Norman Swan: Hello, Norman Swan here with this week's Health Report, nice to have your

company.Today on the program, high times for Australia's boomers. Original sin, or at least a version
of it, and how it might apply to both the flu and COVID-19. At a time when record numbers of
Australian healthcare workers have been infected with the COVID-19 virus, how hospital safety rules
can actually make things worse. And speaking of healthcare workers, you must watch this week's Four
Corners on ABC television or iView, a moving documentary following the work of an Emergency
Department doctor in Cremona, northern Italy, at the height of their epidemic. A lesson in what we've
dodged so far.And going back to today's Health Report, radical new findings on the treatment of first
episode psychosis in young people.

Jeanti: I was trying to pretend that things were all okay, I was working and going to uni, but everything
just added up really quickly. Not being on the proper dose of medication, I think that's what led things
to fall apart so drastically.

Norman Swan: But are medications, with their side-effects, necessary in every young person? Find out
more later.

One of the issues during lockdown and after has been whether we've increased our drug taking, with
anecdotal evidence that we have, at least for alcohol. But key to understanding that is what was our
drug taking before the pandemic hit? Last week the Australian Institute of Health and Welfare
released the latest findings from the National Drug Strategy Household Survey, and it contained some
surprises about the changing habits of the young and the old…well, older. Wayne Hall is professorial
fellow at the Centre of Youth Substance Use Research at the University of Queensland. Welcome back
to the Health Report, Wayne.

Wayne Hall: Thank you Norman.

Norman Swan: A long time between drinks.

Wayne Hall: It has been, yes.

Norman Swan: Give us the findings on the young.

Wayne Hall: Well, it's a phenomena that has been observed in a lot of other comparable countries—
the UK, the US, Canada—that they are drinking less, less likely to binge, they are smoking tobacco less,
they are tending to use most drugs at a lower rate than they used to, they are generally getting much
healthier than their older brethren.
Norman Swan: It's amazing views. Before we go any further, did this survey…how does it do its work,
how reliable is it?

Wayne Hall: Well, it's the survey that has been done now since I think 1985 was the first one, they are
done by market research companies, they involve other face-to-face interviews or dropping
questionnaires off at households and getting people to complete them. The response rates are about
the same as before, which is just under 50% which has become pretty standard for household surveys
these days because of overload amongst us, so we are more resistant to completing surveys than we
once were.

Norman Swan: And what you're suggesting is that because this pattern mimics what has happened
overseas, it's likely to be reliable.

Wayne Hall: I think it is, I think it's probably better for some drugs than others. I think the data from
these surveys are probably much more reliable for drugs like alcohol, tobacco and probably cannabis.
When you're dealing with much less commonly used and much more stigmatised drugs, say, like
heroine or methamphetamine, you're less likely to capture people who are using those drugs in
surveys of this sort and they are probably a bit less likely to acknowledge the use of a drug which is
pretty stigmatised.

Norman Swan: What were the findings on ice, heroine and, say, prescription opioids?

Wayne Hall: Well, a mixture of the findings on methamphetamine were its prevalence of use has
remained pretty much the same as it was in the previous survey in 2016, around 1.5%, a little bit
less. A bit more use of ice, the crystalline methamphetamine form, and those who use that drug were
much more likely to be regular users.

The heroin I don't think has changed a lot. The prescription opioids have declined, largely because we
scheduled codeine, it was no longer available over the counter and required a prescription, so there's
been a lot less use of that drug. And there's other information out there on problems related to
codeine that suggest that it has gone down fairly substantially.

Norman Swan: Before we get to the findings in older people, have we any idea why the young are
such an example to the rest of us or becoming an example to the rest of us?

Wayne Hall: Well, there's lots of speculation, it's an area of very active research. One suggestion is
they're spending more time on social media and have less time to drink and socialise and get out and
about. I suspect it's a combination of factors, but we do see these long waves of alcohol consumption
where generations learn from the behaviour of their parents to moderate their consumption. If they
see bad examples in older adults and older siblings and parents, then they sometimes are inclined to
reduce their consumption. I think we have been through a period, a decade or more of heavier
drinking and alcohol-related problems. There is a lot more media attention to the downside of heavy
drinking now, and I think that's probably having some sort of effect.

Norman Swan: Let's move now to older people, because there were some findings of increased usage,
particularly of cannabis.

Wayne Hall: Yes, amongst older adults, and I think we need to put it into perspective, it's particularly
amongst the 40 to 49 year age group, and this is use in the last year has gone from a bit under 9% up
to a bit over 11%. And in the older adults over 60 it's gone from a bit under 1% in 2001 to just a bit
under 4% in 2019.

Norman Swan: This is cannabis you're talking about?

Wayne Hall: Yes, this is use in the last year amongst this age group. And I think a large part of it is a
birth cohort effect. People now getting into their 60s, as you mentioned earlier, are boomers, and
they would have had a lot more…

Norman Swan: So they've been weed smokers since youth, is what you're telling me?

Wayne Hall: Well, not so much since youth, and I think a lot of people in this age group have stopped
and some are coming back to it possibly. There is probably a group of people who have persisted in
using throughout that period. We are seeing again a very similar phenomena in North America,
particularly in the US at the moment. So I think one part of it is the persistence of use and greater
acceptability of cannabis use in this age group because they have had prior experience with it. I think
the other big factor is of course the very positive media around cannabis as a medicine for everything…

Norman Swan: So medicinal cannabis.

Wayne Hall: Yes, and particularly for things like chronic pain, difficulty sleeping, anxiety, depression,
which are all problems that older adults are more likely to experience.

Norman Swan: Yet there is no evidence that it makes any difference.

Wayne Hall: Pretty soft evidence. I mean, there is evidence of a modest benefit in the case of chronic
pain, but it's better than placebo but not by much. In the case of sleep in the short term it probably
helps people to get off to sleep, but I think the worry with a lot of what people see as medical use in
this age group is that it tends to be pretty regular. In the US, surveys there, medical users tend to be
much more likely to be much more likely to be daily users.

Norman Swan: And the risks?

Wayne Hall: Well, the obvious one is dependence, and I think it's an underappreciated risk of cannabis.
You can develop dependence on the drug. You develop tolerance, that's the downside, the effects of
the drug…

Norman Swan: So you take more and more to get the same effect.

Wayne Hall: That's right, so it can become a bit of an expensive habit. I guess when you are getting
into older age groups, if you've got an increased risk of cardiovascular disease, then smoking cannabis
or smoking anything is not a good idea. We know that cannabis does have direct…or THC has direct
effects on the cardiovascular system, so a higher risk, older adult population, probably not a great idea
to be smoking cannabis.

Norman Swan: And finally and briefly, what about the brain and thinking and memory?

Wayne Hall: Well, I think that's the other one, the cognitive impairment. In older adults we've got less
cognitive reserve, I'd say, than younger adults, and if we are smoking daily, you're probably blunting
your capacity a bit, so there's that downside as well I think that we need to look at.

Norman Swan: A bit of drug education for the older in the community.

Wayne Hall: I think so, yes, I think that would be sensible.

Norman Swan: Wayne, thanks for joining us.

Wayne Hall: You're welcome.

Norman Swan: Wayne Hall is at the Centre for Youth Substance Use Research at the University of
Queensland.
And you are at RN's Health Report with me, Norman Swan.

Psychosis can be a symptom of serious mental illness, and includes a loss of touch with reality and
delusions such as hearing voices. Psychosis usually first appears in late adolescence or a person's 20s,
and work at Melbourne's Orygen, the National Centre for Excellence in Youth Mental Health, has put
a lot of emphasis on detecting a young person's first episode of psychosis and treating it actively to
prevent further episodes and the decline they bring with them. That active treatment is both
psychological and medical, involving antipsychotic drugs which unfortunately have side effects. But
now research at Orygen has found that medication might not always be necessary for recovery. The
Health Report's David Murray has been investigating. And a warning, this story contains references to
self-harm.

Jeanti: I was having thoughts that were to me clearly from outside my own brain, which was really
scary.

David Murray: Jeanti is 23. She goes to university and has a reasonable social life. But in 2014, in her
last years of high school, her mind started to unravel.

Jeanti: I started having mental health problems when I was in year 11. It started with anxiety. It slowly
morphed into depression, and the depression slowly morphed into mania, and then the mania
morphed into psychosis.

David Murray: This is when Jeanti started hearing voices.

Jeanti: Your thoughts mirror how you speak. Like, the words you use and your inflections, and that's
normal inside your head, but I was getting thoughts that weren't my own.

David Murray: Jeanti was prescribed clozapine, an antipsychotic medication. But because of the
potential side-effects, her doctors started on a below therapeutic dose. Her symptoms only got worse.

Jeanti: I was trying to pretend that things were all okay. I was working and going to uni. But everything
just added up really quickly. Not being on the proper dose of medication, I think that's what led
things to fall apart so drastically.

David Murray: Things continued to get worse. Jeanti experienced a major psychotic episode, the voices
in her head urging her into multiple serious acts of self-harm. Eventually in one of these incidents she
lost part of her leg. She chopped it off. After that, Jeanti was admitted to hospital and her medication
levels were increased. It worked. Things started to improve, and today she is much better. But she still
has to deal with the side-effects of the medication that got her here.

Jeanti: It's been really hard. So the main side-effects for me have been weight gain and sedation. I'm
on a pretty low dose now but it still really knocks me out at night. I have to sleep at least eight hours,
usually better if it's more like 10, which is just really hard when you're trying to study, when you've
got things going on, when you want to have a social life. I wish that I could just wake up and feel
refreshed and ready for the day, but that's not really something that happens too often for me.

David Murray: And Jeanti's experience here isn't uncommon. Side-effects can be a particular issue for
young people, and it's part of the reason that some are reluctant to take them, and why others go off
them against the advice of their doctors.

Shona Francey: Medication doesn't suit everyone, and not everyone wants to take medication.

David Murray: Dr Shona Francey is a clinical psychologist and researcher in early psychosis at Orygen.

Shona Francey: Often the side-effects are quite strong in young people, they can be unpleasant.
Weight gain, a very significant and distressing issue for many young people. There can also be sexual
performance side-effects, which is also distressing.

David Murray: Which is why Dr Francey has been looking into whether some young people might be
able to avoid these side-effects and the medication that causes them altogether. In a recently
published study, a team at Orygen compared outcomes for two groups of 15- to 25-year-olds
presenting with first-episode early psychosis. One group received a low dose of antipsychotic
medication, along with an intensive program of cognitive behavioural case management.

Shona Francey: So, helping young people with the broad range of issues that are going on in their life
with a view to reducing stress levels, because we know that stress makes psychosis worse. But also
within that a specific what we call cognitively oriented therapy to look at thoughts and behaviours
that are maintaining the psychotic symptoms.

David Murray: The other group received the case management but no medication. The study found
that at the six-month follow-up period, there was no significant difference in outcomes between the
two groups.
Shona Francey: That's the exciting findings I think from the study. Both groups improved, so everyone
had less symptoms and higher functioning after six months, but the addition of the antipsychotic
medication didn't really seem to make any difference.

David Murray: Which suggests that for young people experiencing early psychosis, heavy duty
antipsychotic medication might not always be needed.

Neil Thomas: Traditionally the mainstay of treatment for psychosis has been antipsychotic medication,
the standard recommended treatment in practice guidelines.

David Murray: Professor Neil Thomas is the director of the Voices Clinic at Swinburne University, a
leader in psychological treatments for people experiencing symptoms of psychosis. He wasn't involved
in the Orygen study but says it starts to fill in a major hole in what we know about the options for how
to treat young people before they experience a major psychotic episode.

Neil Thomas: Antipsychotic medications have been researched for decades, so there is evidence there
that they were effective, so they have become part of the practice guidelines which are issued.
Psychological therapies have tended to be researched as being an add-on to antipsychotic medication.
What we have lacked is what happens when psychological therapies are done as an alternative.

David Murray: Professor Thomas hopes that with the finding that psychological treatments can be just
as effective as medication in the right circumstances, the options presented to patients will start to
change.

Neil Thomas: We hear time and time again from people who use mental health services that they
haven't been given alternatives to antipsychotic medication as an option. What I'd like to see happen
for the data from this study to start informing some of the discussions that practitioners have with
young people at an early stage in their psychosis so that they can weigh up what the best treatment
options are for them.

David Murray: But Dr Shona Francey stresses that not all young people facing psychosis have the
option of going medication free. She says that the clinical guidelines which emphasise early
intervention with medication shouldn't be changing just yet, and more research needs to be done to
work out who is most likely to benefit from cognitive behavioural case management as a standalone
treatment.

END OF THE TEST QUESTIONS

For Jeanti though, who recently marked three years since the psychotic episode that saw her lose a
leg, while she would have liked to get better without using antipsychotics, she also knows that she
probably wouldn't be where she is now without them.
Jeanti: Because things have been so I guess drastic in my story, I can kind of see the good that it's
doing for me. I think I was always destined to have to be on medication, I don't doubt that. But I think
if anyone can forego the medication for something else, I would say yes, go for it, definitely.

Norman Swan: University student Jeanti ending that story from the Health Report's David Murray. If
this story has raised any issues for you, you can reach out to Lifeline on 131114 or Beyond Blue 1300
224 636, or talk to your GP about being referred to Headspace or one of those other places that you
can seek help if you are a young person.

One of the mysteries about the COVID-19 virus is why young children are less affected than teenagers
and adults. One theory is that their immune system might have become imprinted by a common cold
coronaviruses which provide cross immunity to SARS-CoV-2. With influenza, early experience of flu
viruses might affect how we respond to influenza vaccines later in life. It's a concept that goes back
80 years, and it's called original antigenic sin. Dr Seema Lakdawala is at the Centre for Vaccine
Research at the University of Pittsburgh and has been investigating whether original antigenic sin is a
real phenomenon and makes a difference to how we respond to future influenza viruses in our lives.

Seema Lakdawala: What you were originally imprinted with, the first virus you ever experienced for
influenza can influence all of your subsequent interactions with influenza. And so we wanted to take
that little bit further and develop an animal model system and examine it with strains that are relevant
now. And if you are imprinted with one strand of influenza, how does that change your immune
response against a second influenza infection with currently circulating strains?

Norman Swan: And before we move on, what evidence is there that most of us have been exposed to
influenza by aged five?

Seema Lakdawala: There is a number of seroprevalence studies that have been done in children and
following infants from six months, and they show that around aged five more than 90% have
antibodies against influenza.

Norman Swan: And the parents wouldn't have known because it would have just been a cough and a
cold like any other.

Seema Lakdawala: Exactly, at that age kids are sick all the time and you really don't know, unless it's a
severe infection of course.
Norman Swan: So what you did was you infected an animal model, I think it was ferrets, and then
subsequently exposed to them to other influenza viruses as these animals grew up, and you've also
done human studies. Can you summarise what you've found?

Seema Lakdawala: We used ferrets because they are naturally susceptible to human influenza viruses,
so we could take commonly circulating strains and we could infect animals that were immunologically
naïve, so we can imprint them with one virus, and then we could come in three months later with
another virus, then look at the immune response against that second virus and say how much of that
is targeted against the second virus, and how much of that was a recall response to that first infection.

Norman Swan: And if I understand the paper correctly, what you found was that when these animals
were older and they were exposed to another influenza virus, they did get an immune boost but it
was kind of the wrong immune boost, it wasn't to the part of the virus that was actually going to help.

Seema Lakdawala: That's right, and so it's really fascinating to see that what we found was an increase
in antibodies but they were not specific, or cross-reactive is a better term, to the second strain.

Norman Swan: Were they harmful? Because one of the issues, particularly in children, is that they can
get an adverse immune response to influenza which can make them very sick. And is this part of the
enhanced antibody response that is just not productive and might be harmful?

Seema Lakdawala: We have not seen that there was enhancement of disease in the ferret model. That
has been proposed in other animal model systems but we did not observe that in the ferret model.

Norman Swan: And going back to your original finding in terms of you get boosting to one part of the
immune response but it doesn't help you with the new influenza virus. Is there any evidence that that
it occurs in humans now?

Seema Lakdawala: Yes, so a part of this study was in collaboration with Aubree Gordon's group, she
has a great cohort in Nicaragua they've been following for a number of years. Serum samples from
her cohort recapitulated what we found in the ferret model system.

Norman Swan: So intuitively anybody listening kind of knows that you might have had flu in the past
but when you get seasonal variation in flu you're exposed to the next variety of flu that comes along,
and we are all exposed to pandemic flu if we get a really radical jump from, say, pigs or birds into
humans. Intuitively you've shown what laypeople know to be true. But what does it tell us about either
treatment or immunisation to help more effectively prevent influenza infection in the future?
Seema Lakdawala: I think it has really two big implications. One is that what does this mean for
vaccination? When we think about understanding what individuals were imprinted with, how does
that then change their response to vaccination in order to be protected in the next circulating strains
of influenza. And that's an important avenue of research right now that we are really looking at, and
we don't know yet how it will be influenced but we do think that is going to be some age-based
influences that can help explain vaccine efficacy where you see higher vaccine efficacy in younger aged
cohorts compared to older healthy adults in certain seasons, and those numbers of efficacy can change
based on age.

Norman Swan: And why would that be?

Seema Lakdawala: It could be that you lose it as you get older or that what you are imprinted with is
so far away from what you're going to be seeing that the boost doesn't help you.

Norman Swan: I see, so the influenza virus has evolved so much in the last 60 years, something like
that.

Seema Lakdawala: Right.

Norman Swan: What I take from your research and then what you just said, is that you might get to a
point of personalised immunisation where you might check what your original antigenic sin was and
then tailor a vaccine to you later.

Seema Lakdawala: Yes, that might be an avenue forward, is that based on your birth year we can
predict with some certainty what you potentially were imprinted with and then have a tailored vaccine
based on age.

Norman Swan: How does this apply to the other common set of viruses that children are exposed to,
which are of course the coronaviruses?

Seema Lakdawala: Yes, I think there are many potential orthologs from our research that can be
applied to what is happening right now in the current pandemic. Of course there are human
coronaviruses that have been circulating in the human population for a long period of time, and
whether immunity and immune imprinting with these coronaviruses are influencing susceptibility to
the current pandemic is unclear, but it's definitely worth thinking about.

Norman Swan: Dr Seema Lakdawala is at the Centre for Vaccine Research at the University of
Pittsburgh.
The COVID-19 pandemic has seen lots of new procedures and processes put in place in our hospitals.
Mind you, that doesn't seem to have stopped a large number of healthcare workers being infected in
Victoria, although the authorities claim many were infected outside their hospitals. A new study about
to be launched in Australia tests the idea that hospitals may do more harm than good when new rules
are introduced without enough thought. The study is called In the Name of Safety and is based on
findings from similar research in the UK. The lead researcher here in Australia is Dr Deborah Debono
from the Centre for Health Services Management at the University of Technology Sydney. Welcome
to the Health Report Deborah.

Deborah Debono: Thank you very much Norman, thank you for having me.

Norman Swan: So what's your hypothesis here that you are wanting to test?

Deborah Debono: So what the In the Name of Safety Australia study wants to look at is we want to
identify nonclinical safety practices that are used in healthcare that do not actually add to patient
safety, and that could be potentially removed in the future.

Norman Swan: So what do you mean by nonclinical, because in a sense everything is clinical in hospital
because it affects patients.

Deborah Debono: Yes, so we are looking at things like not clinical treatment, not tests, but more things
like doublechecking medications, pressure area assessments, use of paperwork, documentation,
things like that.

Norman Swan: And what's your concern about those?

Deborah Debono: Well, we know that in all healthcare systems, and the Australian healthcare system
is no exception, that we continue to add more initiatives, protocols and interventions, all in an attempt
to make care safer. But what also happens is that it impinges on healthcare workers' time, and we
know there is an acute shortage of time and resources, a constant pressure on staff to do more. And
anecdotally and from our research we know that healthcare workers over time have been complaining
that actually they don't have as much time to spend with patients and to deliver care because they
are caught up with having to follow or attend to bureaucratic administrative and other nonclinical
practices.

Norman Swan: So they see it as red tape.

Deborah Debono: Yes, for a lot of the part, yes.

Norman Swan: And like red tape, if you look at the general economy and you've got governments
coming in saying they are going to remove red tape, their assumption is you've got regulation upon
regulation, and when you're putting in a new one you don't take out an old one, so you've added to
the burden. Is that an issue?

Deborah Debono: Absolutely, Norman, that's absolutely the issue, yes.

Norman Swan: So can you give me other examples? I mean, you're about to start this survey, what
sort of questions are you going to ask?

Deborah Debono: So the survey is actually open, it's underway, so I'd like to give a plug, if I could, for
that, for all healthcare workers. We are particularly interested in people that work in acute care but
actually anyone, we'd like cleaners, porters, doctors, nurses. And what we are asking them is…what
we want to find out are what are the most common nonclinical safety practices that healthcare
workers identify as low value for patient safety. We want to know why they think these practices are
perceived to be low value. And we are also interested in what healthcare workers do to work around
those nonclinical practices that they perceive to be low value.

Norman Swan: A workaround? So, in other words, a barrier is put in the way by the hospital and they
find a way around it.

Deborah Debono: Yes, they do, and we know that when they feel…we know healthcare workers are
constantly juggling different demands to deliver care, and so at times they don't always follow the
rules or procedures as they are intended to be followed, and in fact they do use workarounds. Now,
workarounds are not a problem per se, I'm not saying that they are good or they are bad or they are
safe or unsafe, because in different contexts they can be either/or. But there are a couple of things
about workarounds, and one is that because they are often non-sanctioned practices, healthcare
workers are often not forthcoming in saying that they use them, which means that they hide what
care is actually done.

Norman Swan: And they are also guessing what's safe and they are freelancing when it could be
dangerous, the workaround could be dangerous.

Deborah Debono: The workaround could be dangerous, and in other situations the workaround may
actually create safer care and actually enable care to be delivered. So I guess the argument is not
whether or not workarounds are safe or unsafe, one of the concerns about workarounds is that they
hide how care is actually delivered in some instances.
And the other thing is my research that looked at nurses' use of workarounds identified that a lot of
the time they felt in a position where they had to use workarounds to deliver care, but they actually
felt incredible tension about doing so. And we know that if healthcare providers are feeling stressed
and that level of tension it can potentially impact patient safety, and the other thing that we know is
there's a really high rate of burnout in healthcare workers. So high levels of tension and stress and
feeling like they are in this position of not being able to follow all the rules and all the guidelines
potentially can lead to burnout and people leaving the profession.

Norman Swan: Deborah, we will have a link to your study on the Health Report's website, and thank
you very much for joining us.

Deborah Debono: Thank you so much for your time.

Norman Swan: Dr Deborah Debono is a senior lecturer in the Centre for Health Services Management
at the University of Technology Sydney.

I'm Norman Swan, this has been the Health Report, and I hope you can join me next week.