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avoidance strategies. To promote population healthby taking a ‘first-things-first’ preventative approach,beginning with a prison infection control program, 16would be analogous to removing the ‘pump handle’that is driving the present preventable blood-borne virusepidemic in the prison environment.Prison infection control preventative strategies couldinclude:• Up-to-date post-exposure control plans that minimisethe potential of employee and inmate exposures toblood-borne pathogens, both occupational and nonoccupational;• Systems to ensure staff and inmates are vaccinatedas recommended by national immunisation guidelinesand the outcomes audited; 18• Establishing and enforcing respiratory isolation policiesto a community standard;• Ensuring that personal protective equipment such aslatex gloves and eye shields are available to both staffand inmates;• Environmental hygiene inspections by qualifiedenvironmental health officers in prison food cateringareas, health care centres and hair dressing locations;and• Establishing infection control committees thatinclude prison management, health care providers,environment health officers, housekeeping,food services and occupational health industrialrepresentatives.A prison settings infection control program wouldremove the ‘pump handle’ from our correctionalsystem. It may be time to justify the introductionof a collaborative prison infection control program,underpinned by the hypothesis that our presentHepatitis C virus epidemic and its subsequent burdenof chronic disease will not be controlled unless newpartnerships are formed between the Justice and Healthsectors. Some international jurisdictions are creatingcollaborations, based on scientific evidence to controlprison-mediated infections, and are consequentlyprotecting the general community from contagion. Inthese pragmatic jurisdictions, both human suffering andhealth costs have been reduced. 19,20References1 Department of Health and Human Services, Centres forDisease Control and Prevention (CDC). 150th Anniversaryof John Snow and the pump handle. Morbidity andMortality Weekly Report (MMWR). 2004;53(34):783.Available from: http://www.cdc.gov/mmwr/PDF/wk/mm5334.pdf.2 Joint United Nations Programme on HIV/AIDS. WorldHealth Organization guidelines on HIV infection and AIDS inprisons. Geneva: World Heath Organization; 1993.3 Public Health Agency of Canada. Hepatitis C virustransmission in the prison/inmate population. Canada22Communicable Disease Report. 2004; 30(16):141-148.Available from: http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/04vol30/dr3016ea.html4 Jurgens R. HIV/AIDS in prisons. Final report. Montreal.Canadian HIV/AIDS Legal Network; 1996. Available from:http://www.aidslaw.ca/maincontent/.htm5 Miller E. Hepatitis C infection in Australia: an ongoingepidemic. Public Health Bulletin South Australia. 2004;1:29-31.6 Hellard ME, Hocking JS and Crofts N. The prevalenceand the risk behaviours associated with the transmissionof hepatitis C virus in Australian correctional facilities.Epidemiol Infect. 2004;132:4009-415.7 Toma_evski T. Prison health: international standards andnational practices in Europe. Series 21. Helsinki Institute forCrime Prevention and Control (HEUNI) affiliated with theUnited Nations. Helsinki; 1992, 38.8 Australian Government Productivity Commission. Reviewof government services provision. Policy development, 7.9.Canberra: Corrective Services; 2004. Available from: http://www.pc.gov.au/gsp/rogs.html9 Butler T, Milner L. The 2001 New South Wales Inmate healthsurvey. Sydney: Corrections Health Service (NSW); 2003.10 Dolan K, Rouen DA. Evaluation of an educational comic onharm reduction for prison inmates in New South Wales. Int JForensic Psychol. 2003;1(1):138-141.11 World Health Organization. Ottawa charter for healthpromotion. Health Promot Int. 1986;1(4):i-v.12 Australian Government Productivity Commission. Review ofgovernment services provision. Canberra: Corrective Services.Available from: http://www.pc.gov.au/gsp/rogs.html13 Australian Government Productivity Commission. Reviewof government services provision. South Australiancomments, 7.33. Canberra. Corrective Services; 2004.Available from: http://www.pc.gov.au/gsp/rogs.html14 Kawachi I, Kennedy BP, Wilkinson RG. Crime: socialdisorganization and relative deprivation. Soc Sci Med.1999;48:719-731.15 Crofts N. A cruel and unusual punishment. Med J Aust.1997;166:116.16 Bick J. Infection control in the correctional setting.Infectious Diseases in Corrections Report. July/Aug2004. Available from: http://www.idcronline.org/archives/julyaug04/article.html17 Nelles J, Fuhrer A, Hirsbrunner HP, Harding TW. Provisionof syringes: the cutting edge of harm reduction in prisons?Education and Debate. Brit Med J. 1998;317:270-273.18 National Health and Medical Research Council (NHMRC).The Australian immunisation handbook. 8th Ed. Canberra.Commonwealth of Australia; 2003.19 Lines R, Jürgens R, Betteridge G, Stöver H, et al. Prisonneedle exchange: lessons from a comprehensive review ofinternational evidence and experience. Montreal. CanadianHIV/AIDS Legal Network; 2004. Available from: http://aidslaw.ca20 Centres for Disease Control and Prevention. Prevention andcontrol of infections with hepatitis viruses in correctionalsettings. Atlanta. Morbidity and Mortality Weekly Report(MMWR). 2003;52(RR-1). Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5210a9.htm
Immunisation– a new era for vaccinesHelen MarshallHead, Paediatric Trials Unit,Women’s and Children’s HospitalClinical Lecturer, Dept of Paediatrics,University of AdelaideClinical Lecturer, Dept of Public Health,University of AdelaideVaccines prevent up to three million deaths eachyear and 750,000 children are saved from disabilityglobally. 1 Recent advances in immunisation include themanufacture of several new vaccines including vaccinesto prevent Rotavirus (RV), the commonest causeof gastroenteritis in children and a vaccine with thepotential to substantially reduce the incidence of cervicalcancer in women.Rotavirus VaccinesRotavirus InfectionRotavirus infection causes approximately 440,000deaths worldwide every year in children under 5 yearsof age. 2 Most deaths from gastroenteritis occur indeveloping countries where children can experiencegreater than 12 episodes of diarrhea per year. Almost allchildren have been infected with RV by 2-3 years of age. 3There are an estimated 10,000 hospital admissionsand 115,000 GP visits annually attributable to RVinfection in children < 5 years in Australia. 4 Importantlygastroenteritis is a leading cause of morbidity andmortality in aboriginal children in Australia. Five outof 14 major serotypes are associated with almost allhuman rotavirus infections: G1, G2, G3, G4 and G9. 5Rotavirus VaccineThe first live oral RV reassortment vaccine, RotaShieldwas shown to provide 48% - 68% protection againstany RV disease when administered at 2, 4 and 6months of age. Following licensing in the USA in 1998and introduction into the routine schedule, the vaccinewas withdrawn form the market in 1999 followingseveral cases of intussusception after immunisation.The decision to remove RotaShield from the childhoodschedule in the USA remains controversial. 6 The riskof intussusception following administration of thisvaccine has recently been reassessed and estimatedto be as low as 1:32,000 (background risk of 18 to 56cases per 100,000 infant years). 6 More recently twonew RV vaccines have been manufactured, which arelikely to be available for use in Australia in the next12 months. A pentavalent human-bovine reassortant(G1, G2, G3, G4 and P[8]), 3 dose oral vaccine hasbeen developed by Merck Research Co (Rotateq) and amonovalent (P[8] G1), live attenuated 2 dose oral vaccinehas been developed by Avant Immunotherapeuticsfrom a live human RV strain and licensed to GSK23Biologicals (Rotarix). Pre-licensure studies with samplesizes including >60,000 infants have shown bothvaccines to be safe and efficacious against RV infectionwith no increased risk of intussusception followingadministration of these vaccines (Rotateq: RR 1.6; (95%CI 0.4, 6.4), Rotarix: RR 0.85 (95% CI 0.30, 2.42). 7,8Use of the vaccines is likely to lead to a reduction inthe burden of disease and health care costs associatedwith RV infection in Australian communities, howeverthe most significant potential benefits are reduction ofmorbidity and mortality in the developing world. TheWorld Health Organization has prioritised RV vaccineresearch and the RV Vaccine Programme based at PATHin Seattle, USA, aided by the Global Alliance for Vaccinesand Immunisation (GAVI) is assessing the informationrequired for early rotavirus introduction and accelerateduse in the global community. In addition to establishingRotavirus Vaccine Programs, surveillance for adverseevents associated with use of the new vaccines isimperative.Human Papilloma Virus VaccinesCervical cancer is preceded only by breast cancer as themost common cause of death from cancer in womenworldwide. In developing countries, where mass cancerscreening is not well established, cervical cancer isthe leading cause of death from cancer in womenparticularly affecting the 35-55 year age group. Mostdeveloping countries either have ineffective Pap smearscreening programs or have no such programs at all. 9In developed countries there has been a significantreduction in morbidity and mortality from cervicalcarcinoma due to the success of routine screeningusing the Pap smear. 10 However, despite the successof screening programs there is still significant morbidityand mortality from this disease in our community.Unfortunately not all women present for regularscreening and histologic and cytologic assessmentsof pap smears are subjective and may be prone tooperator error. 10 Pap smear screening alone is thereforenot entirely satisfactory as a preventative method forcervical cancer, even in the developed world and indeveloping countries is not practical.Cervical Carcinoma in Australian WomenThere are approximately 800-1000 new cases of cervicalcarcinoma diagnosed in Australian women each year. 11It is the 14th most common cause of cancer deathin Australian women. The lifetime risk of a womandeveloping cervical cancer is one in 130. In the 4 yearperiod from 2000 to 2003 there were 994 deaths fromcervical cancer in all states and territories comparedwith 1,081 from 1996 to 1999. 12Among aboriginal women there is evidence of a higherrate of cervical cancer compared with non-aboriginalwomen. In the period between 1995 and 1997 therewere 19 deaths (27.6 per 100 000 women) from cervical
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