 9.1) for those aged 12–14 years and 21–25 years, respectively. Only the younger boys had a mean in the moderate range for the K10; means for all other age groups were in the high-distress range.

Stage of illness development reflected the expected age-related trajectory using a population health approach based on the spectrum of mental health interventions21 (Box 3). Overall, there were 14.6% of clients with no mental disorder, 39.6% with mild to moderate symptoms, 16.9% with subthreshold diagnosis, 18.8% with full-threshold diagnosis, 3.5% with periods of remission, and 6.4% with serious and ongoing mental disorder. With increasing age, there were fewer clients in the no mental disorder and mild to moderate groups, relative stability in the subthreshold group, and increased proportions in the full-threshold diagnosis, remission, and serious or ongoing disorder categories.

These trends were confirmed by self-report of whether prior mental health care had been received. Overall, a third of clients reported never previously seeing a mental health professional. The proportion declined with age: 51.6% of 12–14-year-olds, 41.9% of 15–17-year-olds, 31.5% of 18–20-year-olds, and 26.4% of 21–25-year-olds.

Twenty-nine per cent of clients were estimated by clinicians to have full-threshold, remission, or serious and ongoing disorder, yet almost a third of these had no actual clinical diagnosis recorded at presentation, and a further 6.7% were reported as diagnosis not yet assessed. The most common diagnoses recorded were mood disorders (28.2%), followed by anxiety disorders (17.3%), adjustment disorder (4.3%), personality disorders (2.7%), developmental disorders (2.3%), substance use disorders (1.8%), psychotic disorders (1.6%) and eating disorders (1.2%).

Self-reported days out of role in the previous 2 weeks revealed a trend of increasing disability due to mental health problems with age. This was most pronounced for males, who were most likely to report no days out of role when aged 12–14 years (55.5%), decreasing to 44.5% for those aged 21–25 years. For females, this decrease was less pronounced, from 41.2% for those aged 12–14 years to 38.4% for 21–25-year-olds. Overall, 40.6% of headspace clients reported no days out of role, 22.8% reported 1–3 days, 17.8% reported 4–6 days, 6.2% reported 7–9 days, and 12.5% reported more than 10 days out of role in the past fortnight.

Social and vocational functioning, as reported by service providers, showed a similar pattern. The proportions of clients with serious or major impairment (SOFAS scores < 50) were 11.2%, 11.9%, 17.0% and 19.4% for males in each of the ascending age groups, respectively; and 8.1%, 10.0%, 12.3% and 12.6% for females. The mean SOFAS scores were similar across age and sex and closest to the anchor defined as “Moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts with peers or co-workers)”.

Discussion

These are the first data that describe the young people presenting to headspace centres across Australia. Such information is timely, as the initiative is now established and attracting national and international interest. Therefore, it is important to examine whether headspace centres are being accessed by their intended target group.

The results show that almost two-thirds of headspace clients are female, which partly reflects the sex difference in the distribution of mood and anxiety disorders for this age group within the Australian population.14 However, in the future, headspace will need to respond more effectively to mental ill health in young men, which typically manifests through substance misuse and behavioural problems, conditions that can mask underlying emotional disorders. The higher proportion of Aboriginal and Torres Strait Islander clients, compared with their proportional representation in the overall population, indicates the need for mental health support in this population group and that the youth-friendly focus of headspace centres may be attractive to young Aboriginal and Torres Strait Islander people. In contrast, there is a lower proportion of clients born outside Australia compared with their proportional representation in the overall population, which suggests that some of these demographic groups may still experience significant barriers to service use.

That a third of the young adult headspace clients were not engaged in education, employment or training indicates the vulnerability of youth with mental health issues to disengagement from vocational opportunities. This is a situation that must be addressed, particularly during the current period of growing unemployment.22

headspace is serving young people outside major metropolitan areas — an excellent outcome for Australia, which struggles to provide an effective mental health service response in regional and rural areas.23 There has been a deliberate strategy to locate headspace centres in regional areas, with the aim of eventually providing national coverage so that all young people have reasonable access to services.

The presenting issues for young people attending headspace centres are primarily problems with how they feel, mostly related to feeling depressed or anxious. The initiative was set up to better respond to the need for care for such high-prevalence mental ill health in young people. However, formal diagnosis of mental disorder by an appropriately qualified clinician is available for only a small proportion of clients. This partly reflects the multidisciplinary nature of the headspace workforce, many of whom are not trained in formal diagnosis and who use psychotherapeutic approaches that are not diagnosis driven. It also suggests the need for an expanded diagnostic approach that incorporates clinician assessment of at-risk and subthreshold conditions.24 Over half the young people presenting were in the early stages of the development of mental disorder, having mild to moderate or subthreshold symptoms, as specifically targeted by the initiative. Nevertheless, almost 20% had an established disorder and about 10% had a serious ongoing disorder, showing the wide range of clinical presentations that headspace centres need to accommodate.

This description of the presenting characteristics of young people accessing headspace centres suggests that the initiative is mostly achieving its aim to improve service access early in the development of mental illness, although there are demographic groups where access needs to be improved. Further analyses of the new minimum dataset are planned, to examine the types of services that headspace clients are receiving and to determine whether the approach is making a difference to their mental health and wellbeing. Importantly, a process to obtain follow-up data 3 months after young people have received their last service was implemented several months after the initial implementation of the new minimum dataset, and these outcome data will be available for analysis early in 2014. Such analyses, and other evaluation efforts, are required to determine whether headspace is delivering on the aims of this innovative initiative.

1 Proportion of headspace clients reporting each main reason for presentation, by sex and age group

	Male				Female
	12–14 years	15–17 years	18–20 years	21–25 years	12–14 years	15–17 years	18–20 years	21–25 years

Proportion of total male or female clients	13.4%	30.4%	27.3%	28.9%	11.5%	36.8%	27.1%	24.7%
Reason for presenting
Feelings	62.3%	66.7%	73.8%	76.3%	67.5%	71.9%	70.2%	72.6%
Relationships	19.6%	14.1%	9.3%	8.0%	19.6%	13.3%	8.7%	7.8%
School/work	16.2%	10.2%	4.2%	3.9%	9.9%	6.2%	3.4%	4.0%
Physical health	1.1%	3.4%	4.6%	5.5%	2.4%	5.2%	12.0%	11.8%
Alcohol/drugs	0.6%	3.6%	4.8%	4.3%	0.2%	0.5%	0.9%	1.1%
Vocational	0.1%	1.6%	3.1%	1.9%	0.1%	0.4%	0.9%	0.6%
Sexual health	0	0.4%	0.3%	0.1%	0.3%	2.6%	3.9%	1.6%

2 Proportion of headspace clients at each level of psychological distress, by age group and sex

Age group (years)

3 Proportion of headspace clients at each stage of illness, by age group and sex

Age group (years)

Murra Mullangari — Pathways Alive and Well

A clinically qualified and culturally competent Aboriginal and Torres Strait Islander health workforce is vital if Australia is to make a difference to Indigenous health

The Murra Mullangari — Pathways Alive and Well program is an initiative of the Australian Indigenous Doctors’ Association (AIDA) in partnership with other peak Indigenous organisations. Using culture and identity as a strength, the program was developed with the aims of building the aspirations and capacity of Aboriginal and Torres Strait Islander senior high school students to remain in the academic pipeline and pursue careers in health.

In the language of the Ngambri people, upon whose lands the inaugural program was held, Murra is the path and Mullangari is health and wellbeing coming from the ceremonies, including the Bogong Moth Ceremony.

The program was informed by the Patty Iron Cloud National Native American Youth Initiative, run in Washington DC each year by AIDA’s peer organisation — the Association of American Indian Physicians. After attending the program in 2010, three senior members of AIDA returned committed to establishing a similar program across all health careers, rather than just medicine and biomedical research. After almost 2 years of seeking financial support for an Australian program, commitment was given by the Australian Government to establish a pilot program in June 2012.

In April 2013, the inaugural Murra Mullangari — Pathways Alive and Well program commenced, with 30 Indigenous senior secondary students (from almost 200 applicants) travelling to Canberra to participate in a 5-day residential component, which included a traditional welcome to country by Aunty Matilda House at the Aboriginal Tent Embassy, a smoking ceremony and the warm words of former Governor-General and AIDA Patron, Sir William Deane, who highlighted the importance of education and the pursuit of dreams.

The students visited local and national institutions such as the Winnunga Nimmityjah Aboriginal Health Service, the Australian Institute of Aboriginal and Torres Strait Islander Studies and the Australian Institute of Sport. Participants took part in interactive workshops at the Australian National University Medical School and University of Canberra Faculty of Health, as well as learning about university entry pathways and support at the Tjabal and Ngunnawal Indigenous Higher Education Centres. The program also featured workshops led by current health professionals in the disciplines of medicine, exercise science, nutrition, Aboriginal health work, psychology and nursing.

Murra Mullangari Facilitator Gregory Phillips encouraged participants to express themselves and their aspirations through painting. This artwork is a combination of the reflections of all 30 participants along with the program staff, facilitator and group leaders, on culture, the Murra Mullangari experience and their continuing personal goals.

Murra Mullangari partners continue to seek funding support to run further programs and would welcome contact from any MJA readers.

Murra Mullangari — Pathways Alive and Well. By 2013 participants, facilitator, group leaders and program staff.

Thomas Trauer BA(Hons), PhD

Thomas (Tom) Trauer was born in Manchester, England, on 10 November 1944. Although his Jewish parents had escaped the Holocaust, few of their wider family survived and, as an only child, Tom became the sole member of his generation. Previously qualified in Prague, Tom’s father Robert repeated his medical degree in Adelaide in order to practise in Australia, and the family settled in St Kilda. While Robert practised as a general practitioner and pursued his passion for visual art, Tom attended Brighton Grammar School before commencing his psychology studies at the University of Melbourne.

He forged lifelong friendships during his study, and met his future wife Barbara through Melbourne University Choral Society. They married in London in 1971 and had two sons. Tom completed his doctorate, before moving into management roles in the Department of Psychology of King’s College London and with Camberwell Health Authority.

On returning to Melbourne in 1989, Tom worked as a senior psychologist in Mont Park and Larundel psychiatric hospitals, before focusing on research through the 1990s. By the time of his death, he was Professorial Fellow at the University of Melbourne, Honorary Professor at Monash University and Visiting Professorial Fellow at the University of Wollongong.

Tom’s research focused primarily on mental health outcome measurement and service evaluation, but had expanded more recently to include the mental health of the physically ill, transplant recipients, caregivers and patients with cancer. During a research career built on collaboration and the support of colleagues, he authored around 200 peer-reviewed articles and two books, including Outcome measurement in mental health: theory and practice (Cambridge University Press, 2010), which remains a definitive text of the area.

Tom’s interest in mental health service development merged with his passion for travel, and he assisted with research, training and service development in China, Qatar, Laos, Vietnam, Scotland, Canada, the Netherlands, Israel and England. His passion for teaching, support for junior researchers, generosity and helpfulness were renowned.

Tom died on 10 July 2013 after a short illness and is survived by his wife Barbara and sons James and Michael.

The Da Vinci Code and the alphabet of research

We offer an alphabetical guide into the opaque and mystical world of research

Many are called to do research, but few are chosen. How is this possible in an era of improved gender equality, educational access and global connectivity? The answer lies in the secret “Da Vinci Code” of research: the unwritten interpretation of the alphabet of research that touches us all through serial rejection of grant applications and scientific articles. Out of a sense of duty to fellow researchers, and with just a subtle hint of projection, we have chosen to share the secrets of this Code with you.

A is for analysis: biochemical analysis, statistical analysis and the psychoanalysis needed after a few years in a research career. A is also for ambivalent.

B is for blot. There is nothing like a Western blot to induce a collective lather of excitement in a room full of lab scientists — talented, bespectacled people with terrible skin, seldom seen during daylight. B is also for borrowing, a kinder word than plagiarism.

C is for Cochrane reviews. More righteous than a reformed smoker, the Cochrane collaborator preaches the eternal benefits of telling the wood from the forest plots.
C is also for consistency, reflected in the universal finding of any Cochrane review that more studies are needed.

D is for destiny. You will achieve yours either by becoming Dean of the Faculty of Medicine or working in the community. D is also for doctor, as in PhD.

E is for EBM or evidence-based medicine, the mantra of the academic clinician. EBM also stands for expressed breast milk. In neonatal intensive care, where acronyms reign supreme, this can cause considerable confusion.

F is for fantasy. Little research has been done into fantasy but a great deal of fantasy has gone into research. F is also for failure.

G is for governance, a concept that has risen more quickly than the sovereign debt of many European countries. G is also for gratuitous.

H is for your research habitat. Here you will be in a womb of your own, dressed like a sloth but with the mathematical acumen of an actuary. H is also for hierarchy.

I is for Ig Nobel Prize, awarded to researchers with modest ambition and limited aptitude. I is also for island, which no man is, although the researcher comes closest.

J is for jaded, describing the post-traumatic stress disorder arising from receiving the umpteenth rejection of your most precious manuscript by another J, for journal.

K is for the keynote address which all researchers aspire, but never get asked, to deliver. K is also for knowledge, or the absence thereof.

L is for lies, damned lies and scientific fraud, as in the autism and vaccination debate. L is also for lyonisation, whatever that is.

M is for Machiavellian, describing an academic competitor who, by an amazing coincidence, publishes an article
6 months after your grant application on the same highly specific area was rejected. M is also for maturity. You both know what has happened, but it is never discussed.

N is for normal distribution, which applies to data from large cohort studies that you have not performed. N is also for native cunning, as you log transform your limited data to generate a significant P value.

O is for Ondine’s curse, the threat delivered by your PhD supervisor if you do not complete your thesis by the due date. O is also for OMG.

P is for a significant P value, the Holy Grail of research, with the exception of qualitative nursing research, where statistical significance is an oxymoron. P is also for passport, the true reason for your supervisor’s timely review of your abstract for the meeting in Rio.

Q is for qualitative research, which uses patient-reported outcomes as its basis for justifying conclusions, rather than, say, a 20 mL improvement in your FEV1 with a new wonder drug taken five times daily. Q is also for quantitative research, to which the qualitative researcher aspires.

R is for rejection, a character-building exercise that does not get more enjoyable with another R, for repetition.

S is for statistics. A good statistician speaks a language that is unknown even in Babel. S is also for sorcerer, a numerical alchemist who can transform raw data into publication gold.

T is for test tubes, the conduit to conception without copulation. T is also for thesis, if you are lucky.

U is unique (or, more grammatically, u are unique). Unique is a word that cannot be used too often to describe your research. U is also for useless.

V is for validity, which can be internal or external. Your study can be reliable, measuring the same thing, but invalid. V is also for vengeance, usually externalised.

W is for wading through the data to derive your interpretation. As a reviewer this proves challenging, so you suggest further statistical review. W is also for wolfpack, the collective noun for members of a local ethics committee.

X is for exceptional spelling, a legacy of spellcheck. X is also for Generation X, the last generation to read a book from cover to cover.

Y is for yardstick, the benchmark to which your work is compared and others aspire. Y is also for the yacht you will own after you move across to work in industry.

Z is for zzzzzzzzzzzzzz at the end of a lecture on Fourier transformations and their utility in clinical research. Z is also for zeal, reflecting your gift for self-promotion.

Disclaimer: While we will guarantee the integrity of our observations, we cannot necessarily vouch for the statistical rigour with which we concluded that the correlation coefficient with the truth was 0.78.