Environmental health

A national education program would facilitate achieving the full potential of highly effective curative therapies

Paul J Clark

To the Editor: I read with interest the consensus statement on hepatocellular carcinoma (HCC)1 and wonder why it overlooked that smoking is a major cause. Smoking is an independent and dose‐related contributing factor for HCC (relative risk, 1.51; 95% CI, 1.37–1.67) around the world.2,3 In a large European cohort, the population‐attributable fraction — the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario — for tobacco use in HCC was 48 %, more than twice the population‐attributable fraction of the second most common risk factor: hepatitis C (21%).4 In France, where smoking prevalence is high and roughly twice that in Australia, tobacco, viral hepatitis and alcohol contribute to 33%, 31% and 26% respectively of HCC cases.5 The issue is not only about prevention but also about care, as smoking cessation is an important factor in cancer outcomes (ie, treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life). Lastly, only nine out of 31 recommendations in the consensus statement are graded “A1” and none are among the four related to surveillance.

Alain Braillon

To the Editor: The extension of alcohol brands to non‐alcohol products has been part of the marketing strategy of some alcohol companies on several occasions.1 Recent examples highlight that this marketing tactic warrants further research and policy attention in Australia. Following the release of a limited‐edition Bundaberg Rum‐branded Ice Break (iced coffee) in Queensland in 2019, the product was rolled out nationally in supermarkets and petrol stations in October 2020. This follows similar examples of alcohol‐branded chocolates, zero‐alcohol beverages, and fragrances. The alcohol advertising code of practice in Australia, administered by the industry‐managed Alcohol Beverages Advertising Code (ABAC) Scheme, applies to alcohol brand extensions; however, determinations suggest that the code does not restrict alcohol companies from applying their brands to a variety of non‐alcohol products. In 2019 and 2020, the ABAC Panel reviewed nine complaints about brand extensions, including the rum‐branded iced coffee (Box).2 A common theme raised by complainants was concern about children and young people’s exposure. In almost all cases, the ABAC Panel determined that the alcohol‐branded products or associated marketing would not have strong or evident appeal to minors. Most of the complaints were dismissed. Extending well known alcohol brands to non‐alcohol products provides companies with the opportunity to expose new audiences to their brands, including children and adolescents. While some extensions may not have overt appeal to children, the display of alcohol‐branded products in supermarkets and other retail outlets means children will be exposed to the marketing and may develop connections with the brands.3 The use of brand extensions has also been a strategy of the tobacco industry.1Based on the available determinations, the ABAC Scheme permits alcohol brands to be used on a wide variety of products that are not typically related to alcohol. The inadequate controls on brand extensions are consistent with reviews that have concluded that the ABAC Scheme does little to protect young people from exposure to alcohol marketing.4,5 Efforts to encourage governments to hold the alcohol industry to a higher standard in their marketing would be aided by further attention, including research attention, to the use of brand extensions by alcohol companies. Box – Alcohol Beverages Advertising Code (ABAC) Scheme determinations about alcohol brand extensions published in 2019 and 20202 Product Summary of complaint Outcome and summary of ABAC Panel comments VB‐branded Volleys (ABAC determination No. 185/20) Alcohol promotion via a shoe brand will expose children to the marketing and glorify alcohol use. Upheld in part. The VB‐branded shoes are not merchandise primarily used by young people so the product itself does not breach the ABAC Code. However, one of the associated online promotions featuring a person skateboarding while wearing the VB‐branded shoes would have strong appeal to young people. VB‐branded fragrance sold by the national chemist chain Chemist Warehouse (ABAC determination No. 124/20) The VB‐branded fragrance was marketed as an appropriate gift for Father’s Day, appealing to children and young people. The promotion seen outside a chemist included an image of a child hugging a man next to the words “#1 for Father’s Day”. Children and young people visiting the chemist would be exposed to the VB brand. Dismissed. The VB branding on the fragrance and the poster seen outside the chemist would not strongly appeal to young people, and there are no rules restricting the placement of alcohol ads in shopping centres. Heineken 0.0 television ad (ABAC determination No. 99/20) The ad promoted the product as alcohol‐free when it may not be completely alcohol‐free, and children may drink the product believing it is not alcoholic. Dismissed. The ad shows adults in an adult situation, and would not have particular attractiveness to minors beyond the appeal it has for adults. Bundaberg Rum‐branded Paul’s egg nog (ABAC determination No. 118/19) Egg nog is a flavoured milk, which is a soft drink that appeals to young people. The placement of Bundaberg Rum’s brand on the egg nog could be seen by young people. Dismissed. While flavoured milk such as chocolate milk might appeal to young people, egg nog is not considered a drink which would particularly appeal to young people. The packaging is mature and traditional and does not have features that would appeal to young people. Bundaberg Rum‐branded Ice Break drink (ABAC determination No. 82/19) The iced coffee promoted Bundaberg Rum and encouraged young people’s exposure to alcohol products and brands. Dismissed. Iced coffee as a product does not strongly or evidently appeal to young people. The product label is mature and does not contain images likely to appeal to young people. Heineken 0.0 bus stop ad (ABAC determination No. 67/19) It was not clear from the ad that the product was alcohol‐free, and it suggested that people can drink Heineken beer before driving, conflicting with anti‐drink‐driving education. Upheld. The overall impression created by the ad was positioning a Heineken product, which would be assumed to be a type of alcoholic beer, with the consumption of the product by a driver of a motor vehicle. Jack Daniels‐branded barbeque sauce and barbeque tools sold at the department store Big W (ABAC determination No. 59/19) Children would be exposed to the alcohol‐branded products being promoted in connection with Father’s Day. Dismissed. The branded barbeque products do not feature any eye‐catching designs or themes that would appeal to children or young people. Carlton Zero radio ad (ABAC determination No. 44/19) The ad referred to a “beer you can drink anywhere” and provided examples of places where it is inappropriate or irresponsible to consume alcohol, and the ad was broadcast at 12 pm on a Sunday, when children and young people are likely to be listening to the radio. Dismissed. A reasonable person would not take the ad as promoting the use of alcohol in unsafe circumstances. The timing of the broadcast was consistent with the requirements of the ABAC placement rules. Carlton Zero television ad (ABAC determination No. 35/19) Carlton Zero was marketed as a light lunch drink and could easily be misinterpreted as a soft drink. Dismissed. The ABAC definition of “strong and evident appeal to minors” refers to “confusion with a soft drink” as part of an example of how the standard might be breached. The ad taken as a whole did not create a message which could be said to be appealing to minors.

Hannah Pierce · Julia Stafford

Focusing on people at particular risk of self-harm and assault with firearms could reduce injury and death rates

Joel Negin · Jane Bell · Lorraine Ivancic · Philip Alpers · Natasha Nassar

VITT is a potential complication of ChAdOx1-nCov-19 vaccination — early recognition is key to improved outcomes

Vivien M Chen · Jennifer L Curnow · Huyen A Tran · Philip Y‐I Choi

A public health unit in Sydney was notified of two unrelated patients who presented on the previous day with methaemoglobinaemia

Caitlin O’Neill · Zeina Najjar · Andrew Ingleton · Alan Edwards · Andrew Dawson · Leena Gupta

Saliva may be suitable as a stand-alone test specimen for people aged 10 years or more

Jane Oliver · Shidan Tosif · Lai‐yang Lee · Anna‐Maria Costa · Chelsea Bartel · Katherine Last · Vanessa Clifford · Andrew Daley · Nicole Allard · Catherine Orr · Ashley Nind · Karyn Alexander · Niamh Meagher · Michelle Sait · Susan A Ballard · Eloise Williams · Katherine Bond · Deborah A Williamson · Nigel W Crawford · Katherine B Gibney

Quarantine systems required to manage increasing proportions of returning travellers infected with SARS-CoV-2 need improving

Leah Grout · Ameera Katar · Driss Ait Ouakrim · Jennifer A Summers · Amanda Kvalsvig · Michael G Baker · Tony Blakely · Nick Wilson

To the Editor: We congratulate Buising and colleagues1 on their article published in the MJA and agree that the approach needs to be multidimensional and iterative. To expand upon the multidimensional theme of their article, we would like to emphasise the need for the approach to be multidisciplinary and to include the whole of the health service workforce. The article highlighted the ubiquitous nature of coronavirus disease 2019 (COVID‐19) transmission in health care settings, with 18.3% (or almost one in five) of health care workers infected, and that these workers are traditionally regarded as non‐clinical staff (food services, environmental services, administrative and security staff). The non‐clinician workforce has been overlooked in other research investigating COVID‐19 transmission risk factors.2 At Monash Health, we used multidisciplinary shift briefings to ensure all health service team members were included in the information and safety messages.3 Human factor‐designed briefing cards, based on the airline industry pre‐flight safety cards, were used to ensure consistent messaging (Box and online Supporting Information). The early involvement of a design team, from the Design Health Collab at Monash University, ensured clear and unambiguous messaging to health care workers. The images were designed to represent diversity in gender, race and role to ensure all health care workers would see themselves reflected in the briefing card and that the safety messages were relevant and directed towards them. Providing information that is timely and accessible as well as readable and visually clear is important.4 Commentaries have emphasised the need for clear and concise communication to ensure the safety and wellbeing of health care workers during the COVID‐19 pandemic.5 However, we believe that involving all workers, not just clinicians, in the safety messages and interventions is paramount to the health and safety of non‐clinical health care workers and to the ongoing operation of health care services. COVID‐19 does not recognise the individual worker role in the health care service and the pandemic has offered us a unique and powerful opportunity to bring together the whole health care workforce and break down traditional barriers. We believe that a multidisciplinary approach is just as vital as a multidimensional one. Box – Card used to ensure consistent messaging during shift briefings Permission to reproduce this image was obtained from the American Journal of Infection Control.

Diana Egerton-Warburton · Lisa Kuhn · Daphne Flynn

Clinical breast examination can safely be omitted from breast cancer screening of women with BRCA1/2 mutations

Tamara Hettipathirana · Courtney Macdonald · Jing Xie · Kate Moodie · Chris Michael · Kelly‐Anne Phillips

Whether the U=U message is received with scepticism or not, it is clear it is radically challenging the stigma associated with HIV

James H McMahon · Brent Allan · Daniel Grace · Nic Holas

A 31-year-old Caucasian woman presented to the emergency department with a 1-day history of vomiting and lethargy, but no other symptoms

Nardeen S Habashy · Hwang Tan · Emily J Hibbert

Wealthy nations must do much more, much faster

Lukoye Atwoli · Abdullah H Baqui · Thomas Benfield · Raffaella Bosurgi · Fiona Godlee · Stephen Hancocks · Richard C Horton · Laurie Laybourn‐Langton · Carlos A Monteiro · Ian Norman · Kirsten Patrick · Nigel Praities · Marcel GM Olde Rikkert · Eric J Rubin · Peush Sahni · Richard SW Smith · Nicholas J Talley · Sue Turale · Damián Vázquez

The time for actively recommending the screening of asymptomatic men has passed

Justin J Coleman

To the Editor: Published evidence recognises that the recreational misuse of nitrous oxide (N2O) can be associated with vitamin B12 deficiency and subacute combined degeneration of the spinal cord.1 Misuse of N2O is increasing,2 with canisters (known as “nangs” or “whippits”) readily available for legal purchase in convenience stores and online ostensibly for the purpose of whipping cream. In recent years, an increase in the number of emergency presentations and acute hospital admissions related to N2O misuse has been recorded in Australia.3,4 We have also seen an increase in the number of patients requiring specialist multidisciplinary rehabilitation for severe impairments, including proprioceptive deficits, ataxia, disabling lower limb weakness and persistent gait abnormalities. Over recent years, a growing number of patients have been admitted to our inpatient metropolitan Sydney rehabilitation unit with serious disabilities related to N2O misuse. In line with published reports, our experience confirmed that patients are often university students (typically aged < 30 years).3,4 As acute medical specialties recognise the significance of these presentations,3,4 we highlight that the resulting disabilities can remain for months or years at functional, vocational and emotional levels, and many will be lifelong. This will impose a significant disability burden that will require ongoing management by specialist rehabilitation and disability services and will have an impact on the wider health care utilisation and cost. As long as N2O remains legal and accessible and is perceived by many as seemingly innocuous, users will remain largely unaware of the severity and risk presented by its long term use. Compared with messaging surrounding other “hard drugs”, most of the literature and the public health messaging in Australia do not appear to emphasise the potential for catastrophic, permanent injury associated with the misuse of N2O. Given the emerging disability burden resulting from recreational N2O misuse, we recommend enhancing existing public awareness campaigns.5 We suggest that educational resources place greater emphasis on the potential for serious, long term impairments and that education campaigns be targeted to most susceptible people via tertiary and/or secondary education establishments. Widespread restrictions on N2O purchase should also be considered. Such measures may help prevent permanent and devastating disabilities resulting from the misuse of this easily accessible substance.

Simon Mosalski · Anne Tanner · Christine T Shiner

Phasing out retail tobacco sales would be favourably received by most Australians

Emily Brennan · Sarah Durkin · Michelle M Scollo · Maurice Swanson · Melanie Wakefield

The age-specific impact of risk factors on breast cancer detection could inform discussions of risk-stratified screening

Naomi Noguchi · Michael L Marinovich · Elizabeth J Wylie · Helen G Lund · Nehmat Houssami

Community- based studies in five countries show consistent strong benefits from early rollouts of COVID-19 vaccines

David A Henry · Mark A Jones · Paulina Stehlik · Paul P Glasziou

Australian public hospitals’ energy choices are at odds with “first, do no harm”

Hayden Burch · Matthew H Anstey · Forbes McGain

We need to consider offering vaccination to adolescents and young adults

Mary‐Louise McLaws

Estimating expected background rates of hospital transfer and death can inform analyses of vaccine safety

Hazel J Clothier · Yonatan M Mesfin · Steven Strange · Jim P Buttery

The substantial mortality and financial cost means that effective policies are needed to reduce wood heater pollution

Dorothy L Robinson · Joshua A Horsley · Fay H. Johnston · Geoffrey G Morgan

Stillbirth and cancer rates are significantly elevated among Aboriginal people living near the Ranger uranium mine Stillbirth and cancer incidence rates are significantly higher among Aboriginal people living near the Ranger uranium mine than among Aboriginal people elsewhere in the Top End of the Northern Territory, with a stillbirth rate over twice as high and cancer incidence almost 50% higher.1 The NT Chief Health Officer commissioned an investigation into the excess stillbirths and cancers in 2014, but a November 2020 report found no explanatory cause.1 The Ranger uranium mine ceased operations as planned in January 2021.2 Communities expect health departments to respond to reports of clusters of adverse health outcomes such as the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine.3 However, investigating clusters of health outcomes which have complex aetiologies rarely provides definitive answers.3 Even when associations are identified, cluster investigations cannot demonstrate that these associations are responsible for the disease cluster. Nonetheless, important environmental, public health and social problems may be identified through cluster investigations, enabling health education and promotion, and potentially, mitigation of contributing causes.3 The Ranger mine cluster investigation focused on ionising radiation as a potential cause of the excess stillbirths and cancers because this was considered the worst‐case scenario.1 There are well established causative associations between ionising radiation and increased rates of some cancers, particularly lung, head and neck, thyroid cancer in childhood and leukaemia, and fetal malformations that lead to stillbirth.1 Tobacco and alcohol consumption likewise contribute to stillbirths and cancers, and these were also examined in the cluster investigation, together with markers of poor nutrition.1 High levels of alcohol consumption by Aboriginal people in the Ranger mine region have long been a concern.4,5 The Ranger uranium mine in Kakadu National Park Uranium mining began at a location labelled “Ranger” in 1980 on land excised from the Kakadu National Park World Heritage site.6 Aboriginal rights to veto mining were overridden in legislation, and detrimental impacts on Aboriginal people were anticipated, but market prospects for uranium appeared strong and the mine was considered to be in the national interest. Mining was allowed to proceed, with recommendations to monitor and reduce harmful impacts on the region’s Aboriginal people.4,7 Health, social and ecological aspects of the Ranger uranium mine were explored in a 1984 report, whose authors recognised that their immersion into Aboriginal communities gave them deep concern about how uranium mining could affect Aboriginal people.5 They recommended that uranium mining not expand without interventions to mitigate harmful and strengthen positive effects of mining on Aboriginal people.5 Mining continued for 40 years, and the Ranger uranium mine contributed up to $388 million annually to the NT economy before its 2021 closure.2,8 During the period of mine operation, more than 200 leaks, spills and other incidents were documented.9 Five major incidents are outlined in Box 1, highlighting threats to ecosystems and employees more than radiation exposure among Aboriginal community residents.9,10 The Gundjeihmi Aboriginal Corporation represents the Mirarr people of the region and for decades has expressed grave concerns about continuing incidents and the lack of effective government response.7 While the Mirarr people maintain the right to live on their lands, their lives are disrupted by mining operations and incidents that threaten biodiversity, landscapes and livelihoods.7,9 In 2014, the mine operators lodged a proposal to expand. A submission on the proposal by the NT Department of Health noted that rates of stillbirth and cancer among Aboriginal people in the region were elevated.1 NT Department of Health investigation In 2014, the NT Chief Health Officer commissioned an investigation into stillbirth and cancer rates in long term Aboriginal residents around the Ranger mine. The investigation aimed to quantify rates and identify exposures that may have contributed to the excess stillbirths and cancers. Stakeholders including Aboriginal health and land corporations and public health and politics experts oversaw the investigation to ensure transparency, while independent epidemiologists scrutinised the investigation’s scope, design and conduct. The investigation report was released publicly in November 2020.1 The investigation identified all Aboriginal people who had spent more than half of their lives in the mine region during the 1991–2014 study period, with an exposed cohort of about 2200 people. The focus was ionising radiation because this exposure was considered the worst‐case scenario.1 The mine employed few local Aboriginal people, so occupational exposures were not considered.1,2 The comparison group comprised all other Aboriginal people in the Top End.1 Elevated stillbirth and cancer incidence rates among Aboriginal people living near the Ranger mine compared with other Aboriginal people in the Top End were confirmed. Stillbirth was over twice as common (odds ratio, 2.17; 95% CI, 1.13–3.82) and cancer about 50% more common (total cancer incidence ratio, 1.48; 95% CI, 1.17‐1.85).1 Examination of the cancer types showed that no specific cancer was responsible for the excess of total cancers. Cancers of the lip, mouth and pharynx together were the most common cancers and made up 42% of the excess: 16 cases, compared with 5.5 expected. These cancers are not considered to be caused by ionising radiation, but they are associated with tobacco smoking and alcohol consumption.1 The Aboriginal people living near the mine had higher prevalence of tobacco smoking (prevalence ratio, 1.08; 95% CI, 1.04–1.13), alcohol use (prevalence ratio, 1.21; 95% CI, 1.13–1.31) and infrequent intake of vegetables indicating poor nutrition (prevalence ratio, 1.08; 95% CI, 1.02–1.24) compared with other Aboriginal people in the Top End. Other risk factors were not statistically different between the groups. Multivariable analysis did not show that these risk factors contributed to the excess cancer incidence in the people living near the mine (Box 2). However, this analysis had low statistical power because of a lack of risk factor data.1 The investigation found “little evidence that the risk factors investigated … were associated with increased risk of cancer in study participants” in the period for which risk factor data were available.1 Despite this statistical conclusion, higher rates of tobacco smoking and alcohol use and poor diets among Aboriginal people in the mine region were highlighted in relation to the excess stillbirths and cancers. The investigation concluded by recommending that Aboriginal people follow advice about smoking, alcohol and diet.1 Discussion The Ranger uranium mine has had an impact on surrounding Aboriginal communities for over 40 years. The investigation by the NT Department of Health into the rates of stillbirths and cancers among people in the region invested significant resources and expertise in gathering data on stillbirths, cancers, ionising radiation and behavioural risk factors. It focused on cause–effect relationships between possible exposure to ionising radiation and behavioural risk factors, and the increased stillbirth and cancer rates. The investigation was not designed to consider the impact of the imposition of uranium mining on Aboriginal lands, as was recommended when the mine was proposed and developed.4,5 Development of the Ranger mine entailed nullification of veto rights, disempowering Aboriginal communities and threatening their livelihoods.7 With mining came royalty money, expensive commodities, money‐hunger and alcohol.5 Economic development from the mine has increased inequity among Aboriginal people in the region.5 Inequity may contribute to both stillbirths and cancer, although this would not be detected in a cluster investigation.3,11,12 Employment and educational opportunities associated with the Ranger mine did not promote socio‐economic development of the Aboriginal community; rather, Aboriginal wellbeing deteriorated through people relying on royalty income.2,7 Aboriginal people’s rights were ignored, and their expertise, authority and lifeways were devalued by the mine.7 Aboriginal community perspectives, knowledge and research methodologies may offer important insights into adverse Aboriginal health outcomes, while marginalising Aboriginal expertise perpetuates the impacts of colonisation.13 Excess stillbirths and cancers may be associated with a web of interrelationships between individuals, communities and wider ecological, sociological and political environments, which a biomedically focused investigation may overlook.14 Further research is needed to unravel this web, and explain the disparity in stillbirth and cancer rates between Aboriginal people in the region of the mine and the other Aboriginal people in the Top End. The NT Department of Health stillbirth and cancer cluster investigation recommended that Aboriginal people in the region reduce their tobacco and excessive alcohol consumption, although these were not considered the causes of the raised stillbirth and cancer rates.1 This response could be strengthened by a foundational approach to improve understanding and relationships between government, mining companies and Aboriginal community members.2 Conclusion The investigation by the NT Department of Health into the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine was transparent, detailed and publicly available. High level expertise was engaged, although stronger Aboriginal contribution to the investigation’s grounding and methodology may have enhanced two‐way intercultural learning.13 Research from Aboriginal community perspectives that focuses on improving health and wellbeing may lead to possible interventions. While the mine is now closed and undergoing rehabilitation, there is an opportunity for further research to better understand and close the gap in health risk exposures and outcomes between Aboriginal people in the region of the mine and other Aboriginal people in the Top End. Box 1 – Major incidents at the Ranger uranium mine, 1979–20139,10 Date Location Incident Outcome Risk minimisation December 1995 Retention pond 2 at power station 12 000 litres of diesel fuel spilled World’s richest tropical waterbird breeding ground threatened; 40 identified waterbirds perished Office of Supervising Scientist designated this as unacceptable environmental impact. Increases in monitoring not implemented due to mine operator’s other commitments January–April 2002 Headwaters of Corridor Creek, southern side of mine Incorrect stockpiling of low grade uranium ore Water contaminated by leakage of uranium Remedial works undertaken in February 2002. No source found for ongoing run‐off identified in April March 2004 Ranger mine utility site Process water connected to drinking water, leading to water uranium levels 400 times Australian standards 159 workers potentially exposed to contaminated water for drinking and washing Mine operator prosecuted and fined $150 000 January–June 2011 Region wide Extreme wet season Risk of overflow from tailings dam Uranium mill was shut for duration of wet season December 2013 Ranger mine site Collapse of acid leach tank 1 million litres of radioactive ore slurry spilled Area was evacuated until spill contained Box 2 – Total cancer incidence rate ratios for Aboriginal people living near the mine compared with other Aboriginal people in the Top End of the Northern Territory, by selected risk factors*,1 Risk factor Cancer incidence rate ratio (95% CI) Tobacco smoking 1.53 (0.75–3.12) Alcohol use 1.54 (0.76–3.15) Infrequent vegetable intake 1.49 (0.73–3.06) * Poisson regression model adjusted for age and sex.

Rosalie Schultz