On Christmas Day 2014, I started a 6-week placement at the Australian-flagged Ebola Treatment Centre, managed by Aspen Medical, in Freetown, Sierra Leone. I joined about 30 doctors, nurses, environmental health officers, and management and support staff from across Australia and New Zealand, working alongside 120 Sierra Leoneans.
A societal disaster
The West African Ebola virus disease (EVD) outbreak is a medical and societal disaster. Most patients die, leaving devastated families and communities. EVD spreads by interpersonal contact, so the community prevention message is “Avoid Body Contact” — ABC. However, body contact makes us human, and the ABC protocol is freakish in all cultures. Dramatic community-wide behaviour change is needed to control an EVD outbreak.
The EVD outbreak is occurring in West African countries already devastated by ecological, economic and governance crises. Access to food is limited; many people require food aid. Schools have closed, and a generation may never reach their potential. Health care services have collapsed — deaths from malaria, tuberculosis, HIV and diarrhoea will far exceed deaths from EVD.1
Challenges in the Ebola Treatment Centre
Outbreaks of EVD are brutal. The Ebola Treatment Centre assists in controlling the outbreak by isolating patients with EVD infection. A razor wire fence surrounds the treatment centre. Incinerators spew smoke as contaminated clothes, bedding, food and personal belongings are burnt. Controlled access to the treatment centre, and its white, green and red zones, prevents spread of the disease within the centre.
Survivors of Ebola virus disease leave their mark on this special wall at the Freetown Ebola Treatment Centre as they return home free of the disease. Image courtesy of Aspen Medical
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Clean gloves are part of the personal protective equipment (PPE) used every time anyone enters the red zone of an Ebola Treatment Centre. For tasks that do not require dexterity, thick gloves are used. All PPE is carefully removed on exiting the red zone, and the gloves are washed in chlorine and dried in the sun for reuse. Image courtesy of Aspen Medical.
Inside the Ebola Treatment Centre, personal protective equipment (PPE) is conspicuous. This equipment is required for entry to the red zone and is donned under supervision. Scrubs, boots, overalls, double gloves, an apron, an N95 mask, a hood and goggles must cover the entire body. The PPE soon becomes hot and goggles fog up, so time in the red zone is limited to 60 minutes. Patient care is restricted by these time limitations and by the PPE itself, which impairs communication and makes the stethoscope useless. Frequent chlorine spraying damages the available medical equipment.
Personal reflections
Despite the Ebola Treatment Centre’s restrictions and the lack of specific treatment for EVD, the work was satisfying. We offered symptom relief, particularly fluids and opiates, along with compassion, counselling and support. We witnessed life and death and celebrated each EVD survivor. The placement gave me insights into how health determinants can be so cruel, yet individuals so inspiring.
Refugee and asylum seeker health is important in the setting of increasing global forced migration, and the particular physical and mental health issues faced by these groups. The Royal Australasian College of Physicians (RACP) has identified refugee and asylum seeker health as a policy priority, recognising large refugee-background populations in Australia and New Zealand, increased asylum seeker boat arrivals to Australia during 2009–2013, the duration and impact of Australian immigration detention, and complex and changing Australian asylum policy. Key demographics of refugees and asylum seekers are shown in Box 1.
The previous RACP policy (2007) focused on refugee children, whereas the 2015 position statement extends the RACP position across the lifespan and includes both refugees and asylum seekers. The position statement has been developed with extensive consultation across health disciplines (Box 2), with the intention of changing the discourse on refugees and asylum seekers, providing an evidence-based summary of relevant health issues, and highlighting the health impact of refugee and asylum policy. The position statement and accompanying policy summary of evidence are available at https://members.racp.edu.au/page/asylum-seekers.
Main recommendations
The position statement considers four key areas: health assessments, access to health care, promoting long-term health in the community, and asylum seekers in held detention. Each section summarises issues of concern, outlines the actions of the RACP, and provides recommendations for different levels of government and local service providers.
Health assessments
This section addresses post-arrival screening, transfer of health screening information, and age assessments for refugee and asylum seeker children and young people. The RACP suggests that all refugees and asylum seekers should be offered a voluntary comprehensive assessment of their physical and mental health on arrival. The RACP reiterates serious concern over the lack of transparency in Australian immigration detention health screening and the risks associated with rapid health screening processes used before transfer to offshore detention. The RACP proposes that unaccompanied children and young people undergoing age assessment should have an independent advocate present during the assessment.
Access to health care
Refugees and asylum seekers face considerable barriers to accessing health, mental health, immunisation, dental and maternity services after arrival, compounded by varied entitlements and supports. For asylum seekers in Australia, a lack of, or lapse in, Medicare eligibility affects their health service access and is likely to increase overall costs to the health, immigration and service systems. The RACP supports equitable access to health care for refugees and asylum seekers, using targeted strategies and casework support and emphasising the importance of language service support for all health care episodes.
Promoting long-term health in the community
The RACP acknowledges the economic, social and civic contribution of refugee-background communities. Available evidence suggests they do not represent a greater cost to, or burden on, health systems over the long term. The RACP endorses early support for new arrivals, with flexible casework and settlement services that are needs-based and not restricted by age, visa status or time or mode of arrival. The RACP argues for equitable access to education, English language support, and opportunities to work and train for meaningful employment, to promote long-term health. Restricting work rights for asylum seekers (as occurred for most asylum seekers in Australia throughout 2012 to early 2015) is contrary to maintaining health and is likely to increase overall costs due to extreme social disadvantage.
Assessment of asylum seeker claims for refugee status was suspended in late 2012, creating profound uncertainty, with consequent impact on health. There is an urgent need to recommence processing asylum seekers’ refugee claims, to allow people to move forward with their lives. The RACP supports pathways to permanent protection and does not support the use of temporary protection visas (TPVs), based on evidence that TPVs are associated with worse physical and mental health outcomes.
Asylum seekers in held detention
Australia uses mandatory immigration detention for asylum seekers arriving by boat, and indefinite immigration detention is possible under Australian law. New Zealand legislation also allows for mandatory detention of asylum seekers if they are part of a “mass arrival” by boat. However, New Zealand has not had asylum seeker boat arrivals and, in practice, immigration detention is an open arrangement at the Mangere Refugee Resettlement Centre.
Australian held (locked) detention is harmful to the physical and mental health of people of all ages in the short and long term. These findings are consistent across available research, parliamentary inquiries and the 2014 Australian Human Rights Commission (AHRC) report on detained children. In addition to the human costs, the financial costs of detention are enormous, estimated at $3.3 billion over the 2013–14 financial year.
Immigration detention facilities are prison-like, institutional and monotonous environments. The combination of the environment, uncertainty, lack of meaningful activity, erosion of family life and interrupted schooling contributes to high rates of mental health problems, self-harm and attempted suicide in children and adults. Since September 2014, the average duration of detention has been around 400 days; many people have been detained for over 18 months. The risks of held detention are amplified in offshore detention facilities because of infrastructure challenges, limited access to specialist health services, ongoing risk of destabilisation and uncertainty around the future and settlement options.
Held detention presents an extreme and unacceptable risk to children’s development and mental health, especially for unaccompanied children. Children in held detention cannot be protected from physical violence and mental distress in the adults around them, and are likely to be at risk of physical abuse, sexual abuse, maltreatment and neglect. Significant concerns were raised by the AHRC report and the Moss Inquiry into child protection issues on Nauru. Despite these risks, there is no clear or consistent child protection framework in Australian immigration detention.
The RACP does not condone held detention in any form and considers held detention to be a significant breach of human rights. The RACP expresses extreme concern over the use of offshore detention and does not support asylum seekers being transferred to, detained in or resettled in regional processing countries. The RACP also expresses extreme concern that unaccompanied children in detention are under the guardianship of the Minister for Immigration and Border Protection, who is paradoxically responsible for both acting in the children’s best interests and for placing them in held detention.
The RACP acknowledges the ethical issues of providing health care in detention and the tension in defining a standard of care. Health care providers cannot address health problems caused by held detention while people are still detained. The RACP calls for an independent cross-disciplinary health advisory body to oversee health service provision for asylum seekers.
The RACP supports all doctors and health professionals in their duty of care to their patients, including the need to maintain professional standards and to speak out in support of ethical care. The RACP will continue to advocate for best practice and urges a rights-based and humane approach to people seeking asylum.
1
Key demographics of refugees and asylum seekers
Global context (2013)
51.2 million forcibly displaced people
16.7 million refugees, 86% hosted in nearby or developing countries
More than 1 million asylum applications — 100 000 in Germany, 50 000–80 000 in each of the United States, South Africa, France, Sweden and Malaysia
Australia
Over 800 000 refugee arrivals since 1945
13 750 Humanitarian Programme visas annually, due to increase to 18 750 by 2018–19
51 637 asylum seeker boat arrivals during 2009–2013
As of March 2015, there were:
27 216 asylum seekers on bridging visas in the community
2512 asylum seekers in community detention
1848 asylum seekers in held (locked) detention on Christmas Island and the mainland
1707 asylum seekers in held (locked) detention on Nauru or Manus Island
New Zealand
Over 40 000 refugee arrivals since 1976
750 “quota refugees” annually, including up to 300 places for family reunion
300 Refugee Family Support Category entrants annually
About 300 asylum seekers arriving by plane annually; no asylum seeker boat arrivals
2
External consultations in developing the position statement
The Royal Australasian College of Physicians (RACP) is grateful to the following organisations for their review and suggestions, and regards this support for the RACP position as a significant achievement.
Andrew & Renata Kaldor Centre for International Refugee Law
Australian Association of Social Workers
Australasian Society for Infectious Diseases
Australian Medical Students’ Association
Australian Psychological Society
College of Nurses Aotearoa (NZ)
Forum of Australian Services for Survivors of Torture and Trauma
Melbourne Children’s Campus
New Zealand College of Midwives
New Zealand College of Public Health Medicine
New Zealand Medical Association
Public Health Association of Australia
Royal Australian and New Zealand College of Psychiatrists
Royal Australian College of General Practitioners
Royal New Zealand College of General Practitioners
Professor Priscilla Kincaid-Smith, former acting editor of the Medical Journal of Australia, and a trailblazer for Australian female scientists, has died at her Melbourne home from complications following a stroke, the ABC reports. She was 88. Professor Kincaid-Smith was a world-renowned nephrologist, discovering the link between overuse of headache powders and kidney disease. She was the first female professor at the University of Melbourne in 1975, first female chair of the Royal Australian College of Physicians, first female chair of the Australian Medical Association and the first female — and first Australian — chair of the World Medical Association. She was acting editor of the MJA in 1995. A full obituary will be published in a forthcoming issue of the MJA.
Social media use linked to teens’ mental health
A new Canadian study has found that teenagers who use social media sites for two hours or more each day are significantly more likely to suffer from poor mental health, psychological distress and suicidal thoughts, the Huffington Post reports. “It could be that teens with mental health problems are seeking out interactions as they are feeling isolated and alone,” Dr Hugues Sampasa-Kanyinga, the lead author of the Ottawa Public Health study, wrote. “Or they would like to satisfy unmet needs for face-to-face mental health support.” The solution, he suggested, was not to get teens off social media. “Since teens are on the sites, it is the perfect place for public health and service providers to reach out and connect with this vulnerable population and provide health promotion systems and supports.”
Nominations open for 2015 ACHS Medal
Nominations for the Australian Council on Healthcare Standards 2015 ACHS Medal are now open. The award recognises outstanding achievement in the advancement of quality and safety in health care in Australia. “The ACHS Medal provides an opportunity to further promote the work of an individual who has made a strong contribution in their particular field in health, by highlighting the improvements being made in safety and quality,” ACHS Chief Executive Officer, Dr Christine Dennis, said. Recent recipients of the medal include Kae Martin (2014); Adjunct Professor Christopher Brook PSM (2013); and Professor Robert “Bob” Gibberd (2012). The closing date for nominations is 5pm, Friday 25 September, and the nomination form can be found at www.achs.org.au/ACHSMedal
Top Canadian pathologist steps down
Retraction Watch reports that prominent pathologist Dr Sylvia Asa has resigned from running the largest hospital diagnostic laboratory in Canada because of an investigation that uncovered evidence of falsified data in two papers. Dr Asa was the program medical director of the Laboratory Medicine Program at the University Health Network, affiliated with the University of Toronto. Two papers coauthored by Dr Asa have been retracted by the American Journal of Pathology. “Following correspondence in September 2012 from a concerned reader … [an investigative committee] informed the Editors in April 2015 that the articles in question contain falsified data”, the AJP editors said. Problems included “manipulated and/or fabricated data”.
Transgender women show “shocking” HIV rates
A World Health Organisation report shows that a transgender woman was 49 times more likely to be living with HIV [than the general population] in 15 countries in which data was analysed, NPR reports. Transgender people are not receiving adequate health care, and widespread discrimination is largely to blame, according to the WHO paper. Among sex workers, transgender women are nine times more likely to have HIV than their non-transgender counterparts. “What is driving the epidemic is really the refusal of governments to pass legislation that allows [transgendered people] to function in society, and allows them to participate in the workplace”, JoAnne Keatley, a coauthor of the WHO report, said. “Trans people struggle in order to obtain identity documents that allow them to participate in the workforce. Many trans people are not able to obtain health coverage.”
The nation’s top medical officer has issued an urgent call for people, particularly vulnerable groups including pregnant women, the elderly and those with chronic illnesses, to get vaccinated against the flu amid signs the nation is headed for its worst season on record.
Official figures show that so far this year more than 14,124 have caught the flu – double the long-term average for the period – and a third higher than for the same time last year.
In a worrying sign that the flu season is gathering momentum, figures compiled through the National Notifiable Diseases Surveillance System show that in in just one month, from 5 June to 6 July, an extra 4911 laboratory-confirmed cases were reported, including almost 2000 in the first week of July.
Underlining the seriousness of the illness, the Health Department said it had so far been notified of 36 deaths associated with influenza since the beginning of the year, with the likelihood that number will rise sharply as the rate of infection accelerates.
Commonwealth Chief Medical Officer Professor Chris Baggoley specifically urged people considered to be at risk, including those aged 65 years and older, Indigenous Australians, pregnant women, and those with cardiac disease and chronic respiratory conditions and illnesses, to take advantage of the free vaccine provided by the Government.
“Flu is highly contagious and spreads easily from person to person, through the air, and on the hands,” Professor Baggoley said. “We need to get higher uptake [of the vaccine] among these groups.”
The Chief Medical Officer emphasised the importance of doctors and other health professionals in helping ensure people were vaccinated against the disease.
“Immunisation is still the best form of protection from influenza, and health care professionals play an essential role in ensuring high uptake,” he said.
The National Seasonal Influenza Immunisation Program began late this year because of a rare double strain change in the vaccine to cover two new strains of the virus – one of which caused havoc in the northern hemisphere.
In the US alone, around 100 children were reported to have died from the flu during the northern flu season, and there was also widespread illness among the elderly.
For the first time under the national immunisation program, Australians have access to single-dose vaccines covering the four most common flu viruses, including three quadrivalent formulations.
The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.
There have been claims that the delay to the vaccination program has contributed to the strong start to the flu season by leaving a large number of people unprotected, and Professor Robert Booy of the Influenza Specialist Group told the Herald Sun fewer people had been vaccinated that “we would have liked”.
But Health Minister Sussan Ley said the Government was ahead of where it was last year in acquiring vaccine doses.
Ms Ley said that so far in 2015 4.5 million doses had been bought under the National Immunisation Program, 200,000 more than were distributed in 2014.
She did not say how many of these doses had been administered.
Ms Ley said the flu season usually peaked in August and September which, given that it usually takes around three weeks following vaccination to develop immunity, meant people needed to get themselves vaccinated as soon as possible.
Promisingly, early figures suggest vaccinations are helping to reduce the number and severity of infections.
The pilot Flu Tracking surveillance system, a joint University of Newcastle, Hunter New England Area Health Service and Hunter Medical Research initiative that collects data from a weekly online survey, has so far identified only low levels of influenza infection.
But it found that 3.4 per cent of those not vaccinated against the flu suffered fevers and coughs, and 2.1 per cent had to take time off work, while among those vaccinated, 2.7 per cent had coughs and fevers and 1.6 per cent reported having to take sick leave.
The results underline calls from AMA Vice President Dr Stephen Parnis for people, particularly elderly and vulnerable patients and health professionals, to make sure they are vaccinated against the flu.
Dr Parnis said it was important for doctors, nurses and other health workers to get the flu vaccine, for the sake of their own health as well as that of their patients.
By 2050, drug resistant diseases could be killing more people than cancer, an extra 10m deaths per year. They could also cause a loss to the global output of US$100 trillion dollars – equivalent to a sum greater than the size of the current global economy.
A potential future catastrophe in healthcare, where even routine surgical procedures and easily treated infections become significantly more hazardous, is commonly attributed to the appearance of new strains of antibiotic-resistant bacteria. It is often argued that the answer is more funding for the development of new antibiotics.
What is less commonly recognised is the possibility of a future catastrophe in food production. Modern practice means the extensive use of antibiotics in the farming of fish, poultry and meat. In the US, 70% of all antibiotics enter the food chain.
An arms race against natural selection
Antibiotics are effective against bacteria, just one class of microbe, while the term antimicrobial resistance (AMR) covers the development of resistance in a wider group of bacteria, fungi, viruses and protozoa (such as malaria) to the various measures used to combat them.
The development of new antimicrobial drugs is an arms race against natural selection that cannot be won: when antimicrobials (not just antibiotics) are applied, microbes of all types (not just bacteria) have proven to be adept at developing resistant strains from the survivors. If the drug kills 99.99% of a population of microbes, it is the genetic makeup of the survivors that goes forward to the next generation. To mitigate against potential catastrophes in healthcare and food production, measures over and above the development of new antibiotics have to be undertaken.
These include two key elements. One is infection prevention. If a dangerous microbe never enters the body, no antimicrobial is required. The development of new microbe-resistant materials and products, as well as the development of minimally invasive procedures in hospitals and clinics, improvements in waste disposal and a revolution in cleaning, are some of the measures already being researched.
However, this does not just involve scientists and clinicians. To take just one example, despite all efforts, many in the UK and the US persist in washing their hands lamentably short of the 20 seconds in warm soapy water that experts recommend. We need better leadership to rectify this by implementing advice from those who understand behaviours in workplaces and homes, and we need to invest in science and engineering that makes proper handwashing easy for the public to adopt.
The second element to reducing the use of antimicrobials is the removal of environments that encourage resistant strains to develop, for example in the body of the patient or farm animal, with simple measures such as ensuring a full prescription is taken rather than stopping early when symptoms disappear – a practice that encourages the survival of resistant microbes. Other measures include the invention of sensors to detect infection early and identify the specific microbe present, so that targeted antimicrobials can be used in place of broad-spectrum agents, one example of responsible antimicrobial stewardship.
We must understand how society, climate, land and water resources interact to alter the risk of microbes moving from one host to another. It is a realistic scenario that a resistant strain in a UK hospital might have emerged because of livestock practices half way across the world, where increased flooding, cultural practices, conflict, the movement of money and populations, and the accepted patterns of behaviour, create an environment very different to our own. Conversely, we could find that resistant strains in far-off countries might have their roots in the use of antibiotics in intensive farming in the UK.
The way to do it
The figure below illustrates how the problem extends geographically, and across the workforce and society. The patient in the hospital bed has a reduced risk of infection if the surgeons use a minimally invasive procedure illuminated with lights that deter microbes, and if the surgical instruments, the trays, the rooms, and the tubes that enter the patient (the catheters, nasal drips, endoscopes and so on) are made of materials on which microbes do not readily adhere, and are properly and promptly cleaned (weekend closure of sterile services departments might appear to save costs in the short term but must avoid allowing Friday’s contamination to dry on before washing on Monday).
The anti-resistance movement. University of Southampton., Author provided
For the patient shown in the figure, wounds can be cleaned and dressed with materials that deter microbes. If infection does occur, it can be promptly targeted with a specific (as opposed to broadspectrum) antimicrobial if it is detected early and rapidly identified (with instruments that feed into a communications hub that alerts the doctor’s phone, which is already becoming equipped with apps containing guidance informed by local susceptibility data).
Treatment of the waste from this patient (solid, fluids and materials contaminated with them) alters the possibility of AMR spreading. Achieving the right hospital environment requires far more than the development of new drugs, and their use by healthcare workers. It goes into the management and maintenance of the hospital, and in to the practices of the people who implement these. New technologies and practices must be designed to ensure that their use will be adopted, which requires understanding design and understanding people.
Indeed, the world outside of the hospital (in the lower half of the figure above) provides an enormous reservoir in which AMR can develop. Analysis and, if necessary, change of our processes and technologies are required in water and waste treatment, and in the production, transport, packaging and retail practices in the food industry.
In many parts of the world, climate change and flooding, war, corruption, politics, received wisdom, traditions and religious practices, and the supply of fuel and money, play a far greater role in food, water, waste treatment, healthcare and the transport of microbes from one host to another, than do the outputs of the drug companies.
The twin potential catastrophes are global, and so are the causes. The solutions lie with scientists and engineers to develop new technologies and embed new practices in the public and workforce; they lie with farmers, plumbers, office workers, water and sewage workers, medical practitioners, food retailers, innovators in business … indeed most of us. And they lie with those who are responsible for shaping behaviour across the world – not just the pharmaceutical companies.
Researchers have warned of the risk of measles outbreaks among infants, adolescents and young adults because of gaps in the nation’s immunisation coverage against the potentially deadly disease.
While the World Health Organisation has declared Australia measles-free, infectious disease experts have cautioned parents and health authorities that they need to remain vigilant about maintaining high rates of vaccination because of the vulnerability of young people no longer exposed to wild versions of the infection.
A study in the Health Department’s latest Communicable Diseases Intelligence report found the incidence of measles plummeted following the commencement of mass vaccination programs in the 1980s and 1990s, and was now at a level “consistent with elimination of indigenous measles in the country”.
Since the last big outbreak in the early 1990s, when almost 10,000 people caught the disease and four died, the rate of infection has plunged. Between 2000 and 2011, 990 cases were notified but none were fatal.
However, although the disease is no longer considered to be endemic, it is still being brought into the country by people travelling from regions where it is common, raising the risk of infection for vulnerable groups, particularly the very young.
Children are not eligible for their first measles vaccine until they are 12 months, and national figures for 2000 to 2011 show the incidence of the disease was highest in this age group, reaching a peak of 3.8 per 100,000 in 2011.
Next most vulnerable were children aged between one and four years, followed by adolescents aged 10 to 19 years and young adults aged 20 to 34 years.
The authors of the study, who were from the Health Department, the National Centre for Immunisation Research and Surveillance and the Australian National University, speculated that infants could be particularly vulnerable because of a decline in maternal antibodies in women with vaccine-acquired immunity.
“It has been postulated that because measles is becoming rare, the lack of natural boosting thorough exposure to wild virus in both vaccinated women and women with past infection has consequently resulted in infants becoming more susceptible,” they wrote. “It is therefore important…that timely vaccine uptake among infants occurs at the recommended 12 months of age.”
They also highlighted gaps in coverage caused by the staggered introduction of mass vaccination programs in the 1980s and 1990s.
In particular, they noted that those born between 1968 and 1982 were “particularly susceptible as low vaccine coverage existed when they were infants and circulation of wild virus was becoming less common”. In addition, people in this age group missed out on a second round of vaccinations for adolescents carried out between 1994 and 1998, while a 2001 immunisation campaign aimed at reaching many of them had only limited success.
The researchers said there was a risk of under- or un-vaccinated young adults catching the disease while travelling overseas, and urged greater efforts to assess their immunity before they left the country.
“As most outbreak in Australia begin with an importation of measles from an endemic country, it is essential that measles immunity status be assessed when patients attend clinics to receive vaccinations for international travel,” they said, citing research showing that just 4 per cent of travellers who attended hospital within two years of returning from abroad were vaccinated against measles, mumps and rubella.
“Clearly, age-specific vulnerability of populations exist[s], even though measles is so rare in Australia and, consequently, this may lead to outbreaks in these populations,” the authors said. “Hence, there is an ongoing need to improve vaccine uptake in vulnerable populations.”
Rubella has been all-but eliminated and the country may be close to getting rid of mumps amid evidence of an increase in vaccination rates.
Research published by the Commonwealth Health Department in its latest Communicable Diseases Intelligence report suggests that rubella, a mild infection in adults that can nonetheless cause severe congenital abnormalities in unborn babies, is no longer endemic, while the country is close to eliminating mumps despite a recent upsurge in notifications of the disease.
Four years after the Americas were declared rubella-free, researchers from the National Centre for Immunisation Research and Surveillance said it was now so rare in Australia – aside from cases involving infections imported from overseas – that arguably the country met all the criteria for the World Health Organisation to declare it eliminated.
To be declared rubella-free, a country or region must have a low incidence of infection, with only sporadic imported cases with limited spread, high levels of immunity and a robust immunisation program.
Between the mid-1990s and 2005 the average annual notification rate for the disease tumbled from 14.8 per 100,000 to 0.23 per 100,000 by 2005, and there have been just two reported cases of congenital rubella syndrome since 2008. The proportion of imported rubella cases, meanwhile, climbed from 9 to 27 per cent between 2005 and 2012, and the immunisation rate has held above 91 per cent.
The researchers said it only remained to improve surveillance, including genotyping infections to establish their origin, to demonstrate the absence of endemic strains and have Australia declared rubella-free.
Researchers have also held out hope that mumps may soon be eliminated from Australia, if it is not already.
Mumps became a notifiable disease in 2001, and its incidence peaked at 2.8 per 100,000 in 2007 before slipping below 1 per 100,000 by 2012.
As with other countries, there has been an increase in the average age of people with mumps following the introduction of universal child vaccination in 1989. Between 2008 and 2012, it was much more common among 25 to 34-year-olds (1.7 cases per 100,000) than among young children. Those aged one to four years had the lowest incidence, just 0.5 per 100,000.
But researchers admitted that, despite high vaccination coverage against mumps (94 per cent for the first dose of the measles, mumps, rubella vaccine and 90 per cent for the second dose), there was an increasing trend in mumps notifications and the likelihood its incidence was being under-reported.
Nevertheless, that said it was possible that Australia was among those countries to have achieved, or come close to, eliminating the disease, adding that, “sporadic outbreaks in highly vaccinated populations may be due to the force of infection after virus introduction from an endemic area into high-density, high contact environments”.
They concluded that the trend toward increased notifications required careful monitoring.
The possibility that rubella and mumps may soon be eliminated, if they are not already, has come amid evidence that the nation’s vaccination rate is increasing.
The Federal Government has mounted a crackdown on parents who refuse or fail to ensure their children are vaccinated, threatening to withhold benefits worth thousands of dollars from families and abolishing all but medical exemptions.
But even before these latest measures were announced, figures from the Australian Childhood Immunisation Register show vaccination rates were rising in mid-2014, reaching 91.5 per cent of one-year-olds (up 0.6 of a percentage point), 92.8 per cent of two-year-olds (up 0.2 of a percentage point) and 92.2 per cent of five-year-olds (up 0.3 of a percentage point).
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.
Parts of Australia are on track for their worst flu seasons in years, with infection rates in the north and south of the country already far ahead of last year.
So far this year, 9213 laboratory-confirmed cases of the disease have been notified to health authorities, compared with 6225 cases at the same point last year.
Queensland (2757 confirmed cases) and South Australia (1742 cases) have, proportionately, been the hardest hit, while the rate of infections in both New South Wales and Victoria have so far been relatively low.
But the slow start to the flue season in the two most populace states is little cause for complacency.
The Influenza Specialist Group warned that the flu season had not yet begun in earnest, and was likely to develop in the next four weeks.
Evidence from last year suggests there is every reason to be concerned.
While there were less than laboratory-confirmed cases by the end of May 2014, that number quickly accelerated as flu season hit, and by year’s end there were 67,854 confirmed cases nationwide, almost double the long-term average of 34,523.
Promisingly, early figures suggest vaccinations are helping to reduce the number and severity of infections.
The pilot Flu Tracking surveillance system, a joint University of Newcastle, Hunter New England Area Health Service and Hunter Medical Research initiative that collects data from a weekly online survey, has so far identified only low levels of influenza infection.
But it found that 3.4 per cent of those not vaccinated against the flu suffered fevers and coughs, and 2.1 per cent had to take time off work, while among those vaccinated, 2.7 per cent had coughs and fevers and 1.6 per cent reported having to take sick leave.
The results underline calls from AMA Vice President Dr Stephen Parnis for people, particularly elderly and vulnerable patients and health professionals, to make sure they are vaccinated against the flu.
Dr Parnis said it was important for doctors, nurses and other health workers to get the flu vaccine, for the sake of their own health as well as that of their patients.
The National Seasonal Influenza Immunisation Program started late this year, the delay caused by a rush to include vaccines covering two new strains of the virus one of which caused havoc in the northern hemisphere.
In the US alone, around 100 children were reported to have died from the flu during the northern flu season, and there was also widespread illness among the elderly.
For the first time under the national immunisation program, Australians have access to single-dose vaccines covering the four most common flu viruses, including three quadrivalent formulations.
The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.
But Chief Medical Officer Professor Chris Baggoley has been forced to issue an urgent warning to health professionals after it was revealed that at least nine young children had been injected with the Fluvax vaccine despite explicit directions from the Government and the manufacturer that it was potentially dangerous to use on those younger than five years.
The ban has been in place since several young children given Fluvax in 2012 suffered fevers and febrile convulsions, and part of the reason for the delay in starting this year’s flu immunisation program was to ensure that suitable vaccines were available for the very young.
The forgotten children, the Australian Human Rights Commission’s 2014 national inquiry into children in immigration detention, has come and gone. Its findings are clear and damning and should be a surprise to no one.1
A decade earlier, the Human Rights and Equal Opportunity Commission released its national inquiry, A last resort?.2 It is unacceptable that we might wait another 10 years before such gross abuses cease and people are restored to both health and justice.
Further, the United Nations has named Australia for its breach of the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.3 The medical community has been made aware of our ongoing human rights violations over the past decade.1,4–7 Ignorance is not an excuse that we can cling to for being part of this national embarrassment.
What more could be done to make us pay attention to the need to move beyond the multiple peak body position statements? They are only useful in as much as they highlight the chasm between acceptable standards of medical care and what we know is being practised in immigration detention.1,4–7
One option to increase genuine accountability would be to ratify the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The OPCAT is a bipartisan-supported UN protocol signed by Australia in 2009. It is as yet unratified.6,8–10 At the time of publication, the OPCAT has been ratified by 78 countries (Box). It was established recognising the need to take measures beyond the simple agreement not to engage in the inhumane treatment of people in detention.8
Ratifying the OPCAT would ensure adequate oversight of the conditions of detention within Australia through the establishment of a national preventive mechanism (NPM) and through international scrutiny.8–10
Such a need for monitoring and independent oversight in immigration detention was not addressed through the establishment of the Detention Health Advisory Group in 2006, later remodelled as the Immigration Health Advisory Group, which was abandoned in 2013.11
An NPM would include a system of regular visits and reporting undertaken by independent national and international bodies. NPM assessments should inform legislation and intervention, as well as act as deterrents in their own right.8–10
An NPM would extend protections well beyond immigration detention centres. Monitoring would apply to people in all forms of detention where the protection of human rights is more challenging. This includes involuntary psychiatric admissions, aged care placements such as secure dementia wards, mental health facilities, forensic disability units, police lockups, juvenile detention centres and correctional environments.8–10
There is already considerable support for Australia’s ratification of the OPCAT. This was demonstrated in September 2014 when 64 organisations wrote to the Attorney-General calling for its endorsement.6,12 Significant work has been completed on the requirements for implementation.9 Tasmania, the Australian Capital Territory and the Northern Territory have released draft bills.6
We have the benefit of seeing different ways the OPCAT has been implemented and ratified internationally in comparable countries such as New Zealand and the United Kingdom (Box),9,10,12,13 where this process has led to strong review mechanisms with legal force that regulate places of detention of all kinds. These mechanisms also find expression in legislative changes to procedures in situations where human rights might otherwise be threatened.9,10,13
Such a mechanism would also assist in alleviating dual loyalty conflict experienced by the health workforce, whereby a lack of appropriate transparency and accountability leads to conflict between fulfilling duties to patients and the demands of employers. Many doctors and other health care providers have stated that such conflicts are commonplace in the detention of asylum seekers, as is a lack of ethical guidance when faced with decision making in the absence of a system grounded in human rights.4,5,14
For doctors, preserving and protecting the right to health falls squarely within our duty of care. As the World Medical Association makes clear:
As health professionals, physicians have a key role to play in providing high quality care to all patients without discrimination and preventing and reporting acts of torture and ill treatment that constitute gross human rights violations.15
Further, as all human rights are intimately connected, the preservation of the right to health serves to protect justice and dignity for asylum seekers. It is our obligation to ensure appropriate safeguards are put in place to regulate a clear separation between the management of health care and immigration policy. This is imperative when, despite the best intentions of the health care workforce and the bodies that represent them, we have thus far failed so badly.
1 Ratification of the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment*
Country status: dark blue = state party (78 countries); light blue = signatory (18 countries); orange = no action (101 countries). * Reproduced with permission from United Nations Human Rights, Office of the High Commissioner for Human Rights. Optional Protocol to the Convention against Torture Subcommittee on Prevention of Torture. http://www.ohchr.org/EN/HRBodies/OPCAT/Pages/OPCATIndex.aspx (accessed May 2015).
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