Environmental health

Objective: This study examined the knowledge of stroke warning signs and risk factors among the general public, including what they would do if they were to develop such symptoms.Design, setting and participants: Population study of randomly selected members of the general public in Adelaide, South Australia. A simple survey assessed knowledge of stroke warning signs and gave four options for management. The survey was conducted on three separate occasions: before, immediately after and 3 months after the National Stroke Foundation’s National Stroke Week in 2009.Main outcome measures: The outcome measures were the public perception of risk factors and warning signs of stroke and what the members of the public would do if presented with a range of warning signs. They were also asked about their knowledge of the Face, Arms, Speech, Time (FAST) test.Results: The three surveys were completed by 251 members of the public. Hypertension and smoking were recognised as risk factors for stroke by 71% and 53% of respondents respectively. Before National Stroke Week, slurred speech was identified by 51% and both slurred speech and upper limb sensory loss was identified by 62% as warning signs to provoke presentation to an emergency department (ED). Amaurosis, upper limb sensory loss, upper limb numbness and upper limb weakness were correctly identified individually as warning signs to attend an ED by fewer than one-third of respondents. There was no significant difference in the survey results following National Stroke Week. Conclusions: Public awareness of the symptoms of stroke, and what to do about them, is limited. There was little improvement after the national week-long awareness campaign. The lack of public awareness about stroke warning signs must be addressed to reduce mortality and morbidity from stroke.

J Ian Spark MD, FRCS, FRACS · Nadia Blest MB BS · Sheralee Sandison RN, MN · Phillip J Puckridge MB BS, FRACS · Hafees A Saleem MB BS, MRCSEd · David A Russell MB ChB, MD, FRCS

To the Editor: We have previously argued that the recent rapid increase in the popularity of low-carbohydrate (“low-carb”) beers, in Australia and other countries, is more a community health risk than a healthy alternative to traditional beers.1 This contention has since been supported by a survey conducted by the Victorian Health Promotion Foundation (VicHealth), which found that “low carbohydrate beer drinkers mistakenly believe these beverages are a healthier choice than other varieties”.2 Seventy-one per cent of respondents believed that low-carbohydrate beer is healthier than full-carbohydrate beer, despite having the same alcohol content. Alarmingly, 15% of respondents indicated that they consume more beer when drinking low-carbohydrate beer because they believe it is healthier than full-carbohydrate beer. The potentially insidious marketing of health benefits for alcohol products has recently been followed by the release of lower-alcohol, lower-calorie wines such as the McWilliam’s Balance range, Cockatoo Ridge’s Low Calorie Brut Cuvée, Beringer Blass’s White Lie, and the JMB Beverages Brightlite range. These are represented as containing a “lower” rather than “low” alcohol content because, at between 6.5% and 9.5% alcohol by volume, these wines clearly contain a far higher alcohol content than the ≤ 1.15% alcohol by volume that is required by Australian food standards to be represented as a low-alcohol product.4 The health-based marketing of these wines is similar to that of low-carb beer — it implies that consuming these products is healthier than consuming traditional versions. This implied health benefit message is reinforced by endorsement of McWilliam’s Balance wines by Weight Watchers and inclusion of these wines in the Weight Watchers diet program, which is followed by over 1.8 million Australians annually.4 According to its manufacturers, “McWilliam’s Balance is destined for incredible consumer demand”.4 McWilliam’s Balance wines contain about one-third less alcohol and one-third fewer kilojoules than regular wines.4 If these wines are being consumed to replace regular wine consumption in the same quantity, they could offer a community health benefit. If they are consumed instead of soft drinks or water in the belief that they are healthier than regular wines, or consumed in larger quantities than regular wine in the belief that they are healthier, they could represent a community health threat. Presently, the Australian Government is considering making alcohol companies display nutritional information and ingredients on all beer, wine and spirits labels as a result of a submission by the Alcohol and other Drugs Council of Australia.5 Governments need to modify food regulations to help make the message more explicit: lower-alcohol, lower-calorie wines are not a licence to drink to your own health.

Stephen P McKenzie · Evie R Leslie · Peter G Miller

Respect, tolerance and trust in Aboriginal and Torres Strait Islander people are needed from government to improve the health and wellbeing of Indigenous Australians Reflecting back over 30 years of working in Indigenous health, I think that it has been a time of change rather than improvement. This is not to say that some improvements have not occurred. No longer do I see children dying of gastroenteritis and pneumonia. Instead, young men are dying of heart disease, diabetes is prevalent, and so many young people are smoking. But even this is not totally bad news; the life-expectancy gap between Indigenous and non-Indigenous Australians narrowed from about 17 years for both males and females between 1996 and 20011 to 11.5 years for males and 9.7 years for females between 2005 and 2007.2 However, we are doing very badly at the level of social determinants — the foundations of how we arrange society, which determines the health and wellbeing of people. Despite commitments from individual bureaucrats and politicians over the years, in the main, both parliamentary parties seem to ignore the fundamental lesson — that social and individual health is founded on wellbeing, and wellbeing is grounded in the respect given to people, and the control afforded to them, in their daily lives.3,4 Two cases illustrate this. In 2007, the Northern Territory Emergency Response (the “Intervention”) was perpetrated on Aboriginal people in the NT, and in doing this the Racial Discrimination Act 1975 (Cwlth) was waived.5 Further, this approach bypassed the Aboriginal leadership, undermining their sense of control over their communities and destiny. It overtook and failed to acknowledge progress that was already being made by Aboriginal health services.6 The psychological and emotional effects of this are not negated by the later increase in consultation and improvements in health service funding that have occurred. The second case is the public “law and order” response to current social disruption in Alice Springs by the dominant section of the town’s society,7 which both ignores the complexities of the situation and reinforces the stereotypes about Aboriginal people to the wider Australian society and to Aboriginal people themselves. In turn, this intolerance fuels more substance misuse and more violence, as the oppressed take out their negative emotions on each other and, where they can, the oppressors.8 I use this blunt language deliberately, to emphasise the nature of the conflicts and the social construction that are the foundational causes of the gap between Indigenous and non-Indigenous Australian health that we are attempting to close. Until, as a nation, we can have the conversation at this level, to understand how the social and political situations of Aboriginal people drive their ill health, we are only tinkering at the clinical level. Clinical services, while essential, are not of themselves sufficient. Dr Richard Denniss, executive director of the Australia Institute, speaking at the Fenner Conference 2010 at the Australian National University, asked the audience to list reasons why Indigenous health is not improving and why governments are not responding to climate change despite the evidence. After a series of expected answers, he responded by postulating that it is actually because governments don’t want to. When you look at the NT Intervention, at gun control measures after the Port Arthur massacre, or at military operations in Iraq and Afghanistan, some of which were unpopular actions, one has to agree that when governments decide to act, they do so. The idea that they don’t act because they don’t want to then carries some weight. However, inaction is not necessarily total. The National Aboriginal Health Strategy in the 1990s is an example. The original strategy required funding in the order of $2.5 billion to implement, but only received around $232 million over 5 years. It looked good. Then, when reviewed, people were amazed that it hadn’t worked.9 I contend that if governments are serious about “closing the gap”, adequate funding is one essential component. The other major component is working with Aboriginal leadership in the spirit of a true partnership. In three decades of working in Indigenous affairs, it is not a lack of willing Indigenous leadership that I have noticed. It is a lack of respect for and trust in that leadership by Australian governments. Respect, tolerance and trust in Aboriginal people has to be led from the top. I am not saying that Indigenous leadership is more capable than non-Indigenous government leadership; but it is not less. I’m not saying that Indigenous people have no responsibility for their own situation, but responsibility is what Indigenous leadership has been demanding — along with the respect and resources to shoulder that responsibility. I’m not saying that Indigenous leadership has all the answers; but nor do Australian governments. But in broad terms, we do know what to do. There are mechanisms in place to face the challenge: for example, the National Congress of Australia’s First Peoples, established in 2010 to be a national representative body for Aboriginal and Torres Strait Islander interests.10 Paul Keating’s 1992 Redfern Speech opened the door;11 Kevin Rudd’s 2008 Parliamentary Apology to the Stolen Generations12 stepped through it. We need to pick up again so that in another two decades we are not reflecting on more change but no real progress. Disclaimer The views represented in this article are not necessarily those of the Central Australian Aboriginal Congress.

Peter W Tait MB BS, FRACGP

The Australian Health Survey will deliver key health measures for all Australian children and adults, and collect information across Australia. The Australian Bureau of Statistics has consulted widely on the development of the Survey, and has shaped the survey according to strong and consistent advice in relation to Aboriginal and Torres Strait Islander peoples. It is hoped that this approach will maximise survey response rates and place us in good trust to embark on the next survey round.

Paul L Jelfs PhD

To the Editor: Indigenous Australians have a higher risk of vision loss from preventable and treatable causes than non-Indigenous Australians1 and have been reported to attend eye care services at a lower rate than non-Indigenous Australians.2 Here, we report results from the National Indigenous Eye Health Survey1 which indicate that many Indigenous Australians with vision problems have accessed eye care services but not as frequently as recommended by the National Aboriginal Community Controlled Health Organisation (NACCHO) and the National Health and Medical Research Council (NHMRC), particularly for high-risk groups of patients with diabetes.3,4 The survey methods have been reported elsewhere.1 Briefly, 1694 Indigenous children and 1189 Indigenous adults from 30 communities across Australia had a standardised eye examination and completed a questionnaire in 2008. Recruitment rates were 84% for children aged 5–15 years and 72% for adults aged ≥ 40 years, and 96% of responses to questionnaire items were complete. Seventy-nine per cent (936/1189) of Indigenous adults reported vision problems, of whom 83% (778/936) had sought care from an eye care service (Box 1). Similar to previous studies,5 we found use of eye care services increased with increasing age, but being male and having no education were barriers to accessing services. There was a significant association between higher education levels and higher rates of using of eye care services, with the odds for using eye care services being the highest among those with the highest level of education (data not shown). These factors should be considered when designing public health messages on the importance of using eye care services. As elsewhere in Australia, optometric services were the most frequently used facilities (49%, 378/778) across all regions except very remote inland, where primary health care services had the highest reported usage (33%, 49/149). Participants from very remote coastal and very remote inland regions were twice as likely to consult an ophthalmologist compared with the other regions (Box 2). Twenty-three per cent (179/769) of participants with vision problems reported that they had last seen someone about their vision problem within the previous year, 67% (519/769) within the previous 3 years, and for 33% (250/769) it had been ≥ 3 years. Only 20% (87/444) of participants with self-reported diabetes had seen someone about their vision problem within the previous year. NACCHO recommends that Indigenous adults aged ≥ 40 years should be screened for reduced visual acuity at least every 2 years,3 and NHMRC guidelines recommend that Indigenous adults with diabetes have their eyes checked every year.4 Our results show that we are far from reaching these targets. As regular eye examinations have the potential to reduce the incidence of vision loss, this is a matter of great concern. The importance of regular eye examinations and follow-up, particularly for high-risk groups, should be emphasised to health care providers and the community. Reasons given for not seeking eye care were: not enough time (41%, 62/153); condition not severe enough (22%, 33/153); too expensive (17%, 26/153); eye care not available in area (14%, 22/153); decided not to seek care (14%, 22/153); transport or distance issues (10%, 15/153); and waiting time too long (10%, 15/153). The two most common reasons for not seeking care indicate a lack of awareness about the importance of regular eye examinations, possibly because of a lack of culturally appropriate public health messages. 1 Self-reported history of vision problems, facilities used and resolved vision problems for Indigenous adults 2 Indigenous adults with self-reported vision problems, by facility used and region Primary health care (n = 255) Hospital (n = 48) Optometrist (n = 378) Ophthalmologist (n = 91) Not specified (n = 6) No consultation (n = 156) Total χ2 P Major city 34 (31%) 6 (6%) 48 (44%) 7 (6%) 0 13 (12%) 108 22.5 < 0.01 Inner regional 39 (28%) 4 (3%) 71 (52%) 8 (6%) 1 (1%) 14 (10%) 137 17.7 < 0.01 Outer regional 51 (34%) 6 (4%) 56 (37%) 13 (9%) 1 (1%) 25 (16%) 152 18.3 < 0.01 Remote 55 (28%) 9 (5%) 79 (40%) 12 (6%) 2 (1%) 42 (21%) 199 — 0.16* Very remote coastal 27 (14%) 8 (4%) 81 (43%) 30 (16%) 2 (1%) 41 (22%) 189 — 0.87* Very remote inland 49 (33%) 15 (10%) 43 (29%) 21 (14%) 0 21 (14%) 149 12.7 0.03 * Fisher exact test.

Anna-Lena M R Arnold · Lucy Busija · Jill E Keeffe · Hugh R Taylor

This article critically analyses the prospects for introducing United States anti-fraud (or anti-false claims) laws in the Australian health care setting. Australian governments spend billions of dollars each year on medicines and health care. A recent report estimates that the money lost to corporate fraud in Australia is growing at an annual rate of 7%, but that only a third of the losses are currently being detected. In the US, qui tam provisions — the component of anti-fraud or anti-false claims laws involving payments to whistleblowers — have been particularly successful in providing critical evidence allowing public prosecutors to recover damages for fraud and false claims made by corporations in relation to federal and state health care programs. The US continues to strengthen such anti-fraud measures and to successfully apply them to a widening range of areas involving large public investment. Australia still suffers from the absence of any comprehensive scheme that not only allows treble damages recovery for fraud on the public purse, but crucially supports such actions by providing financial encouragement for whistleblowing corporate insiders to expose evidence of fraud. Potential areas of application could include direct and indirect government expenditure on health care service provision, pharmaceuticals, medical devices, defence, carbon emissions compensation and tobacco-related illness. The creation in Australia of an equivalent to US anti-false claims legislation should be a policy priority, particularly in a period of financial stringency.

Thomas A Faunce LLB(Hons), BMed, PhD · Gregor Urbas BA, LLB (Hons), PhD · Lesley Skillen BA(Hons), LLB(Hons), LLM

The Cancer Council Australia (CCA) Alcohol Working Group has prepared a position statement on alcohol use and cancer. The statement has been reviewed by external experts and endorsed by the CCA Board. Alcohol use is a cause of cancer. Any level of alcohol consumption increases the risk of developing an alcohol-related cancer; the level of risk increases in line with the level of consumption. It is estimated that 5070 cases of cancer (or 5% of all cancers) are attributable to long-term chronic use of alcohol each year in Australia. Together, smoking and alcohol have a synergistic effect on cancer risk, meaning the combined effects of use are significantly greater than the sum of individual risks. Alcohol use may contribute to weight (fat) gain, and greater body fatness is a convincing cause of cancers of the oesophagus, pancreas, bowel, endometrium, kidney and breast (in postmenopausal women). The existing evidence does not justify the promotion of alcohol use to prevent coronary heart disease, as the previously reported role of alcohol in reducing heart disease risk in light-to-moderate drinkers appears to have been overestimated. CCA recommends that to reduce their risk of cancer, people limit their consumption of alcohol, or better still avoid alcohol altogether. For individuals who choose to drink alcohol, CCA recommends that they drink only within the National Health and Medical Research Council guidelines for alcohol consumption.

Margaret H Winstanley BA · Iain S Pratt GradDip(Diet), APD, AEP · Kathryn Chapman BSc, MNutrDiet · Hayley J Griffin BMedSc, MNutrDiet, PhD · Emma J Croager PhD, MBA · Ian N Olver MD, PhD, FRACP · Craig Sinclair MPubPolMgt, GradDipOrgBehav, BEd(Sec) · Terry J Slevin MPH, FPHAA

To the Editor: Van Der Weyden states that “obesity” has negative connotations and the capacity to stigmatise.1 “Intending to give minimal offence and shifting the focus from the person to the condition”, people substitute politically correct terms.1 Medical practice should be scientifically, rather than politically, correct. Language aside, obesity is a blind spot in clinical practice because of the lack of any useful and accurate measure to categorise the condition. Body mass index (BMI) is the universal standard, but it is a very flawed measure. The results of epidemiological studies that support its use depend on huge population numbers, ethnic homogeneity and the exclusion of confounders including smoking and coexisting chronic disease. There is an absence of any epidemiological data showing that reducing overweight or obesity improves outcomes, despite them being frequently cited as risk factors. However, bariatric surgery has been shown to reduce cardiovascular disease, diabetes and cancer incidence.2 Central obesity is a much more powerful predictor of total mortality and cardiovascular disease mortality than BMI.3 In particular, the waist-to-hip ratio (WHR) is useful in population studies, showing precision and a lack of bias over a wide range of ethnic groups.4 Waist circumference is a better predictor than BMI but, like BMI, requires ethnic-specific criteria and is difficult to implement in today’s multiracial societies. WHR performs better as a predictor of cardiovascular disease than all lipid fractions, including total cholesterol and low-density lipoprotein cholesterol.3,5 Lowering lipid levels by drug therapy in the clinical trial setting reduces cardiovascular end points by 20% to 25%. In this context it is pertinent to note that the cost of subsidising prescriptions for lipid-lowering drugs in the financial year 2009–10 was almost $1.5 billion.6 In contrast, there is no simple prescription available to reduce levels of obesity. Healthy eating will always be important. And to make an impact on obesity, 60–90 minutes of moderate physical activity daily is required,7 but the importance of exercise is constantly overlooked and underprescribed. Studies in the United States show that physical activity, recorded daily, reduces cardiovascular disease mortality by about 37%–53%.8 Japan has undertaken an ambitious campaign to identify and counsel employees with excessive waistlines.9 This initiative will be followed with interest. A public health focus on early identification and prevention of central obesity is therefore at least as important in reducing cardiovascular disease mortality as is the measurement and treatment of lipids and hypertension. People with central or abdominal obesity have a serious health hazard and should be informed. “Political correctness” describes a practice that avoids giving offence to minorities. In view of the current epidemic of obesity, the language that we use should be explicit.

Timothy A Welborn · Satvinder S Dhaliwal

Screening plus equitable provision of vitamin D supplements could mitigate many adverse outcomes For nothing worthy proving can be proven, Nor yet disproven: wherefore thou be wise, Cleave ever to the sunnier side of doubt. Alfred, Lord Tennyson, The ancient sage Tennyson may not have been alluding to the need for high-level evidence from randomised controlled trials (RCTs) to alter clinical practice, but he would have been aware of children with rickets. Evidence has accumulated linking vitamin D deficiency to adverse outcomes in pregnancy, such as pre-eclampsia, hypertension, higher rates of caesarean section and preterm delivery. Lau and colleagues (→ Serum 25-hydroxyvitamin D and glycated haemoglobin levels in women with gestational diabetes mellitus) contribute to this evidence by demonstrating that, in women with gestational diabetes mellitus (GDM), a lower serum 25-hydroxyvitamin D (25[OH]D) concentration was independently associated with poorer glycaemic control.1 Of 147 women who were studied late in pregnancy (at a mean of 35 weeks’ gestation), about 40% had vitamin D insufficiency or deficiency (serum 25[OH]D concentrations ≤ 50 nmol/L). Most of the women in this study were not white, and ethnicity, occupational status and season, not surprisingly, all influenced 25(OH)D concentrations, while body mass index did not. Perhaps more surprisingly, however, 25(OH)D concentrations were inversely associated with fasting and 2-hour glucose levels measured during an oral glucose tolerance test and with the marker of glycaemic control, glycated haemoglobin. Most importantly, serum 25(OH)D was an independent predictor of glycaemic control. In adults, a number of large cross-sectional studies have shown a consistent, independent and positive relationship between serum 25(OH)D and insulin sensitivity, and an inverse relationship with risk of diabetes.2-5 Serum 25(OH)D levels have been shown to account for 42% of the variation in insulin sensitivity assessed by hyperglycaemic clamp.3 Consistent with Lau et al’s findings, fasting and 2-hour levels of glucose and insulin have been shown to be independently and inversely associated with serum 25(OH)D levels.3-5 In a United States study, the odds ratio for diabetes was 0.25 (95% CI, 0.11–0.60) for non-Hispanic white participants in the highest versus the lowest serum 25(OH)D quartile.2 The highest-level evidence to date comes from a large prospective study with a 17-year follow-up that showed people in the highest quartile of serum 25(OH)D had a 40% decreased risk of type 2 diabetes compared with those in the lowest quartile.6 Based on these data, RCTs of vitamin D supplementation in adults to improve insulin sensitivity and reduce diabetes risk are underway. GDM is becoming increasingly more common, affecting up to 10% of pregnancies. The presence of GDM is not trivial and has long-term implications for the health of mothers and their children. The former have an increased risk of developing type 2 diabetes, while their offspring have an increased risk of obesity and diabetes later in life. Vitamin D deficiency is also very common in pregnancy. The prevalence of inadequate levels of vitamin D in Lau et al’s study is comparable with rates of vitamin D insufficiency of 47.1% and 83.5% in white and black pregnant women, respectively, in the northern US (defined as 25[OH]D < 80 nmol/L)7 and 65.3% in pregnant women in rural Victoria (defined as 25[OH]D < 75 nmol/L).8 RCTs of vitamin D supplementation, initiated early in pregnancy, are now required to demonstrate whether vitamin D supplementation might reduce the incidence or severity of GDM. International debate is currently focused on the optimal level of serum 25(OH)D. Based on meta-analyses using musculoskeletal end points in older individuals, cut points of 60 nmol/L and 75 nmol/L seem appropriate to prevent falls and fractures, respectively.9 However, a recent Institute of Medicine report recommended at least 50 nmol/L,10 which appears overly conservative and does not take season into account. The public health implications of vitamin D deficiency in pregnancy are far broader than glycaemic control. In Australia, there has been a resurgence of rickets — partly owing to an increased refugee population comprising dark-skinned and veiled women with vitamin D deficiency, and also because of decreased exposure of babies to sunlight, lack of supplementation of infant feeds with vitamin D and weaning of infants onto non-milk liquids. Milder forms of bone disease may also occur with vitamin D deficiency. Recently, a study that used three-dimensional ultrasonography in pregnant women showed that vitamin D deficiency was associated with increased femur metaphyseal cross-sectional area and increased femur splaying (the ratio of femoral metaphyseal cross-sectional area to femoral length) at as early as 19 weeks’ gestation.11 In addition, it was previously shown that children born to mothers with vitamin D deficiency (< 50 nmol/L) during pregnancy exhibit deficits in total body bone mineral content as great as 11% at 9 years of age.12 This could lead to an increased risk of osteoporotic fracture later in adult life, but this is unlikely to be evaluated in long-term studies. In addition, maternal or early life vitamin D deficiency has been linked to an increased risk of several other disorders, including neonatal craniotabes, prematurity, type 1 diabetes mellitus, schizophrenia, and childhood respiratory infections and wheeze.13,14 Current evidence strongly supports routine screening for vitamin D deficiency early in pregnancy. Furthermore, vitamin D supplementation to correct deficiency should be initiated early in pregnancy as it might reduce the incidence or severity of GDM and because changes in skeletal morphology of the fetus associated with deficiency are seen as early as 19 weeks’ gestation. The most common recommended daily doses of cholecalciferol are 1000 IU–2000 IU, however, daily doses of up to 4000 IU have recently been shown to be safe in pregnancy (Bruce W Hollis, Professor, Department of Paediatrics, Medical University of South Carolina, USA, personal communication). What is problematic is the equitable provision of vitamin D supplements to pregnant Australian women with deficiency. Pregnant and breastfeeding women who are most at risk of vitamin D deficiency are often the least likely to be able to afford supplements. In the United Kingdom, vitamin D supplements are provided free of charge to such women through the Healthy Start program.15 There is evidence to support more widespread use of vitamin D supplements during pregnancy in Australia, although more research is required. One way to increase access might be to alter the scheduling of higher-dose, lower-cost vitamin D supplements.

Peter R Ebeling MB BS, MD, FRACP

A national interdisciplinary body is urgently needed to manage the looming antimicrobial resistance crisis The introduction of antibiotics was one of the most important developments in modern medicine. Their availability has facilitated increasingly complex care and, not surprisingly, microbial resistance to antibiotics has been identified as one of the greatest threats to human health. A return to the “pre-antibiotic era” would render many routine infections untreatable and would seriously affect current practice in surgery, intensive care, organ transplantation, neonatology and cancer services through major increases in morbidity and mortality. The time to act is now — before we lose these “miracle” drugs for good. Preserving the “miracle” of antibioticsIn response to a looming crisis in antimicrobial resistance, the Australasian Society for Infectious Diseases and the Australian Society for Antimicrobials convened the Antimicrobial Resistance Summit in Sydney on 7–8 February 2011. The meeting brought together an interdisciplinary group of experts from the medical, veterinary, agricultural, infection control and public health sectors to establish priorities and a joint plan for action, focusing on the key elements shown in Box 1. The threat of antibiotic overuseThe keynote address at the Summit was given by Professor Otto Cars (Professor of Infectious Diseases, Uppsala University, Sweden, and Chair of STRAMA, the Swedish strategic program against antibiotic resistance). STRAMA, a government-funded body, has supervised a multidisciplinary effort to improve surveillance and infection prevention and promote rational antimicrobial usage. This has been very successful in reducing usage in Sweden. Professor Cars highlighted that the key factor contributing to the alarming resistance trend in bacteria is the indiscriminate use of antibiotics. This is occurring in a number of settings including hospitals, general practice and veterinary medicine. Agricultural practices involving the use of antibiotics for prophylaxis and growth promotion rather than treatment also contribute to this problem. Repeated studies have demonstrated that a significant proportion of antibiotic use is unnecessary and that antibiotic use varies markedly between countries despite similar clinical outcomes.1 For many bacterial pathogens, resistance to last-line antibiotics, such as carbapenems, fluoroquinolones, glycopeptides and third-generation cephalosporins, is now commonly found in Australian hospitals and, to an increasing extent, in the community. Examples include methicillin-resistant Staphylococcus aureus, multiresistant Streptococcus pneumoniae, vancomycin-resistant enterococci and multiresistant Escherichia coli.2 This growing ineffectiveness of once-reliable drugs has seen health care professionals increasingly turning to alternatives that are more toxic, more expensive and less likely to be orally available, putting increased pressure on a strained hospital system. In addition, compared with susceptible bacteria, antibiotic-resistant strains are associated with increased patient morbidity and mortality and increased costs of health care.1 A dwindling pipelineWhile the issue of antimicrobial resistance is not new, it has long been assumed that this problem would be overcome by the ongoing development of new compounds. However, there has been an alarming decline in antibiotic development over time, highlighting that this strategy cannot be relied upon.1 The Antimicrobial Resistance Summit plan for actionSurveillanceMeasuring the extent of antimicrobial resistance in community- and health care-associated infections is crucial to defining the issue and measuring outcomes of any interventions designed to address it. While passive surveillance by electronic collation of routine susceptibility results can provide the broadest view of phenotypic changes, targeted surveillance by prospective studies of specific pathogens of interest provides details of newly emerging resistance mechanisms and strains. At present, the extent of antimicrobial resistance in Australia remains poorly defined. The current systems of data collection and collation vary between states and territories and there is limited coordination at a national level. In addition to measuring antimicrobial resistance, it is important to understand antibiotic usage. Currently, the National Antimicrobial Utilisation Surveillance Program represents the only nationwide systematic surveillance of antibiotic usage, but it is based on voluntary data submitted from major hospitals, representing about 50% of Australian tertiary referral beds3 (Box 2). Education and stewardshipEducation of the public as well as medical, veterinary and public health sectors is a crucial component in achieving judicious prescribing and dispensing of antibiotics. However, research has demonstrated that education campaigns and guidelines are ineffective unless they are combined with sustained interventions such as audit and feedback methods and/or a system where proactive steps are taken to assist prescribing and interventions are made to address poor performance.4 Antimicrobial stewardship acts at an organisational level and defines collective strategies to optimise antimicrobial prescribing through sustainable changes in practice. Further initiatives are required in the community, where the majority of human antibiotics are prescribed (Box 3). Infection prevention and control strategiesGeneric measures such as hand hygiene, avoidance of patient contamination during invasive procedures, environmental cleaning and disinfection, vaccination, and antibiotic stewardship are crucial in infection prevention and control. Surveillance is critical for determining the health care infection burden, identifying the people who are most at risk, and demonstrating the effectiveness of infection prevention or control interventions. To be effective, nationally coordinated surveillance is essential. Screening and effective isolation of patients carrying multiresistant organisms also has an important role1 (Box 4). Future research agendaWhile basic science research on microbiology is currently adequately funded by the National Health and Medical Research Council (NHMRC) and the Australian Research Council, a number of essential aspects required to combat antibiotic resistance do not find a ready place in existing project grant structures (Box 5). RegulationImplementing effective regulatory controls represents an important aspect of reducing indiscriminate use of antibiotics and keeping levels of antimicrobial resistance low in both human and animal settings (Box 6). An urgent call to actionThe threat of multiresistant bacteria is a critical public health issue that requires a coordinated, multifaceted response. To achieve this level of cooperation, we propose the creation of a national antimicrobial resistance management body comprising a wide range of stakeholders, including health care professionals, veterinarians, agriculturalists, pharmaceutical manufacturers, government, media representatives, consumers and other interested parties. The role of this body would include: implementing a comprehensive national resistance monitoring and audit system coordinating education and stewardship programs implementing infection prevention and control guidelines expanding funding to support research into all aspects of antibiotic resistance reviewing and upgrading the current regulatory system applying to antibiotics. This strategy is recommended by the World Health Organization1 and has been adopted by many other countries. The scourge of antimicrobial resistance has increased inexorably over the years. We believe that the window for overcoming antimicrobial resistance is still open, but we must act decisively now — Australia cannot bury its head in the sand any longer and hope that the problem will just go away. 1 An agenda for addressing antimicrobial resistance 2 Surveillance: key recommendations Antimicrobial resistance surveillance A comprehensive national surveillance system encompassing both passive and targeted components should be developed to monitor how much resistance is present, in which bacteria and where. This should include medical (hospital and community) and veterinary areas, as well as agriculture (including imported food). Priority should be given to staphylococci and Escherichia coli, which have the greatest impact on human health (emerging resistance in E. coli and other Gram-negative bacteria poses a major new threat). Methods used in resistance testing should be standardised wherever possible to enable comparison and pooling of data. In particular, minimum inhibitory concentration breakpoints need to be standardised. Antibiotic usage surveillance A comprehensive national monitoring and audit system covering all areas of antibiotic usage should be established. This should include comprehensive surveillance of hospital usage (eg, by expanding the National Antimicrobial Utilisation Surveillance Program), representative sampling of community prescribing, and collating distribution data from agricultural antibiotic suppliers. Data on the appropriateness of usage should also be evaluated (using point-prevalence surveys comparing diagnosis with prescription). Voluntary identification of hospitals in surveillance programs is recommended to encourage benchmarking and transparency. 3 Education and stewardship: key recommendations Educational initiatives need to define antimicrobial resistance as an urgent public health issue. The skills of social marketers and behavioural change experts should be used to drive a national campaign targeting both the public and prescribers. The National Prescribing Service (NPS) antibiotic educational campaign should also be reinstituted. A uniform national medical curriculum should be implemented that acknowledges overuse of antibiotics and embraces better stewardship, building on the NPS National Prescribing Curriculum. Stewardship, based on national antibiotic guidelines and local epidemiology, must be mandated in all hospitals within a quality framework based on audit and feedback. Effective stewardship requires a team-based approach including infection prevention units, microbiologists, pharmacists and clinicians. It must be strongly supported by senior hospital management and underpinned by effective use of information technology. Stewardship should also be extended beyond health care institutions to community care, long-term care facilities and non-medical antibiotic use. A well resourced national body should be created to provide effective national coordination of educational activities and antibiotic stewardship. Recognising that antibiotic resistance does not respect international borders, Australia has an obligation to contribute to international programs to control antibiotic use and resistance. 4 Infection prevention and control strategies: key recommendations Improved training on strategies for infection prevention and control should be provided to health care workers. All major hospitals should have the epidemiological capacity to identify and investigate outbreaks of multiresistant organisms, and to monitor and respond to changing patterns of pathogens causing health care-associated infections. National evidence-based standards for multiresistant organism control in aged care facilities should be developed, implemented and robustly enforced and monitored. A national coordinating centre for the control of antimicrobial resistance is needed, with the authority and capacity to collect and analyse data on multiresistant organisms from all jurisdictions. This will facilitate timely, consistent and effective control of multiresistant organisms. 5 Future research agenda: key recommendation A new National Health and Medical Research Council funding call (similar to that for pandemic [H1N1] 2009 influenza) is needed for research on antimicrobial resistance and usage in Australia and its near neighbours. The key areas of focus should be: epidemiology (in both human and animal settings) effective interventions for the public sectors, focusing on education and behavioural change effective interventions for the health care sector. 6 Regulation: key recommendations Resistance risk assessments should be part of the regulatory process for bringing new antibiotics to market for both humans and animals. The Pharmaceutical Benefits Advisory Committee should consider resistance in the criteria for inclusion or restriction of antibiotics in the Pharmaceutical Benefits Scheme. Strategies should be implemented to fast-track important new antimicrobials through the regulatory approval system. Strategies should be implemented to enable the registration of non-commercial “orphan” drugs that have the potential to improve patient outcomes and reduce disease burden. Adopting an antibiotic importance rating system as regulatory policy should be considered.

Thomas Gottlieb MB BS, FRACP, FRCPA · Graeme R Nimmo MD, FRCPA, FASM

Newborn screening (NBS) programs are a well established and cost-effective method for early identification of genetic disorders. However, a raft of legal questions surrounds the collection, storage, ownership and secondary use of NBS cards. The absence of clear legal rules governing NBS programs in Australia means that there are few straightforward answers to these questions. A series of controversial incidents have exposed this uncertainty in Australia, and remarkably similar controversies have occurred in the United States and European Union. We review the situation, using Victoria as a case study. We also make the case for a dedicated regulatory regime for NBS programs, arguing that the lack of such a regime threatens public trust and the robust operation of NBS programs in Australia. New rules would likely introduce stricter requirements for informed consent at the point of blood collection than has been the norm to date. However, the scope for use of cards in research could expand rather than contract, and it may be possible to reduce the risk that vast card archives will need to be destroyed in response to future public outcries.

Diana M Bowman BSc, LLB, PhD · David M Studdert LLB, ScD, MPH

To the Editor: The article by Nelson and colleagues1 is a welcome contribution to understanding trends in varicella zoster virus (VZV) disease epidemiology in Australia, particularly ambulatory medical attendance, for which few data sources are available. They report a decline in general practitioner encounters for varicella (chicken pox) since the introduction of varicella vaccine that is consistent with the observed 69% reduction in national hospitalisation rates in children aged 1.5 to 4 years seen from January 2006 to June 2008, 2.5 years into the National Immunisation Program (NIP).2 Nelson et al also report a trend towards higher GP encounter rates for herpes zoster (HZ [shingles]) over time. Although it may be tempting to take this rise on face value, additional analyses are required for a full understanding of patterns in HZ-related health care use, particularly accounting for age and changes in the use of prescription medications, including antivirals and opioid analgesics. Increased HZ-related health care use commencing before varicella vaccine availability has been reported in countries with universal vaccination programs, including the United States3 and Australia,4 as well as in countries where varicella vaccination is not recommended universally, including the United Kingdom.5 In Australia, prescribing of antiviral drugs for HZ increased between 1995 and 1999.6 Australia’s ageing population will contribute to the increasing prevalence of HZ over time due to the propensity of the virus to reactivate with advancing age. An analysis that we conducted shows that an increase in crude national hospitalisation rates for HZ preceded varicella vaccine availability, and that there was no increase over time in age-specific and age-standardised rates (National Centre for Immunisation Research and Surveillance, unpublished data). In addition, the suggestion from modelling studies that HZ may increase under a universal varicella vaccination program because of reduced opportunity for immune boosting in adults has yet to be observed in the US, the country with the longest-standing universal program of varicella vaccination.3 These complexities in monitoring VZV-related diseases highlight the need for very sensitive and well validated surveillance systems for both varicella and HZ in Australia. Although the authors request consideration for a universal HZ vaccination program for those over 65 years, they may not have been aware that since April 2009 The Australian immunisation handbook, ninth edition, online version has had new guidelines on HZ vaccination recommending a single dose of live attenuated VZV vaccine from the age of 60 years.7 In March 2008, the Pharmaceutical Benefits Advisory Committee recommended that this vaccine was suitable for inclusion in the NIP for those aged 60 years, with a catch-up dose for all individuals aged 61 to < 80 years. A decision regarding NIP funding has not been made, possibly because of a shortage of vaccine due to manufacturing problems.

Anita E Heywood · Kristine K Macartney

To the Editor: In Australia, addition of thiamine to bread flour (at 6.4 mg/kg) was made mandatory on 1 January 1991 in an effort to reduce the incidence of Wernicke’s encephalopathy and Korsakoff psychosis.1 Recently, an isocratic high-performance liquid chromatography (HPLC) method for the assessment of thiamine, thiamine monophosphate and thiamine diphosphate (TDP) in human erythrocytes has been described.2 This direct method of measuring thiamine in blood is superior to measuring red blood cell transketolase. We used an HPLC reagent kit (Chromsystems Instruments and Chemicals GmbH, Munich, Germany) to measure whole blood TDP concentrations in a population of 156 people who had alcohol use disorders. They were consecutive cases presenting between June and September 2010 at a driver assessment clinic in South Australia after they were convicted of two or more drink-driving offences. Thirty-two people taking a thiamine-containing medication or vitamin supplement were excluded. Based on the Diagnostic and statistical manual of mental disorders, fourth edition, text revision, of the remaining 124 people, 42 fulfilled criteria for “alcohol dependence” and 82 fulfilled criteria for “alcohol abuse” in the preceding 12 months.3 Of those tested, none had biochemical thiamine deficiency (defined as 2 standard deviations below the reference mean TDP concentration [< 66.5 nmol/L]). The lowest whole blood TDP concentration was 106 nmol/L. The highest concentration found was 362 nmol/L. The mean concentration was 217 nmol/L. This value is 2.5 standard deviations above the mean for the reference population (mean, 133 nmol/L; SD, 33 nmol/L).4,5 The reference range (66.5–200 nmol/L) was derived from a population that did not receive thiamine supplementation in foods. The characteristics of the distributions of thiamine concentrations in the Australian and reference populations are shown in the Box. The mean age of our population was 36 years, the youngest person was aged 19 years and the oldest, 73 years. The mean body mass index was 26.6 kg/m2 and the lowest was 18 kg/m2, so this group was not malnourished. The mean daily alcohol intake reported was 22 g/day but there was wide variation (range, 0–272 g/day; SD, 35 g/day). The results from the population with alcohol use disorders show remarkably elevated thiamine concentrations and no evidence of thiamine deficiency. The very high mean concentration of thiamine shows that this population is not at immediate risk of thiamine deficiency. It also suggests that mandatory supplementation of flour with thiamine has raised the baseline concentration of thiamine in Australians. Distribution of thiamine diphosphate (TDP) concentration in an Australian population with alcohol use disorders compared with a reference population4,5

Philip M Crowley · Matt D Gaughwin

Objective: To describe the use of surveillance and forecasting models to predict and track epidemics (and, potentially, pandemics) of influenza.Methods: We collected 5 years of historical data (2005–2009) on emergency department presentations and hospital admissions for influenza-like illnesses (International Classification of Diseases [ICD-10-AM] coding) from the Emergency Department Information System (EDIS) database of 27 Queensland public hospitals. The historical data were used to generate prediction and surveillance models, which were assessed across the 2009 southern hemisphere influenza season (June–September) for their potential usefulness in informing response policy. Three models are described: (i) surveillance monitoring of influenza presentations using adaptive cumulative sum (CUSUM) plan analysis to signal unusual activity; (ii) generating forecasts of expected numbers of presentations for influenza, based on historical data; and (iii) using Google search data as outbreak notification among a population.Results: All hospitals, apart from one, had more than the expected number of presentations for influenza starting in late 2008 and continuing into 2009. (i) The CUSUM plan signalled an unusual outbreak in December 2008, which continued in early 2009 before the winter influenza season commenced. (ii) Predictions based on historical data alone underestimated the actual influenza presentations, with 2009 differing significantly from previous years, but represent a baseline for normal ED influenza presentations. (iii) The correlation coefficients between internet search data for Queensland and statewide ED influenza presentations indicated an increase in correlation since 2006 when weekly influenza search data became available.Conclusion: This analysis highlights the value of health departments performing surveillance monitoring to forewarn of disease outbreaks. The best system among the three assessed was a combination of routine forecasting methods coupled with an adaptive CUSUM method.

Justin R Boyle BEng(Hons), PhD · Ross S Sparks MSc, PhD · Gerben B Keijzers MB BS, MSc(ClinEpi), FACEM · Julia L Crilly MN(Hons), PhD · James F Lind BS BM, BMedSci, FACEM · Louise M Ryan MA, PhD

Objective: To describe the epidemiology of adult patients hospitalised with influenza or pneumonia during a pandemic season in a sentinel network in Australia.Design, participants and setting: Prospective case series of adult hospital admissions to eight acute care general public hospitals (Influenza Complications Alert Network [Flu CAN] sentinel hospitals) in six Australian jurisdictions, 1 July to 4 December 2009.Main outcome measures: Demographic, clinical and outcome measures in patients admitted with laboratory-confirmed pandemic (H1N1) 2009 influenza in the sentinel hospitals compared with data from national notifications and intensive care unit (ICU) surveillance; admissions for influenza and pneumonia over time in each jurisdiction.Results: During 190 hospital-weeks of observation, there were 538 influenza admissions. Of these, 465 patients (86.4%) had the pandemic strain, representing 9.3% of total admissions with pandemic (H1N1) 2009 influenza (n = 4992) recorded nationally in 2009. Of these patients, 250/465 (53.8%) were women, 67/453 (14.8%) were Indigenous, and the median age was 46 years (interquartile range, 29–58 years). Comorbidities were present in 354/464 patients (76.3%), and 40 were pregnant (30.3% of women aged 15–49 years). FluCAN reported that 102 patients (21.9%) were admitted to ICUs, and of patients admitted to hospital, 26 (5.6%) died. FluCAN results were very similar to national notification data and published ICU admissions data. Of those who were followed to 30 days after discharge, 30 (6.5%) were readmitted. Of 1468 patients hospitalised with pneumonia, 718 (48.9%) were tested for influenza and 163 (11.1%) were co-infected with the pandemic strain.Conclusions: Sentinel surveillance systems can provide important and reliable information in a timely fashion and can monitor changes in severity of influenza during a pandemic season.

Paul M Kelly MB BS, PhD, FAFPHM · Tom Kotsimbos MD, FRACP · Anna Reynolds BSc, PhD · Richard Wood-Baker DM, FRACP · Bob Hancox MD, FRACP · Simon G A Brown MB BS, PhD, FACEM · Mark Holmes MB BS, MD, FRACP · Graham Simpson MD, FRCP, FRACP · Simon Bowler MB BS(Hons), FRACP · Grant Waterer PhD, FRACP, FCCP · Louis B Irving MB BS, FRACGP, FRACP · Christine Jenkins MD, FRACP · Phillip J Thompson MD, FRACP · Allen C Cheng FRACP, MPH, PhD

Objective: To examine the costs and cost-effectiveness of full implementation of biennial bowel cancer screening for Australian residents aged 50–74 years.Design and setting: Identification of existing economic models from 1993 to 2010 through searches of PubMed and economic analysis databases, and by seeking expert advice; and additional modelling to determine the costs and cost-effectiveness of full implementation of biennial faecal occult blood test screening for the five million adults in Australia aged 50–74 years.Main outcome measures: Estimated number of deaths from bowel cancer prevented, costs, and cost-effectiveness (cost per life-year gained [LYG]) of biennial bowel cancer screening.Results: We identified six relevant economic analyses, all of which found colorectal cancer (CRC) screening to be very cost-effective, with costs per LYG under $55 000 per year in 2010 Australian dollars. Based on our additional modelling, we conservatively estimate that full implementation of biennial screening for people aged 50–74 years would have gross costs of $150 million, reduce CRC mortality by 15%–25%, prevent 300–500 deaths from bowel cancer, and save 3600–6000 life-years annually, for an undiscounted cost per LYG of $25 000–$41 667, compared with no screening, and not taking cost savings as a result of treatment into consideration. The additional expenditure required, after accounting for reductions in CRC incidence, savings in CRC treatment costs, and existing ad-hoc colonoscopy use, is likely to be less than $50 million annually.Conclusions: Full implementation of biennial faecal occult blood test screening in Australia can reduce bowel cancer mortality, and is an efficient use of health resources that would require modest additional government investment.

Michael P Pignone MD, MPH · Kathy L Flitcroft BBSc, MA(Govt), GradCertHlthPolicy · Kirsten Howard MPH, MHlthEc, PhD · Lyndal J Trevena MB BS, MPhilPH, PhD · Glenn P Salkeld MPH, PhD · D James B St John MD, FRACP, AGAF

To the Editor: Dinh and colleagues present data on head injuries among cyclists admitted to the emergency department of Sydney’s Royal Prince Alfred Hospital (RPAH) from 1991 to 2010,1 and conclude with their opinion that legislation mandating the wearing of bicycle helmets should be maintained. However, their data provide poor evidence of the efficacy of helmets and of the effectiveness of legislation requiring helmet use. Almost all studies of helmet efficacy are case–control studies, which, to be of high quality, require a well defined and matched control group. In the study by Dinh et al, the control group was made up of patients who had been wearing a helmet. Many possible explanations for injury severity were not considered. For example, were the non-helmeted cyclists drinking alcohol or riding faster? Were they more likely to be risk-takers? Were the helmet wearers also wearing high-visibility vests or using lights at night? Case–control studies of this kind are a weak form of evidence (ranking just above anecdotal evidence and case studies) and cannot answer questions of causality. The two graphs presented by Dinh et al show that head injury rates among cyclists were very low and fairly stable over most of the time period examined. RPAH treats thousands of trauma patients each year. The study reported on 287 cyclists admitted in a 2.5-year period — an average of 115 per year. Of these, only 14 (eight helmeted; six not wearing helmets) incurred major trauma — about six per year. Given that helmet legislation was in place for the entire study period, these data add no evidence for its effectiveness. In public health terms, the risk of injury needs to be weighed against the benefits of increased physical activity, reduced chronic disease and reduced air pollution due to more people cycling. Because of the low absolute rate of cycling injuries, these benefits are nine to 20 times the size of the risk.2,3 Further, it is well documented that levels of cycling in Australia dropped by 30%–40% when helmet legislation was introduced. This had the unfortunate effect of making cycling less safe for the remaining cyclists because of the “safety in numbers” phenomenon.4 The poor uptake5 of the two public bicycle-hire schemes in Australia (in Melbourne and Brisbane) indicates that helmets are a significant barrier to short-trip and spontaneous cycling, with few potential or casual users carrying a bicycle helmet in case they decide to hire a bicycle. Dinh and colleagues obviously believe in the efficacy of the bicycle helmet, but this does not mean that mandating their use is the best public health policy response. When helmet legislation was introduced, we did not have the epidemics of diabetes and obesity that now threaten to bankrupt state health budgets. Strategies to increase levels of physical activity among the whole population are desperately needed, even if there is a small risk involved.

Chris E Rissel · Paul Martin

Objective: To evaluate trends in the incidence and serotype profile of invasive pneumococcal disease (IPD) in Australian children under 2 years of age after the introduction of the 7-valent pneumococcal conjugate vaccine (7vPCV).Design and setting: Analysis of incidence rates calculated using IPD surveillance data (including age, Indigenous status and serotype of the pneumococcal isolate) from 2002 to 2007 obtained from the National Notifiable Diseases Surveillance System and population estimates obtained from the Australian Bureau of Statistics.Main outcome measures: Trends in IPD incidence among Indigenous and non-Indigenous children between 2002 and 2007; change in the serotype profile of IPD in non-Indigenous children after the introduction of universal 7vPCV vaccination in 2005.Results: Overall incidence of IPD decreased by 74% in all children < 2 years of age between 2002 and 2007 (P < 0.001). While the incidence of IPD caused by 7vPCV serotypes decreased significantly among both Indigenous and non-Indigenous children, the incidence of non-7vPCV serotype IPD increased significantly in non-Indigenous children (from 9.7 to 15.7 per 100 000, P < 0.001). Compared with a pre-vaccination period (2002–2004), the 2007 incidence of serotype 19A IPD in non-Indigenous children increased significantly (from 2.7 to 8.6 per 100 000, P < 0.001). In 2007, 19A was the predominant serotype causing IPD (37.7%) in all children aged < 2 years.Conclusions: The overall incidence of IPD decreased from 2002 to 2007, primarily driven by a reduction in IPD caused by 7vPCV serotypes. However, this was partially offset by a significant increase in the incidence of IPD caused by non-7vPCV serotypes, particularly 19A, in non-Indigenous children.

Scott R Williams BSc(Hons), MB BS · Paul J Mernagh BEc(Hons), MCom · Michael H T Lee BA, MB BCh BAO · Jonathan T Tan BSc(Hons), PhD

To the Editor: About 5% of Australians of Asian, African, Middle Eastern or Mediterranean descent have glucose-6-phosphate dehydrogenase (G6PD) deficiency.1 Affected babies can develop massive haemolysis within hours of exposure to clothes stored with mothballs containing naphthalene. It has long been known that this results in severe jaundice, which may lead to kernicterus2 and profound brain damage, for which the cost is either a lifetime of dependency and very expensive care, or death. We are aware of three cases of kernicterus in babies with G6PD deficiency in Australia in the past 3 years, one of which was associated with exposure to naphthalene in mothballs. One baby died. The exact incidence of severe neonatal jaundice and kernicterus in Australia is unknown, but it is the subject of an ongoing study funded by the Cerebral Palsy Foundation and coordinated through the Australian Paediatric Surveillance Unit. In Australia, packages of naphthalene mothballs must carry a warning that the product is harmful to children. However, clinical directors of neonatal units that comprise the Australian and New Zealand Neonatal Network have unanimously agreed that warning labels give insufficient protection. They have called on the Australian Pesticides and Veterinary Medicines Authority (APVMA) to act in harmony with the European Union, which banned the sale of mothballs containing naphthalene in 2008,3 following a report by the European Chemicals Bureau.4 The adverse risk–benefit ratio for naphthalene provides strong justification for its withdrawal. A submission to this effect has been lodged with the APVMA. Some mothballs contain paradichlorobenzene, a chemical related to naphthalene and associated with haemolysis. Less toxic products that protect clothes against moths exist. Department stores in the United Kingdom have replaced moth repellents containing naphthalene with products containing natural substances, such as sandalwood and lavender. Between 2004 and 2010, the New South Wales Poisons Information Centre reported that it received about one call per week concerning children exposed to naphthalene in moth repellents (Box). The Victorian Poisons Information Centre reported 53 calls in 2008.5 While acknowledging the importance of raising awareness of the dangers of naphthalene, we believe that the safest course is prevention — that is, an Australia-wide ban of mothballs containing naphthalene. Readers who wish to report cases of naphthalene toxicity are encouraged to contact APVMA at aerp@apvma.gov.au. Number of calls to the New South Wales Poisons Information Centre reporting children exposed to napthalene in moth repellents, 2004–2010 Year Number of calls 2004 55 2005 59 2006 65 2007 67 2008 73 2009 45 2010 71 Total (average) 435 (62) Source of data: Judith Kirby, Department Head, NSW Poisons Information Centre, personal communication.

on behalf of the Advisory Committee of the Australian and New Zealand Neonatal Network

To the Editor: Douglas and other senior epidemiologists have described the imminent demise of the Master of Applied Epidemiology (MAE) program.1 This program has produced around 160 graduates, at least 104 of whom (65%) are working in the broad area of infectious diseases epidemiology. It may be thought, therefore, that there is no further scope for employing MAE graduates. My experience indicates otherwise and I would be very surprised if it were unique. In a small epidemiology unit of a state reference laboratory, two of the six staff members are MAE graduates. One past employee, also an MAE graduate, is a close collaborator. Last year, on very short notice, this person was able to take over coordination of the infectious diseases epidemiology course in the Master of Public Health program (MPH) at the University of Melbourne after the previous coordinator, also an MAE graduate, accepted a position as Head of the School of Health and Social Development at Deakin University. The MAE graduates from the epidemiology unit contributed to the MPH teaching program as guest lecturers. The University of Melbourne was unable to attract a full-time infectious diseases epidemiologist to the coordinating position, suggesting a lack of suitably trained and experienced people in this discipline. There is no doubt that the MAE program produces suitably trained and experienced people, as attested by Douglas et al1 and Kelly et al in the Journal.2 It also fits with my experience as an employer of MAE graduates and a collaborator with other graduates and staff from the program. Continued funding of the MAE program was recommended by independent reviewers.3 There are many who believe that, not only should the MAE program continue, it should continue as part of a national infectious diseases prevention and control program.2 It is appropriate that similar Australian programs already exist for heart disease, cancer and diabetes. In a letter to the Journal, Givney eloquently described the arcane processes of interlocking acronym-rich, mandate-limited committees that constitute Australia’s approach to the national coordination of infectious diseases.4 This description would be recognised by many, who would agree with Givney and Kelly et al that the time has come for Australia to establish its own independent expert body for monitoring and control of infectious diseases.

Heath A Kelly

Objective: To determine the impact that mandatory fortification with folic acid of wheat flour used in breadmaking has had on the blood folate levels of an Australian population since it was introduced in September 2009.Design, setting and patients: A retrospective analysis of serum and red blood cell (RBC) folate levels of 20 592 blood samples collected between April 2007 and April 2010 from a wide variety of inpatients and outpatients and analysed in a large public hospital diagnostic pathology laboratory.Main outcome measures: Prevalences of low levels of serum and RBC folate and monthly mean levels before and after introduction of mandatory fortification.Results: Between April 2009 and April 2010, there was a 77% reduction in the prevalence of low serum folate levels (from 9.3% to 2.1%) in all samples tested and an 85% reduction in the prevalence of low RBC folate levels (from 3.4% to 0.5%). In April 2010, the prevalence of low RBC folate levels for females of childbearing age was 0.16% for all samples. There was a 31% increase in mean serum folate level (from 17.7 nmol/L to 23.1 nmol/L; t = 9.3, P < 0.01), and a 22% increase in mean RBC folate level (from 881 nmol/L to 1071 nmol/L). The greatest increment in mean serum folate levels occurred in September 2009, the month that mandatory fortification was introduced, although there was evidence of a gradual change during the preceding months.Conclusion: The introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in women of childbearing age.

Ross D Brown PhD, MBA, FAIMS · Mark R Langshaw BAppSci, GradDipIT · Elaine J Uhr MSc(BiolSc) · John N Gibson PhD, FRACP, FRCPA · Douglas E Joshua DPhil, FRACP, FRCPA

Objective: To determine antibody levels and estimate incidence of infection with pandemic (H1N1) 2009 influenza in children and pregnant women during the 2009 winter in Western Australia.Design, setting and participants: Two cross-sectional serosurveys using stored specimens collected for unrelated pathology testing, from before and after (3 August to 30 November 2009) circulation of the pandemic virus, and before commencement of the pandemic vaccination program. Specimens were from three groups: children aged 1–4 years, older children and teenagers aged 5–19 years, and pregnant women aged 21–45 years. The groups were geographically representative of the WA population.Main outcome measures: Reactivity against pandemic (H1N1) 2009 and seasonal A(H1N1) influenza viruses measured using haemagglutination inhibition (HI) assays.Results: Antibody titres were determined for 648 individuals in the prepandemic period and 736 in the postpandemic period. In the prepandemic period, HI titres ≥ 40 against the pandemic virus were found in 0 (95% CI, 0.0%–1.6%) children aged 1–4 years, 8.3% (95% CI, 5.3%–12.7%) of older children and teenagers, and 4.5% (95% CI, 2.4%–8.3%) of pregnant women. In postpandemic specimens collected from 1 September 2009 (when influenza activity had declined to near-baseline levels), estimated infection rates (subtracting prepandemic levels) were 25.4% (95% CI for difference, 18.6%–33.4%) in 1–4-year-old children, 39.4% (95% CI, 29.8%–48.5%) in older children and teenagers, and 10.2% (95% CI, 4.1%–17.1%) in pregnant women.Conclusions: A quarter of preschool children and about 40% of school-aged children and older teenagers had serological evidence of pandemic influenza infection during winter 2009, indicating high levels of mild or asymptomatic infection. The infection rate in pregnant women was much lower. The high infection rates in children help explain the reduced impact of the pandemic virus during the 2010 winter. Augmented by vaccination, there should be sufficiently high levels of immunity in the Australian population to significantly reduce the impact of the virus in future influenza seasons.

Gary K Dowse MB BS, MSc, FAFPHM · David W Smith BMedSc, MB BS, FRCPA · Heath Kelly MB BS, MPH · Ian Barr PhD · Karen L Laurie BSc(Hons), PhD · Anthony R Jones BSc, MASM · Anthony D Keil MB BS, FRCPA · Paul Effler MD, FAFPHM

Four formal rounds of Trans-Pacific Partnership Agreement (TPPA) negotiations took place in 2010. They involved over 200 officials from Australia, the United States, New Zealand, Chile, Singapore, Brunei, Peru, Vietnam and Malaysia. Future negotiations officially are set to include three issues with public health and medicines policy implications for Australia and our region: ways to approach regulatory coherence and transparency; how to benefit multinational and small–medium enterprises; and multilateral investor–state dispute settlement. US-based multinational pharmaceutical companies are lobbying for TPPA provisions like those in the Australia–US Free Trade Agreement, which reduce government cost-effectiveness regulatory control of pharmaceuticals, threatening equitable access to medicines. They also advocate increased TPPA intellectual monopoly privilege protection, which will further limit the development of Australian generic medicine enterprises and restrict patient access to cheap, bioequivalent prescription drugs. Of particular concern is that proposed TPPA multilateral investor–state dispute settlement procedures would allow US corporations (as well as those of other TPPA nations) to obtain damages against Australian governments through international arbitral proceedings if their investments are impeded by Australian public health and environment protection legislation.

Thomas A Faunce BA LLB, BMed, PhD · Ruth Townsend RN, LLM

An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a "surgical vaccine" against future sexually transmitted HIV has attracted strong criticism from many of our readers (MJA 2011; 194: 97-101) To the Editor: In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy.1 In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.2 While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission,3 this is not so in low-prevalence environments where homosexual transmission is more important.4 Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited.5 Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase.6 There is minimal protection against homosexual acquisition of HIV.4 The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted.7 The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks.2 The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks. To the Editor: In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia.1 However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals. Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision2 and heterosexually transmitted HIV infection.3 Circumcision removes the most sensitive tissue of the penis4 and serious complications include death (about 0.9 deaths per 10 000 circumcisions).5 If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications. Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic,6 which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost-effectiveness.7 In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision.8 In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medicolegal issues. New 2010 Royal Australasian College of Physicians guidelines9 continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group.10 Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys.11 To the Editor: We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission.1 The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact.2 However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV.3 Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections.4 In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM. With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM. The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P = 0.90). As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than large-scale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse. To the Editor: In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV.1 There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy. There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results.2 The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence.2-4 There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection. Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost-effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodologic limitations and data insufficiencies”.2 Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices. In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue. To the Editor: In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV.1 However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%.2 Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission. Common law recognises the right of bodily integrity.3 International human rights law enshrines the right to security of the person.3 The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic.3 As male circumcision amputates healthy, functional, protective, erogenous tissue,3 imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault.3 Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%).4,5 HIV infection in Australia occurs mostly among homosexual men.6 It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant,7 so male circumcision would be of little value in reducing future Australian HIV infection rates. Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm8 on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.3 To the Editor: Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection.1 They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine. The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques),2,3 the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection. This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent.4 We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised. As others point out,5 moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians6) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously. To the Editor: I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy.1 The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function. Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary,2-4 and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis3 — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction.4,5 It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need. To the Editor: I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission.1 Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission. In reply: In our editorial we, just as other academic experts in various countries,1-4 likened infant male circumcision to a “surgical vaccine”. Both vaccination and male circumcision effectively, safely and inexpensively afford lifelong protection against a wide array of adverse, sometimes fatal, medical conditions. Both are most effective if provided early in life. Both are criticised vigorously and relentlessly by opponents. There is now an impressive and growing number of high-quality research publications attesting to the wide-ranging benefits of male circumcision.2,4 The letters to the Journal in response to our editorial rely largely on opinions, and often cite superseded and spurious references. Forbes ignores the high prevalence in Australia of sexually transmitted infections (STIs), which male circumcision protects against, including oncogenic human papillomaviruses. Moreover, male circumcision provides similar protection against heterosexual HIV infections in men in low-prevalence settings as those in high-prevalence settings.1-5 In the United States, infant male circumcision is cost-saving for HIV prevention.6 In claiming that male circumcision increases HIV risk to women, Forbes, Boyle and Hill cite an outlier study, ignoring a meta-analysis and new data which show that male circumcision reduces the risk of male-to-female transmission.7,8 There is no reason to expect that male circumcision would protect a man who engages in receptive anal intercourse, the primary mode of HIV transmission in Australia and the US. Australian data show, however, greater than 90% protection against HIV and syphilis in the smaller proportion of homosexual men who are insertive only.9 While there are few Australian studies of other STIs and male circumcision in heterosexual people, research in the US and elsewhere, including randomised controlled trials (RCTs), shows strong protection.2,4 Paix argues that circumcision is a “highly mutilating operation which seriously impairs penile function”, while Travis and colleagues assert that circumcision “removes the most sensitive part of the penis”. However, there is now strong research evidence, including RCTs, showing not only no loss of function, satisfaction, sensitivity or sensation,2 but, in one large RCT, that sexual experience is enhanced by male circumcision.10 In rejecting male circumcision for HIV prevention, Travis et al and Boyle and Hill present arguments against circumcision repudiated previously by 48 international academic experts.11 Moreover, in response to Darby, it is well established that condoms are often not in place during sex, whereas male circumcision always is. Also, population-level condom use does not correlate with reduced HIV transmission.12 Parents have a duty to help prevent renal damage, physical, inflammatory and hygiene problems, STIs and cancers in their sons and their sons’ future sexual partners. They can do this by arranging for their son to be circumcised. The level of risk and severity of such adverse medical conditions in Australia is sufficiently high to support infant male circumcision. Not to do so may have legal ramifications.13 Chin argues that male circumcision should be delayed until the boy can make up his own mind. He fails to recognise that, as for vaccination, infancy is by far the safest, quickest, cheapest and most convenient time for male circumcision; when performed in infancy, circumcision confers immediate benefits with very limited short- and long-term risks.1-4 While our warning of a future HIV epidemic in Australia unless infant male circumcision is increased is based on a rise in the proportion of new infections attributable to heterosexual sex (from 841 in 2000–2004 [20% of total diagnoses] to 1185 [23%] in 2005–2008),14 there are currently epidemics of other STIs, many of which could have been prevented by male circumcision. The very low risk and considerable benefits of male circumcision attest to the wisdom of performing the procedure in infancy to maximise individual and public health gains.

David A Forbes · John W Travis · Sarah J Buckley · Paul Mason · Ken McGrath · Robert S Van Howe · George Williams · Anthony N Lyons · Marian Pitts · Anthony Smith · Jeffrey Grierson · Niall Conroy · Gregory J Boyle · George Hill · Robert J L Darby · Bruce R Paix · Jeremy J Chin · David A Cooper · Alex D Wodak · Brian J Morris

To the Editor: Trachoma control guidelines from the World Health Organization1 and Communicable Diseases Network Australia (CDNA)2 recommend the “SAFE” strategy that includes surgery for trichiasis, antibiotic treatment, facial cleanliness and environmental improvement. Lack of access to antibiotics in isolated areas should not be a major contributor to the persistence of trachoma in Australia because special Pharmaceutical Benefits Scheme arrangements (SPBSA) under section 100 of the National Health Act 1953 for the supply of medicines to remote-area Indigenous health services should enable a ready availability of azithromycin. The 1999–00 to 2001–02 evaluation of the SPBSA suggested that the program had led to major increases in the supply of medicines in remote areas, but that the supply of azithromycin did not change as a result of the introduction of the program.3 We assessed the relationship between reported azithromycin treatment of people with trachoma, their household contacts, and community members; levels of treatment recommended by WHO and CDNA guidelines; and the total number of courses of azithromycin available through the SPBSA. The National Trachoma Surveillance and Reporting Unit (NTSRU) provided 2008 data on treatment with azithromycin and trachoma prevalence in the Northern Territory, South Australia and Western Australia (refer to the report for limitations of the data).4 Data for 2007–08 on the supply of azithromycin to health services under SPBSA were obtained from Medicare Australia. The WHO guidelines recommend treatment of an entire community if the prevalence of active trachoma among children is above 10%.1,5 The CDNA guidelines2 recommend that contacts (> 6 months of age) of infected children within a household be treated. Our estimate of trachoma treatment according to CDNA guidelines is based on multiplying the number of infected children (from the NTSRU data) by the average number of members in remote Indigenous households.5 The impact of shared and multiple residence on estimates of household contacts could not be taken into account. The Box shows the numbers of azithromycin courses available through the SPBSA to remote-area Aboriginal and Torres Strait Islander health services in the three states. In the NT, the reported number of courses given (3069) fell well below the level recommended by both WHO (by 34%) and CDNA (by 41%) guidelines. In SA, reported courses of azithromycin given (7) fell well below the 45 suggested by the CDNA guidelines. The prevalence of trachoma did not exceed 10% in any SA community, so no treatment was required under WHO guidelines. In WA, the reported number of courses given (2917) also fell below recommended levels, although the deficit (WHO, 35%; CDNA, 81%) varied substantially depending on which guidelines were used. Reported treatment with azithromycin was below levels recommended by the CDNA and the WHO despite health services having sufficient courses available to them to mostly meet these targets. All aspects of the SAFE strategy are important in the eradication of trachoma. However, improving the supply and distribution of azithromycin should be relatively easy to implement, fund and monitor. Azithromycin courses* available, 2007–08;† courses given, 2008;‡ and WHO- and CDNA-recommended courses,§ in three Australian states with remote-area Indigenous health services WHO = World Health Organization. CDNA = Communicable Diseases Network Australia. * Azithromycin courses are given to those with active trachoma, their household contacts, and community members. † Under special Pharmaceutical Benefits Scheme arrangements and reported by Medicare Australia. ‡ Reported by the National Trachoma Surveillance and Reporting Unit (NTSRU). § Based on NTSRU data and using community population estimates.

Margaret Kelaher · Angeline S Ferdinand · Hugh R Taylor