Healthy adventure beyond the backyard

REVIEWED BY CHRIS JOHNSON

If outdoor adventure is what keeps your mind, body and soul healthy, then there is no shortage of places to go and activities to attempt across this huge planet of ours.

But discovering just what is on offer and where might be easier said than done.

So much to see. So many things to try. So little time.

A new release from travel publishers Lonely Planet provides a perfect snapshot of outdoor experiences to be had in more than 150 countries around the globe. How helpful is that?

Lonely Planet’s Atlas of Adventure is a beautifully produced coffee table book full of stunning photographs and inviting, succinct descriptions of outdoor romps to tackle from Afghanistan to Zimbabwe.

With maps, expert advice and interviews from those who have dared before, the atlas offers an inspiring and informative globetrotting tease of more places and adventures than can hardly be imagined.

Diving in Thailand, sea kayaking in Antarctica, cycling the Canary Islands, white water rafting in Canada, skiing in Switzerland, or climbing in Mexico are just a few examples of what’s on offer.

And that’s just for the faint at heart.

Why not also try parachuting in Pokhara or trekking around Everest (both in Nepal), kitesurfing off Mozambique, riding with eagle hunters in Mongolia, or surfing the deserted swells of Kiribati.

And everyone wants to know about dune boarding in Namibia!

This atlas is a fascinating read – all 336 pages of it – entertaining and engaging.

With a thorough 17 pages on Australia alone (one of the larger sections of the book), it also showcases some of the best outdoor adventures to be had in our own backyard.

Below are a couple of extracts from the book, just to whet the adventure appetite.

FRANCE
Bouldering

An hour south of Paris is the best, most famous and historic bouldering area in the world: Fontainebleau. Imagine all the things that would make for a perfect bouldering area – flat, sandy landings, endless boulders, soft-on-the-skin sandstone, unique shapes, densely concentrated problems – and you find it here. Originally considered a training ground for the Alps, bleausards (local climbers) have been bouldering here for more than 100 years, and it’s considered a rite of passage to get burnt off by geriatric (but well-muscled) bleausard, who generally have all the classics wired. Best of all, you are never too far from a café au lait and croissant, while rest days can be sent touring the art galleries and museums of Paris.

BELIZE
Diving

There are few diving destinations in the world as magnetic as the Blue Holeon Belize’s Lighthouse Reef. Seen from the air this deep-blue 300m-diameter watery pupil, rimmed by a shallower aquamarine iris, is the visual icon of diving in Belize. The descent into the sinkhole is relatively deep – up to 40m – and inky dark, despite the clarity of the water. The nerve-racking but exhilarating part is gliding beneath the limestone overhang and along the underwater walls. Most dives are sub 10 minutes, but it’s an otherworldly underwater experience not to be missed.

A day in Portugal’s Douro Valley

I certainly was not expecting to meet Mr Bean’s doppelgänger in the Douro Valley. But more of that later.

By the third morning of my Douro River cruise I know to chose the sort of breakfast that will neutralise the effects of the coming day. Our first stop today is the Douro Museum, where we learn about the history of port making in the region, all the way back to Roman times – wine being much safer to drink than water. Of course, this newly-gained knowledge must be celebrated with a tipple or two of port.

This has fortified me for the trek up the zigzag stairway to the Sanctuary of Nossa Senhora dos Remedios (Our Lady of Remedies). The staircase is completely over the top baroque with stone balustrades, urns, fountains and statuary. I adopt a sudden and keen interest in the blue and white tiles depicting religious scenes along the way – more dyspnoea than devotion. Reaching the charming chapel after 686 steps, I pray to Our Lady to grant a remedy for my creaking knees, or, at the very least, for my intemperance over the past few days. I am grateful, though, that I am not a pious pilgrim crawling up on my knees during the annual feast day.

Next we are twisting and turning our way up a ridiculously narrow road through a never-ending sea of grape vines. Many thousands of hours of hard yakka have gone into terracing and training these rocky slopes into vineyards. From our destination, the Quinta da Avessada, I admire the neatly terraced contours of the valley walls, the Douro meandering leisurely below, a glass of delicious muscatel in hand. I have been on plenty of wine tours in my time so I am not expecting anything special until our host, Luis Barros, arrives with his little band of musicians – including a piano accordionist, of course – and launch into some cheerful local folk songs. Luis regales us with stories of his family, the winery, the wines. His madcap facial expressions, fluctuating tone and wildly exaggerated gestures have me in stitches. This IS the Portuguese Mr Bean!

We visit a room where, bizarrely, a bunch of animatronic men demonstrate grape stomping in the old tradition. I am pretty sure the Japanese still have the inside run on robotics, although I muse that I might prefer an animatronic wine stomper over a robotic nurse to look after me in my very old age. Then to the cellar, a classic dimly lit stone and timber cave with oak barrels where I learn to appreciate the range of wines and ports produced in the Douro Valley. Really all too delicious to spit out, and it would be so unlady-like.

We weave our way to the restaurant where Luis continues his performance – I mean his explanations of the food and yet more wines. He is hilarious and, as they say, there isn’t a dry seat in the house. I force myself to try every dish on offer, all hearty local peasant foods and ensure I match the wines correctly. Only to be polite, naturally. More music from the merry men and a final fire-in-your- throat brandy and I and the rest of the gang are singing and dancing along with Mr Bean. No-one notices the treacherously winding road down to the river and the boat. Time for a well-earned siesta before dinner. I think I can take a lot more of this.

Dr Margot Cunich, MB,BS,FRACGP

Director, Unconventional Conventions

Airline policies for passengers with nut allergies flying from Melbourne Airport

Australian flights carry 90 million passengers each year.1 About 1–2% of passengers have documented food allergies, of whom 2–10% report having experienced allergic reactions during air travel.2,3

Peanut and tree nut allergies are among the most serious of food allergies, and typically persist for life.4 The cornerstone of managing a food allergy is strict avoidance of the allergen. Should anaphylaxis occur, an intramuscular adrenaline injection may be life-saving.

During June and July 2015, we conducted a telephone and website survey of all domestic and international airlines that fly from Melbourne Tullamarine Airport to assess public access to airline nut allergy policies, the availability of nut-free meals and the ability to restrict the distribution of packaged nuts, and the in-flight availability of emergency adrenaline.

Of 33 airlines, 20 (61%) had accessible telephone information about a nut allergy policy, and this information was published on the websites of 20 airlines (61%). Telephone and website advice was discordant for three airlines, in that the customer service representatives advised that all nut allergies could be accommodated, but the website indicated that this applied only to peanuts.

Nine airlines (27%) offered nut-free meals, two routinely and seven on request (Box). For the other airlines, nut-allergic passengers would need to fast (only practical on short domestic routes) or bring their own food.

Twelve airlines (36%) could restrict the distribution of packaged nuts if requested, either totally or within an exclusion zone comprising the affected passenger’s row and the rows immediately in front of and behind them (Box). Four airlines (12%) could both offer a nut-free meal and restrict the distribution of packaged nuts.

People consuming packaged nuts place nut-allergic neighbours at risk of physical contact with nuts and accidental ingestion. Requesting nearby passengers not to consume nuts and wiping tray tables may reduce this risk.2 It is unclear whether nut-allergic individuals are at risk from airborne nut proteins, but instances of allergic reaction following such exposure have been reported.5

Only one airline confirmed that emergency adrenaline was available on all flights.

The diverse approaches by airlines to nut allergies reflect the lack of clear evidence supporting any specific policy. Airlines could nevertheless improve the access to relevant information. Given the discordant advice provided in some instances, the critical distinction between peanuts and tree nuts should be emphasised during customer service training. Carrying emergency adrenaline on all flights would seem prudent in light of the reported frequency of food allergy reactions.

We contacted only airlines flying from a single Australian airport, so that our survey is a representative sample of the industry rather than an exhaustive investigation. Telephone information from each airline was based on a single call, and the advice we received was current at the time of our telephone enquiries or website visit; in the meantime, airlines may have updated their policies.

We recommend that nut-allergic individuals contact airlines before travelling, develop an allergy management plan with their doctors, carry their own emergency medical supplies, and consider bringing their own food. Airlines should make their nut allergy policies more accessible and consider carrying emergency adrenaline on all flights.

Box –
Airline policies on the availability of nut-free meals and restricting the distribution of packaged nuts in all cabins or within an exclusion zone

* No routine distribution of nuts. † Includes the affected passenger’s row and the rows immediately in front of and behind it.

News briefs

Fungus v Aedes aegypti: battle on

Scientists looking to combat the Zika virus are trying to “weaponise” a fungus called Metarhizium brunneum which has the happy knack of being able to eat mosquito larvae from the inside out, Wired reports. Research published in PLOS Pathogens has shown that the fungus spore sticks to the mosquito larva, then “eats its way through the exoskeleton and starts to grow, fast”. The larva itself helps the process by eating more spores, which work their way through its gut and into its body cavity. The fungus grows, destroying the larva from the inside. “The fungus actually attacks mosquitoes in two ways. One variety of the fungus spore, the conidium, is airborne — it attacks adult mosquitoes. The blastospore, though, does better underwater — that’s the one that attacks the larvae … [and] is so much more virulent than the conidium. Mosquitoes are now developing resistance to pesticides, but it’s harder to resist predators and parasites that are evolving right along with them. Metarhizium brunneum could be a crucial part of the arsenal [against Zika] — as long as it doesn’t spread so widely that it starts killing more than mosquitoes.”

Aussie heads WHO’s Health Emergencies program

Dr Peter Salama, a medical epidemiologist and a University of Melbourne and Harvard University alumnus, has been appointed as the Executive Director of the World Health Organization’s (WHO) new Health Emergencies Program. Dr Salama, 47, has spent the last 18 months as the United Nations Children’s Emergency Fund (UNICEF) Regional Director for Middle East and North Africa and Global Emergency Coordinator for the crises in Syria, Iraq and Yemen. Before that was UNICEF’s Country Representative in Ethiopia and Zimbabwe, as Global Coordinator for Ebola, and as Chief of Global Health. He previously worked at the Centers for Disease Control in the US and with Medecins Sans Frontieres. According to a statement from the WHO: “WHO’s new Health Emergencies Program is designed to deliver rapid, predictable and comprehensive support to countries and communities as they prepare for, face or recover from emergencies caused by any type of hazard to human health, whether disease outbreaks, natural or man-made disasters or conflicts. The development of the new Program is the result of a reform effort, based on recommendations from a range of independent and expert external reports, involving all levels of WHO — country offices, regional offices and headquarters.

The dead don’t rest

It’s 12 February, 2009. The time is 9pm at Newark Liberty International Airport. Dr Alison Des Forges is waiting to board a flight to take her back to her home in Buffalo, New York. Alison’s spent most of her work life in Rwanda, investigating killings, kidnappings and human rights transgressions. She was one of the loudest voices to be heard on the world stage in 1994, when she called for the recognition of what we now know as the Rwandan genocide.

She was named a MacArthur Fellow in 1999, as well as taking a senior position with Human Rights Watch. But the year isn’t 1994, and we’re not in Rwanda. It’s 2009, and she’s flying home to be with her family in the USA.

The plane has already been delayed by two hours, and the bleary eyed passengers are finally allowed to board the plane. They aren’t the only tired people on-board, however. First Officer Rebecca Shaw has made the commute from Seattle to Newark to co-pilot the flight, and complains to her pilot of feeling tired and unwell. Similarly, Captain Marvin Renslow complains of fatigue, due to a lack of rest over the preceding few days and abrupt changes to his sleep-wake cycle.

What follows is a series of errors that ultimately result in a fatal stall during the landing approach. The Captain responds incorrectly to the stall, as does his First Officer, and the errors are compounded. The plane ploughs into the house of Douglas and Karen Wielinski, and a total of 50 people perish that day, including Dr Des Forges.

To err is human, but we often don’t like facing this harsh reality. This is equally as true in medicine as it is in aviation.

Our workforce is by no means in balance, and it poses a headache for doctors and employers alike.

We’re awash with graduates, but hospitals struggle to fill gaps in rosters due primarily to a lack of workforce coordination. This leads to over-employment of current doctors, increasingly unsafe shifts, workplace dissatisfaction, absenteeism and resignations, all which continue to compound the initial problem.

Sound dramatic? Good. It should. We’re human and we’re not that special. You’d no sooner go to work with a blood alcohol level of 0.05 than you would eat your own face, but we know that after eighteen hours of continuous work, humans behave as if they’re too drunk to drive a car.

In the case of Eastman vs Namoi Cotton Co-Operative (2014), an employee was awarded $498,950 in compensation for a car crash where she drifted into oncoming traffic. The cause? Six 12-hour night shifts in a row with a two-day break. I can name at least five hospitals around Australia off the top of my head with similar rosters, and that’s without breaking an investigative sweat.

Around the time Dr Des Forges was being named a MacArthur Fellow, the AMA was adopting a National Code of Practice for Safe Working Hours.

The code was, and remains, a flexible and common sense guide to work hours. Rather than being a prescriptive and unmanageable set of rules, the code instead highlights patterns and situations which lead to unsafe working hours.

It outlines the responsibility of both the employee and the employer, recognising that fatigue management involves both parties. It’s tailored to the Australian medical workforce, and it has recently been renewed and updated by the AMA Federal Council.

In August, the Council of Doctors in Training will be conducting its five-yearly safe working hours audit, to see whether we as a country are getting better or worse at managing fatigue.

I’ve heard many emotive arguments for and against the importance of fatigue management.

I’ve heard people glorify the dark old days as a superior form of education. I’ve seen workforce units threaten doctors with future offers of employment as incentive for unsavoury rosters. I’ve seen doctors belittled by other doctors for their lack of ‘commitment’ to their vocation. But I’ve also seen a 66-year-old human rights activist, and fervent advocate for hundreds of thousands of slaughtered Rwandans, die partially as a consequence of poor fatigue management.

It is unconscionable to think that fatigue management isn’t core business for doctors, and a key element of good patient care. After all, if one person can fight for thousands of oppressed people, surely I can fight for the welfare of my patients.

Dengue fever in travellers: are we missing warning signs of severe dengue in a non-endemic setting?

Worldwide, there are an estimated 50–100 million cases of dengue virus infection each year. Far North Queensland has experienced dengue epidemics, with deaths reported in outbreaks in 2004 and 2008–2009.1

A 38-year-old man presented one day after returning from Colombo, Sri Lanka. He was a Sri Lankan-born Australian resident with no significant past medical history. He was admitted 10 days after the onset of a biphasic febrile illness: fever, chills, and generalised myalgia for 4 days, resolution of symptoms, then recurrence of symptoms on Day 7. On the day of admission, he developed diarrhoea and bloodstained vomiting. Dengue non-structural protein 1 (NS1) antigen was detected, and results of tests for dengue immunoglobulin (Ig) M and dengue IgG antibody were positive, suggesting secondary dengue virus infection. Persisting high fever, worsening thrombocytopenia (platelet count, < 50 × 10⁹/L; reference interval, 150–400 × 10⁹/L) and bloodstained vomitus led to a diagnosis of dengue fever (DF) with warning signs. The 2009 World Health Organization (WHO) guidelines for the management of dengue2 were followed (Box), with close monitoring of fluid status and haematocrit (HCT). On Day 4 of admission, the fever resolved, heralding the critical phase of DF. Haemoconcentration was noted, with HCT rising to 0.51 (> 20% above the baseline). Within 2 days of defervescence, a new pruritic rash was noted on the arms and legs that was characteristic of the convalescent phase of DF. There was slow resolution of the HCT, and intravenous fluid infusions were ceased. The patient was discharged 7 days after admission.

The revised 2009 WHO guidelines are based on validation studies from DF-endemic countries,3 and classify cases into DF, DF with warning signs and severe DF.2 In travellers, warning signs may also predict progression to severe dengue.4,5

Our patient’s case of DF with warning signs prompted a retrospective study of DF admissions at our institution. From 2012 to 2014, we identified 35 confirmed cases (median age of patients, 31 years). All cases were in returned travellers from dengue-endemic countries. Assessment for dengue severity was not well documented. No cases met the definition for severe DF and there were no deaths. Over 50% had warning signs for severe DF, including minor bleeding, abdominal pain and persistent vomiting. Warning signs were recognised in less than 30% of cases, and less than 10% of cases were managed according to WHO guidelines with strict fluid balance and HCT monitoring.

In conclusion, many returned travellers admitted with DF have warning signs, which predict the development of severe conditions with life-threatening endpoints, such as severe organ dysfunction and refractory shock. Hospitals in non-endemic areas should develop protocols for diagnosing and managing DF based on the WHO guidelines. Further research into the utility of warning signs in travellers with DF for predicting severe disease is needed.

Box –
Suggested dengue case classification and levels of severity

Reprinted from World Health Organization. Dengue: guidelines for diagnosis, treatment, prevention and control. New edition 2009. Geneva: WHO, 2009.

ALT = alanine aminotransferase. AST = aspartate aminotransferase. CNS = central nervous system. DSS = dengue shock syndrome. HCT = haematocrit.

Photobacterium damselae and Vibrio harveyi hand infection from marine exposure

Clinical record

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

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

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

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

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

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

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

Lessons from practice

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

Figure

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

MERS: worst may be past

The World Health Organisation has indicated that the Middle East Respiratory Syndrome (MERS) outbreak that has so far claimed 24 lives in South Korea may have passed its peak.

While warning that it was critical health authorities closely monitor the situation, the WHO’s Emergency Committee has nonetheless declared that South Korean efforts to track and quarantine infected people had “coincided with a decline in the incidence of cases”.

Since the first case was reported in South Korea last month, 166 people in the North Asian country are confirmed to have been infected with MERS, including 30 currently receiving treatment, while a further 5930 are in quarantine at home or in medical facilities.

Fears that the disease might spread further in the region were fuelled earlier this week when Thai officials reported a visiting businessman from Oman had fallen ill with the disease, and 59 people who had been in contact with have been placed in quarantine.

But the WHO praised South Korean health authorities for rapidly alerting their Chinese counterparts about an infected traveller, who was quickly located and isolated.

The World Health Organisation’s Emergency Committee, which met earlier this week to discuss the outbreak, said it was not yet serious enough to warrant the declaration of a public health emergency, and advised that travel restrictions and airport screening were not necessary.

Nonetheless, the Committee warned the outbreak was “a wake-up call” for governments about the speed with which serious infectious diseases could spread “in a highly mobile world”.

“All countries should always be prepared for the unanticipated possibility of outbreaks of this and other serious infectious diseases,” it said. “The situation highlights the need to strengthen collaboration between health and other key sectors, such as aviation, and to enhance communication processes.”

No cases have been reported in Australia, and a Federal Health Department spokeswoman said the risk of MERS arriving in Australia was considered to be low, at least for the time being.

But health and border protection authorities are on alert for the disease, and the Federal Government is planning to warn Australians travelling overseas, particularly to the Middle East as part of the Hajj pilgrimage, about MERS and what precautions they need to take to minimise the chances of infection.

Though Korean authorities have been praised for the strength of recent actions to control the spread of MERS, serious shortcomings in their initial response have been blamed for helping the outbreak gain momentum.

The WHO Emergency Committee detailed a number of factors that helped the disease spread, including ignorance of MERS among health workers and the broader public; “suboptimal” infection prevention and control measures in hospitals; keeping patients infected with MERS in crowded emergency departments and wards for extended periods; the behaviour of patients in going to several different doctors and hospitals for treatment; and the custom of family and friends staying with their infected loved ones in hospital.

“There are still many gaps in knowledge regarding the transmission of this virus between people, including the potential role of environmental contamination, poor ventilation and other factors,” the Committee said, though adding that there was no evidence of sustained transmission in the community.

Adrian Rollins

AMA in the News – 7 April 2015

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

E-health record scheme a $1b flop, Hobart Mercury, 27 February 2015
The botched Personally Controlled Electronic Health Record program has been operating for nearly three years but fewer than one in 10 Australians has one. AMA President A/Professor Brian Owler said the scheme remains in limbo, and to have spent that much money and yet still not have anything of widespread value was terrible.

Upfront payments for doctors, Australian Financial Review, 3 March 2015
Health Minister Sussan Ley could end Medicare’s universal “fee for service” approach and pay GPs a lump sum per patient, rather than for each visit. Ms Ley has been in constant contact with AMA President A/Professor Brian Owler about potential changes to Medicare.

Dumped policy to cost $1bn, The Australian, 4 March 2015
Tony Abbott has dumped the GP co-payment but maintained a freeze on Medicare payments to general practitioners. AMA President A/Professor Brian Owler warned the freeze would force bulk billing rates down and increase out-of-pocket expenses for private health insurance policyholders.

Medicare rebate freeze to stay, Australian Financial Review, 4 March 2015
The Federal Government will keep more than $1 billion by freezing indexation of Medicare rebates, but has dumped the GP co-payment. AMA President A/Professor Brian Owler welcomed the decision to axe the co-payment, but said keeping the Medicare rebate indexation freeze was lazy reform.

Ley rules out bulk billing means test, Australian Financial Review, 5 March 2015
Health Minister Sussan Ley has ruled out means testing bulk billing as fix in the search for savings to replace the dumped $5 GP co-payment. The Minister said the Government will persist with its search for policies that would impose a value signal on Medicare. AMA President A/Professor Brian Owler said he was happy to co-operate with Ms Ley but did not agree a price signal had a place in primary care.

Don’t be shy about health, MX Sydney, 5 March 2015
New research shows Australians are still choosing to suffer in silence, instead of talking about an awkward health problem. AMA Chair of General Practice Dr Brian Morton said self-treating basic conditions is fine, but alarm bells should ring if the conditions are recurring.

Co-payment could still happen as GP gap-fee option considered, The Age, 9 March 2015
Despite declaring its Medicare co-payment dead, the Government is considering proposals to give GPs the option of charging gap fees for bulk billed patients. AMA President A/Professor Brian Owler said the AMA had long supported such a change, which he said would benefit patients who are currently privately billed.

Why we can’t keep trusting celebrity diet books, Women’s Weekly, 10 March 2015
AMA Vice President Dr Stephen Parnis said we live in an era where people sometimes equate celebrity with expertise, which is not the case. At best, alternative health and diet advocates may advocate something which is supposed to be therapeutic, but actually has no effect. But, at worst, it can be dangerous, he warned.

‘Price signal’ would hit old, poor hardest, The Age, 19 March 2015
Patients who visit the doctor most often tend to be older and poorer than those who visit their GP less, and would be hardest to hit by the introduction of a price signal. AMA President A/Professor Brian Owler said the data undermined the arguments of some proponents of a Medicare co-payment.

Valley of the unwell, The Herald Sun, 19 March 2015
The Goulburn Valley has emerged as the sickest spot in Victoria, with more than one in six residents seeing a GP more than 12 times a year. AMA President A/Professor Brian Owler said the report showed people who most frequently visited their GP have complex and chronic conditions.

Make vaccination law, The Sunday Telegraph, 22 March 2015
The Sunday Telegraph has launched a national campaign for pregnant women to get free whooping cough boosters in the third trimester. AMA President A/Professor Brian Owler called on Federal Health Minister Sussan Ley to fund the boosters.

Call to name medical ‘bad apples’, Sydney Morning Herald, 24 March 2015
Medical specialists who charge exorbitant fees should be named and shamed in a bid to rein in excessive charging. AMA Vice President Dr Stephen Parnis said more doctors than ever were accepting fees set by private health insurers, and almost 90 per cent of privately insured medical services were delivered with no out-of-pocket cost to the patient.

Doctors to anti-vaxxers: you’re endangering kids, The News Daily, 24 March 2015
AMA Vice President Dr Stephen Parnis told The News Daily that anti-vaccination groups don’t know better than the weight of evidence from the medical and scientific profession.

Misogyny in medicine: don’t put up with it, The Age, 25 March 2015
AMA President A/Professor Brian Owler said he was proud of Australia’s medical profession and added it was challenging to hear assertions that doctors were acting in unacceptable ways, particularly when it came to sexual harassment.

Radio

A/Professor Brian Owler, 666 ABC Canberra, 18 February 2015
AMA President A/Professor Brian Owler talked about the proposed $5 cut to Medicare rebates and the prospect of a $5 co-payment for GP visits still on the table. A/Professor Owler said the idea floated by the Federal Government had not been raised with him.

Dr Stephen Parnis, Radio Adelaide, 23 February 2015
AMA Vice President Dr Stephen Parnis said he was concerned about the Trans-Pacific Partnership trade agreement and what it could mean for affordable health care, with fears it could raise the cost of drugs and limit access to biological agents used in treatments.

A/Professor Brian Owler, 666 ABC Canberra, 3 March 2015
AMA President A/Professor Brian Owler discussed the Federal Government’s decision to abandon the GP co-payment. A/Professor Owler said it was a good result for GPs and their patients because the policy was poorly designed.

A/Professor Brian Owler, Radio National, 3 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government dumping the Medicare co-payment. A/Professor Owler said the AMA would not support a mandatory price signal, but did not see it as unreasonable for patients who can afford it to make a modest contribution to the cost of their care.

A/Professor Brian Owler, 4BC Brisbane, 31 March 2015
AMA President A/Professor Brian Owler talked about the Federal Government changing aviation rules to require two people in a cockpit at all times. The AMA is not sold on the idea of doctors who treat pilots being able to break doctor-patient confidentiality if they think a pilot is unfit to fly.

Television

A/Professor Brian Owler, ABC News 24, 3 March 2015
AMA President A/Professor Brian Owler talked about the Government dumping the GP co-payment. A/Professor Owler said the tragedy of this whole negotiation period was that other pressing health issues had been neglected.

A/Professor Brian Owler, Sky News, 3 March 2015
AMA President A/Professor Brian Owler discussed the dumped Medicare co-payment and the Medical Research Future Fund.

A/Professor Brian Owler, Channel 9, 17 March 2015
AMA President A/Professor Brian Owler discussed suggestions that teenagers should undergo a psychological assessment before any cosmetic surgery. A/Professor Owler said cosmetic surgery was the source of a number of patient complaints.

Germanwings tragedy prompts mandatory reporting calls

The AMA has warned that calls for the mandatory disclosure of information around the mental health of airline flight crew could dissuade troubled pilots from seeking necessary treatment.

There have been proposals to require treating doctors to report airline pilots and flight engineers who have mental health problems following the deliberate downing of a Germanwings airliner carrying 150 passengers and crew in the French Alps late last month.

Investigators have concluded that 27-year-old co-pilot Andreas Lubitz deliberately flew the Airbus A320 plane into the side of a mountain on 25 March after locking the plane’s captain out of the cockpit. All on board were killed.

It has been reported that Mr Lubitz suffered bouts of depression, was concerned about his eyesight, and had received treatment for suicidal tendencies before obtaining his pilot’s license.

Last week Germanwings’ parent company Lufthansa revealed that Mr Lubtiz had notified the company of his struggle with depression during his pilot training course in 2009.

The case has prompted some to call for laws requiring medical practitioners to report pilots being treated for mental illness to aviation authorities.

But the AMA and other medical experts have questioned the necessity or usefulness of such a measure.

Australasian Society of Aerospace Medicine President Dr Ian Cheng told Medical Observer Designated Aviation Medical Examiners who gave pilots their compulsory annual health checks were already legally obliged to report any significant health condition.

Dr Cheng said that before Australian aviation authorities decided several years ago to allow pilots to continue flying after a depression diagnosis, as long as they were receiving treatment and met strict conditions, the problem had been driven underground because pilots with depression were afraid of losing their license.

AMA Vice President Dr Stephen Parnis warned against any rush to institute mandatory reporting obligations for airline pilots receiving medical treatment.

“Doctors may disclose information about a patient’s medical record if they judge there is a serious threat to the life, health or safety of an individual or the public,” Dr Parnis told Medical Observer. “The last thing we want is a shopping list of things requiring mandatory reporting. That would undermine the confidence of the patient in the doctor.”

The AMA Vice President said mandatory reporting rules for medical practitioners had been blamed for deterring some doctors from seeking help, and there could be a similar risk with such rules for pilots.

Revelations that Mr Lubitz had notified Lufthansa about his battles with depression is likely to intensify the focus on how to best monitor and manage pilots with mental health issues.

Adrian Rollins