Environmental health

A national policy forum in Sydney connected researchers, clinicians, advocates, consumers and policymakers The Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC) is Australia’s first population-based study designed to identify modifiable factors that will enhance resilience and reduce vulnerability to the psychosocial and economic impacts of epilepsy. SEISMIC involves collaboration between The George Institute for Global Health, Epilepsy Action Australia, the Epilepsy Society of Australia, Sydney South West Area Health Service, the University of Sydney, hospitals and clinicians in Sydney, and Austin Health in Melbourne. The study is funded by research grants from the National Health and Medical Research Council and the Australian Research Council. A key aspect of SEISMIC is the inclusion of a series of policy forums to ensure appropriate translation of evidence into policy and practice; the first forum was convened on 4 August 2010. The burden of epilepsyWorldwide, epilepsy is one of the most common neurological disorders. With a prevalence of 7 per 1000,1,2 an estimated 140 000 people are living with epilepsy in Australia. One-third of these people have had the diagnosis since childhood and, for many, it has a significant, life-long impact.3 The fundamental characteristic of epilepsy — recurrent, unprovoked seizures manifested by sudden, variable, transitory disturbances of consciousness and motor, sensory, autonomic or psychic function — can be successfully controlled by medication in most people. However, the diagnosis has wide-ranging ramifications, including significant disability (which is difficult to quantify). Medication compliance is often problematic, and there are many barriers to effective management (Box 1). Help-seeking behaviour and adherence to recommended care are adversely influenced by ignorance, fear, misunderstanding, cultural attitudes, fragmentation of health and social services, inconsistent referral practices, variable support systems across jurisdictions, exclusionary eligibility criteria for services and costly treatment options.4 Even with effective treatment, people are often affected in many aspects of everyday life, such as in their education, employment, relationships and mobility. Stigma, whether experienced or perceived, continues to be a major issue.4-7 Strategies for translating research evidence into policyFifty key stakeholders from academia, medicine, government and the community were introduced to practical strategies that are essential for development of health policy. Some preliminary lectures outlined the clinical and epidemiological aspects of epilepsy and gave an overview of the SEISMIC study and perspectives on consumer services from the non-government sector (Epilepsy Action Australia). Professor Stephen Leeder, Director of the Menzies Centre for Health Policy — who likened developing health policy to making sausages (“messy but effective”) — and Dr Andrew McDonald, Parliamentary Secretary for Health for the New South Wales Government, reinforced the importance of ensuring that the issues being addressed in SEISMIC are clearly defined so that feasible and cost-effective solutions can be proposed. The key “take-home” messages are summarised in Box 2. Priority areas identifiedWithin several working groups, the attendees went on to define the key health and social issues that require a policy response. Four priority areas were identified: (1) to develop a model of care; (2) improve systems to maintain education, employment and mobility; (3) address stigma; and (4) identify research needs. 1. Develop a model of care for patients diagnosed with epilepsyThere was collective concern about the absence of a defined “best practice” standard of care for people with epilepsy. Importantly, from a medical perspective, epilepsy is not one disorder, but a large group of conditions needing specific diagnosis to determine the best treatment and prognosis. Determination of specific diagnoses in a community cohort is an important aspect of SEISMIC. The development of an optimal pathway which specifies a continuum of care, inclusive of medical and community services, would streamline the referral process and overcome some of the barriers people face while navigating the health, social welfare and community sectors. Such a model of care would make explicit the roles of the various health professionals involved in the initial assessment, diagnosis and management of patients with epilepsy, including general practitioners, general physicians (adult and paediatric), neurologists and epilepsy specialists. This could address the current gap in transition care — the gap between paediatric and adult care — which affects the special needs of adolescents. A suite of services could be “packaged” to simplify the patient journey. Essentially, a standard model of care would improve the quality of epilepsy care to ensure successful adjustment and outcomes from the condition. 2. Improve systems to maintain education, employment and mobilityPeople with epilepsy are often restricted in their ability to live independently. This is most evident in the barriers to employment and education, and the negative impact that driving restrictions have on people’s mobility and quality of life. While support services are available to assist in the completion of Centrelink and Medicare forms, and there are various community transport schemes and taxi voucher programs in place, efforts are required to raise awareness of the range of services available, address the inconsistency in the services being offered across jurisdictions, and refine eligibility criteria to reflect the diverse needs of people with epilepsy. The strong disincentives to maintaining employment must also be eliminated. Although people with epilepsy want to gain and maintain employment, they lose access to subsidies by doing so, and working conditions limit sick leave or medical attendance allowances. There also needs to be improvement in the education system to foster more awareness about people with epilepsy and to encourage greater tolerance towards them. Information about whether disclosure of illness is mandatory, when disclosure is necessary and to whom individuals are required to disclose their illness must also be clarified in this process. There are likely to be societal benefits to supporting people with epilepsy and allowing them to become and maintain themselves as productive citizens. 3. Address the stigma of epilepsy by normalising the conditionThe stigma of epilepsy continues to negatively affect self-esteem, educational performance, productivity and health outcomes. Redefining epilepsy to encompass “fits, faints and funny turns that affect one in ten individuals” could improve public and government perception of the condition and its importance. Several other strategies were considered, including using prominent figures with epilepsy as “ambassadors”, expert “champions”, and harnessing the influential role of the media to raise awareness about epilepsy. Efforts to “normalise” epilepsy would help combat the associated stigma. 4. Identify further research needsValuable new evidence, with wide applicability, about the impact of epilepsy will be generated by SEISMIC. As the study plans to recruit several hundred children and adults soon after their diagnosis, it has the scope for being a repository of “whole-of-life” information on the long-term outcomes of the illness and impact of interventions. Securing ongoing funding was therefore acknowledged as a priority of the research group. Concluding remarksThe forum was closed by Dr Andrew Bleasel, President of the Epilepsy Society of Australia, who reaffirmed SEISMIC’s raison d’être (in fewer than 18 words, as recommended): to identify strategies to improve the lives of people with epilepsy and their families. 1 Impacts of epilepsy Clinical impacts: diagnostic assessment and investigation, usually involving hospital and specialist services requirements for long-term medication, sometimes with multiple agents, and for regular medical review potential for repeat investigations, and sometimes surgery, in those with poor seizure control the unpredictable paroxysmal nature of epilepsy with associated life disruption for variable periods of time afterwards seizure-related illness, injury and acute medical care potential for cognitive and physical adverse effects of medication, either dose-related or idiosyncratic risk of premature mortality including unexplained sudden death, and long-term complications associated with medications or injury Psychosocial impacts: depression and anxiety fatigue, drowsiness and reduced quality of life social restriction related to driving restriction, alcohol avoidance, and maintenance of adequate sleep hygiene stigma and exclusion from sports, work, education, and in relationships and marriage Economic impacts: costs of medication and primary and specialist health care indirect costs related to lower educational attainment and job opportunities lost income and productivity related to illness lost economic opportunities and costs to households associated with caring 2 Recommendations for negotiating with government on health policy issues Have a consistent and coherent message about what needs to be done, and stick with it (“life in 18 words or less”). Be reasonable, realistic and persistent in options being put forward, but always be ready to offer alternatives. Plan to effect change by strategically using research evidence to influence the policy process, including reframing the issue (or solution) in light of the current political priorities. Learn to spot and harness opportunities for policy engagement as they arise unpredictably, and have research evidence readily at hand at these times. Don’t annoy the minister.

Beverley M Essue MPH · Stephen Jan · Maree L Hackett PhD · Andrew F Bleasel MB BS, PhD, FRACP · Carol A Ireland Dip(RehabCouns), AFAIM · Samuel F Berkovic MD, FRACP, FRS · Craig S Anderson PhD, FRACP

Objective: To model the impact of both population and high-risk strategies on cardiovascular disease (CVD) outcomes.Design, setting and participants: A CVD risk-factor survey was carried out in rural south-eastern Australia from 2004 to 2006. Using a stratified random sample, data for 1116 participants aged 35–74 years were analysed. Applying the Framingham risk equations to risk-factor data, 5-year probabilities of a coronary heart disease event, stroke and cardiovascular event were calculated. The effect of different changes in risk factors were modelled to assess the extent to which cardiovascular diseases can be prevented by changing the risk factors at a population level (population strategy), among the high-risk individuals (high-risk strategy) or both.Results: Among men, a population strategy could reduce cardiovascular events by 19.3% (193 per 1000 per 5 years), the high-risk strategy by 12.6% (126 per 1000) and a combined strategy by 24.1% (241 per 1000); and among women, by 21.9% (219 per 1000), 19.0% (190 per 1000) and 28.7% (287 per 1000), respectively.Conclusions: For prevention of CVD in Australia, it is important both to treat high-risk individuals and to reduce the mean risk-factor levels in the population. We show how risk-factor survey data can be used to set targets for prevention and to monitor progress in line with the recommendations of the National Preventative Health Taskforce.

Erkki A Vartiainen MD, PhD · Tiina Laatikainen MD, PhD · Benjamin Philpot BSc · Edward D Janus MD, PhD · Nathalie Davis-Lameloise PhD · James A Dunbar MD, FRACGP

Objective: To quantify and characterise the reports of syncope and seizures following quadrivalent (4v) human papillomavirus (HPV) vaccination.Design and setting: Retrospective case series of notifications to SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community), May 2007 – April 2009.Main outcome measures: Incidence of syncope and seizure following 4vHPV vaccination; clinical outcomes.Results: 97/1653 SAEFVIC reports met the study criteria: afebrile seizures (3), syncopal seizures (31) and syncope alone (63). Median age at vaccination was 15 years (range, 8–26 years). Injuries were reported in seven cases, including one vertebral fracture. A SAEFVIC clinic review was undertaken in 41% (40/97) and 22 patients received further 4vHPV vaccine doses administered supine, with no recurrences. The reporting rate after 4vHPV vaccine for syncope and syncopal seizures was 7.8/100 000 and 2.6/100 000 doses distributed, respectively.Conclusion: Syncope and syncopal seizures occurred after 4vHPV vaccination in Victoria at rates similar to those seen internationally. Clinical review allowed clarification of the diagnosis and management, including safe administration of further doses under supervision.

Nigel W Crawford · Hazel J Clothier MEpid · Sonja Elia RN · Teresa Lazzaro MB BS · Jenny Royle MB BS, MD · Jim P Buttery MB BS, MSc

Objective: To determine the prevalence and diagnosis rates of Klinefelter syndrome (KS) in Victoria, Australia, and compare these to previous international findings.Design, setting and participants: A Victorian population-based descriptive study of all cytogenetic examinations resulting in a diagnosis of KS, including prenatal diagnoses from 1986 to 2006 and postnatal diagnoses from 1991 to 2006.Main outcome measures: Birth prevalence and diagnosis rates of KS.Results: The birth prevalence of KS in Victoria is estimated to be 223 per 100 000 males (95% CI, 195–254), with about 50% of cases remaining undiagnosed.Conclusions: KS may be occurring more frequently than has been reported previously, yet many cases remain undiagnosed. Our results highlight the need for increased awareness leading to timely detection.

Amy S Herlihy BSc, GradDipGenCounsel · Jane L Halliday BSc(Hons), PhD · Megan L Cock BSc(Hons), PhD · Robert I McLachlan MB BS, PhD

The national health reform agenda appears to have omitted public health. In this article, I outline how public health is different from primary care, and why a holistic approach to reform should include public health. The current reform agenda is very much focused on addressing the problems in acute care and the hospital system, with the focus on primary care being a means to this end. Until the health system is addressed as a whole, with all its essential components integrated and interlinked, truly successful reform of the health system, with genuine long-term vision and sustainability, will not be possible.

C Raina MacIntyre FRACP, FAFPHM, PhD

To the Editor: We would like to report the deaths of three young children in Australia as a result of hanging from bicycle helmets. Our aim is to draw attention to this rare but entirely preventable cause of childhood death. Helmets are required to be worn when bicycles are ridden, and have been the subject of mandatory standards since 1989.1 A number of accidental deaths have, however, been reported in the United States, Scandinavia and Canada as a result of young children becoming suspended by their bicycle helmets while playing on playground equipment. This has led to a series of warnings about not allowing children to wear helmets in playgrounds.2,3 The National Coroners Information System (NCIS)4 is an electronic database containing information on coronial cases from all Australian states and territories since 2001. We undertook a review of the NCIS for all deaths of children in Australia that were associated with bicycle helmets from 2001 to 2009. Three cases of deaths due to hanging were identified; these involved a 2-year-old boy who was suspended by his helmet strap between a bunk bed and a wall (in 2003), a 3-year-old boy who was suspended by his helmet strap when he tried to climb out of a home window (in 2007), and a 5-year-old boy who was suspended from an overhead clothesline while jumping on a trampoline (in 2009). These cases show that accidental hanging is still occurring among young children who wear bicycle helmets while engaging in activities other than bicycle riding. Importantly, hanging from bicycle helmets can occur in places other than playgrounds, sometimes by quite unusual mechanisms. Although such deaths are rare,5 it is important for parents and child carers to ensure that bicycle helmets are only worn by children for their intended purpose, and not during other activities.

Roger W Byard · Allan Cala · Donald Ritchey · Noel Woodford

Objective: To describe an in-depth analysis of the content and quality of stories about new cancer interventions in Australian media.Design and setting: Search of the Media Doctor Australia media-monitoring website for stories about newly reported cancer interventions, including drugs, diagnostic tests, surgery and complementary therapies, that had been collected from June 2004 to June 2009 and rated for quality using a validated rating instrument. A mixed-methods approach was used to analyse data and story content. Data from the website on stories about other new health interventions and procedures were compared.Main outcome measures: Differences in quality scores between cancer-related news stories (“cancer stories”) and other stories, and between types of media outlet; differences in how cancer was reported in terms of cancer type, morbidity, mortality, and in the use of hyperbole and emotive language.Results: 272 unique cancer stories were critically reviewed by Media Doctor Australia. Cancer stories had significantly higher scores for quality than other stories (F = 7.1; df = 1; P = 0.008). Most cancer stories concerned disease affecting the breast or prostate gland, with breast cancer appearing to be over-represented as a topic relative to its incidence. Pairwise comparisons showed statistically significant superiority for broadsheet newspaper stories over online stories (F = 12.7; df = 1; P < 0.001) and television stories (F = 10.7; df = 1; P = 0.001). Descriptions of morbidity and mortality were variable and often confusing in terms of numbers, time periods and locations. Literary devices including hyperbole and emotive language were used extensively, mostly by the researchers.Conclusions: While reporting of cancer in the general media is of low quality, many of the poorer aspects of content are directly attributable to the researchers. Researchers and journals need to do more to ensure that a higher standard of information about cancer is presented to the media.

Amanda J Wilson PhD · Billie Bonevski PhD · Alison L Jones FRCP · David A Henry FRCPE

To the Editor: A patient of mine recently reported that she had had a busy week, with the death and funeral of her sister. The woman had died with lung cancer at the age of 77, after having smoked tobacco for 61 years from the age of 17. On further enquiry, I was informed that the woman had “smoked all day and all night”, at the rate of 60 to 80 cigarettes per day. People could hardly stand to visit her home because “the house was always full of smoke”. Two different brands were used, including packs of 40. She had required oxygen therapy for the past 12 to 18 months and was severely disabled by breathlessness. She would “chain smoke”, with one cigarette behind each ear and one in her mouth. Rather than light them with a match or cigarette lighter, she would light her next cigarette from the butt of the one she was just finishing. At an average of 70 cigarettes every day for 60 years, the total intake amounts to around 1 500 000 cigarettes. At, say, 50c for each cigarette, this equates to a cost of $35 a day or $12 775 for a single year. A principal reason for taking the trouble to offer this anecdote for publication is that this is the greatest number of cigarettes I have ever heard of being smoked by any one person.

C Ross Philpot

The Australian Government’s recent decision not to renew federal funding for the Master of Applied Epidemiology (MAE) program at the Australian National University (ANU) puts the nation’s public health response capacity at serious risk. This program has provided the investigative backbone to the Communicable Diseases Network Australia for nearly 20 years. A charitable view is that its disestablishment came about as an administrative accident — collateral damage when Cabinet decided to terminate the much larger Public Health Education and Research Program (PHERP) after a 20-year funding cycle had reached its promised end. Funding for the MAE was rolled into the PHERP quite recently as an administrative convenience, after being supported through a distinct funding stream for most of its life, but the two are in fact very different types of public health activity. Although other PHERP-funded courses are traditional campus-based degree programs, the MAE puts its intake of outstanding health professionals through intensive field apprenticeships as disease detectives. Over 2 years, trainees undertake brief campus-based training blocks, but, for most of their time, they are placed at health agencies around the nation where they are immersed in disease surveillance and outbreak investigations. They serve as a flying squad to respond at short notice to unusual infectious disease events that present potential threats to the population’s health.1 The program has been a bargain for the government, with a budget under $2 million per year (the cost of about six tertiary hospital beds), which meets trainees’ stipends and supports a small team of academic supervisors. Over two decades, 160 MAE trainees have played central roles in stemming the spread of about 200 epidemics, including severe acute respiratory syndrome (SARS), pandemic (H1N1) 2009 influenza, Hendra virus, food-borne infections, and many others. Their work has generated over 500 academic publications, often of national and global public health significance.2-4 The program was originally modelled on the world-renowned Epidemic Intelligence Service at the Centers for Disease Control and Prevention (CDC) in the United States. The Australian MAE has helped spawn equivalent programs in China, India, Indonesia and Malaysia. In addition to serving as a standing national response team during their 2-year apprenticeship, graduates of the MAE program have gone on to become national, and in some cases international, leaders in public health. The employment distribution of 104 non-Indigenous graduates who completed a survey recently is shown in the Box. The MAE has a particular emphasis on supporting Aboriginal and Torres Strait Islander trainees, recognising that the burden of infectious diseases in Australia falls disproportionately on the Indigenous population. Placements have been made in settings that have allowed Aboriginal trainees to work closely with Aboriginal communities. Twenty-seven Aboriginal MAE graduates have gone on to make a unique contribution to several areas of Aboriginal health and have become role models for Aboriginal health research in Australia.5 Thirteen of these have used their training in this program as a portal of entry to PhD candidacy. A review of the program commissioned jointly by the Australian Government and ANU in February 2010 was unequivocal in recommending that it should continue as a key element of Australia’s disease control activity.6 The MAE program was born as a response to the urgent need, recognised during the early years of the HIV epidemic, for Australia to upgrade its national disease intelligence capacity. It was initiated with assistance from the US CDC, and its first Australian Director was the late Professor Aileen Plant, who would be appalled at its disappearance with no apparent replacement in sight. This will leave Australia vulnerable at a time when increasing population movements, changing climate and other pressures increase the likelihood that we will face new pandemics and the re-emergence of old ones.7 Although Australia is now one of few industrialised nations that has no national centre for disease control, the MAE program at least represented one of the essential elements that such a national organisation would provide.1 Infections respect neither state nor national boundaries, and under Australia’s political structure their control can only be achieved through a consistent, coordinated effort by the federal and jurisdictional governments. The ongoing human resource represented by the MAE trainees is a highly cost-effective insurance policy that we cannot risk losing in the challenging times ahead. Non-Indigenous Master of Applied Epidemiology graduates by current employer and type of work, 1991–2010 Employment classification Institution Epidemiologist Other public health Policy advisor Academic Other research Clinician Laboratory Total Federal government 6 — — — — — — 6 State government 22 9 2 — 1 — 1 35 Research institute 11 — — 3 2 — — 16* International health organisation 7 2 2 — 1 — 1 13† Non-government organisation 2 — 2 — — — — 4 Private enterprise — 1 1 — — 2 — 4 Hospital 1 — — — — 5 — 6 University 4 — — 16 — — — 20 Total 53 12 7 19 4 7 2 104‡ — = zero or not applicable. * Eight of the current jobs are at research institutes that provide services to government in communicable disease surveillance. † Ten of the current jobs are with the World Health Organization. ‡ Twenty-nine students did not complete the survey.

Robert M Douglas MD, FRACP, FAFPHM · Fiona J Stanley MD, MSc, FAFPHM · A Rob Moodie MB BS, MPH, FAFPHM · Anthony I Adams MB BS, MPH, FAFPHM · John M Kaldor PhD

Objective: To examine cancer incidence and mortality in Indigenous Queenslanders.Design, setting and patients: Assessment of indirectly standardised incidence and mortality ratios for Indigenous Australians in Queensland diagnosed with cancer from 1997 to 2006, compared with the total Queensland population.Main outcome measures: Standardised incidence and mortality ratios.Results: Compared with the total Queensland population, Indigenous Queenslanders had a lower overall incidence of cancer (standardised incidence ratio, 0.79; 95% CI, 0.75–0.82), but a higher incidence of some of the more fatal cancer types. Overall cancer mortality was higher (standardised mortality ratio, 1.36; 95% CI, 1.28–1.45) and similar to rates for Indigenous people in other Australian states.Conclusion: Cancer rates for Indigenous Queenslanders, a mostly urbanised population, are similar to rates for Indigenous Australians mostly living in remote areas.

Suzanne P Moore BHSc(Nursing), MPH, PhD · Peter K O’Rourke BSc(Hons) BA(Hons), PhD · Kylie-Ann Mallitt BSc(Hons) · Gail Garvey BEd, MEd · Adèle C Green MB BS, MSc, PhD · Michael D Coory MB BS, PhD, FAFPHM · Patricia C Valery MD, MPH, PhD

To the Editor: The benefits of bicycle helmet use have been the subject of recent discussion, with calls from some experts to review laws mandating the wearing of helmets.1 The objective of this brief report is to summarise long-term trends in cyclist head injuries seen at an inner-city major trauma centre and determine the odds of any skull fracture or intracranial bleed associated with not wearing a helmet. This was a retrospective study conducted at the Royal Prince Alfred Hospital (RPAH, Sydney, New South Wales), covering several local government areas that have the highest bicycle-use rates in NSW,2 where the law for mandatory helmet wearing was enacted in 1991. Patient data were obtained through the hospital trauma registry, which contains data on all patients admitted to the hospital with trauma. These data included information on helmet use routinely abstracted from ambulance and medical notes. Inclusion criteria were cyclists admitted from 1991 to 2009, who were over 16 years of age and involved in an incident on a public road. We excluded patients transferred from other hospitals. Head Abbreviated Injury Scale (AIS) scores (AIS 1990, 1998 and 2005 versions3) were used, with a head AIS score ≥ 3 indicating severe head injury, such as significant intracranial bleeding or depressed or comminuted skull fracture. Injuries with an AIS score of 2 included isolated concussion and simple skull fractures. To investigate the association between helmet use and head injury, we reviewed the medical charts of all cyclists admitted with trauma from 2008 to June 2010. We compared mechanism of injury (fall off bike without collision versus collision with another vehicle or object), anatomical injury (skull fracture or intracranial bleed), helmet use and the type of road where the incident occurred (state or regional roads versus local roads), according to NSW Roads and Traffic Authority classifications. Data were analysed using Stata software, version 10.1 (StataCorp, College Station, Tex, USA). Percentages were calculated with 95% confidence intervals, and categorical data were compared using χ2 tests. Mean ages were compared using the Student t test, and a logistic regression model was used to obtain odds ratios for any skull fracture or intracranial bleed associated with not using a helmet, after adjusting for mechanism of injury and road type. The study was approved by the Sydney South West Area Health Service RPAH Ethics Review Committee (RPAH Zone). There were 979 patients who met our inclusion criteria. The long-term trend in the number of cyclists sustaining severe head injuries remained low (range, 0–3 per year) (Box 1). Cyclists as a percentage of total admissions for trauma increased from 1.3% in 2005 (29/2258 [95% CI, 0.9%–1.8%]) to 3.9% in 2009 (122/3104 [95% CI, 3.3%–4.7%]). Trends in helmet use and severe head injury are summarised in Box 2. Severe head injury rates as a percentage of total cyclists admitted decreased from 10.3% (3/29 [95% CI, 3.6%–26.4%]) in 2005 to 2.5% (3/122 [95% CI, 0.8%–7.0%]) in 2009, a relative reduction of 76%. Helmet use in admitted cyclists from 1991 to 2009 ranged from 85% to 100%. Information was available about the location of the fall and helmet use for 287 of the 313 cyclists identified from 2008–2010 (Box 3). Their mean age was 36 years (95% CI, 34–37 years) and 81% were men. Non-helmet wearers had five times higher odds of intracranial bleeding or skull fracture compared with helmet wearers after adjusting for road type and mechanism of injury (odds ratio, 5.3 [95% CI, 1.7–17.1]; P = 0.005). The increase in admissions for bicycle injury is consistent with recently reported population trends.4 In addition, the number of cyclists sustaining severe head injuries has remained consistently low over the long term, with an apparent decline in the rate of severe head injuries in admitted patients since 2005. The odds reduction for skull fractures and intracranial bleeds in those wearing helmets is within the range reported in a Cochrane review of helmet use.5 The benefits of helmet use need to be placed in the context of lifetime costs of severe traumatic brain injury, estimated to be around $4.8 million per incident case.6 It is the opinion of the trauma service at RPAH, based on these findings, that mandatory bicycle helmet laws be maintained, and enforced as part of overall road safety strategies. 1 Trends in cyclist admissions and head injuries in admitted cyclists, RPAH, Sydney, New South Wales, 1991–2009 AIS = Abbreviated Injury Scale. RPAH = Royal Prince Alfred Hospital. 2 Trends in bicycle helmet use and severe head injury as a percentage of total cyclist trauma admissions, RPAH, Sydney, New South Wales, 1991–2009 AIS = Abbreviated Injury Scale. RPAH = Royal Prince Alfred Hospital. 3 Head injury in helmet and non-helmet users among 287 cyclists admitted to Royal Prince Alfred Hospital with trauma, 2008 to June 2010 Helmet (n = 241) No helmet (n = 46) Significance† Age, years (95% CI) 36 (34–38 years) 33 (29–37 years) P = 0.14 Men (%; 95% CI) 196 (81%; 76%–86%) 39 (85%; 71%–92%) P = 0.60 Fall off bicycle* (%; 95% CI) 83 (34%; 29%–41%) 13 (28%; 17%–43%) P = 0.75 State/regional road (%; 95% CI) 63 (26%; 21%–32%) 11 (24%; 14%–38%) P = 0.75 Skull fracture or intracranial bleed (%; 95% CI) 8 (3%; 2%–6%) 6 (13%; 6%–36%) P = 0.005 * Without direct collision with another vehicle, object or person. † Two-tailed P < 0.05 significant.

Michael M Dinh · Susan Roncal · Timothy C Green · Elizabeth Leonard · Amanda Stack · Chris Byrne · Jeffrey Petchell

To the Editor: It is incorrect for Chong and colleagues to state that “during the financial year 2006–07, 32 777 people were admitted to hospital in Australia due to road crashes”. It is also wrong for them to claim “it is often not clear how many of these road crashes are traffic crashes, and how many are non-traffic crashes”.1 Henley and Harrison report that there were 52 066 people seriously (but not fatally) injured due to land transport injury in 2006–07, and 32 777 of these (63.0%) occurred in traffic (on-road) accidents.2 A further 13 639 (26.2%) land transport injury cases in that year were explicitly described as non-traffic (off-road) accidents. The National Injury Surveillance Unit of the Australian Institute of Health and Welfare regularly publishes transport injury-specific analyses, including reports on land transport injuries (both traffic and non-traffic), rail-related transport injuries and transport injuries involving Indigenous Australians. The most recent of these reports is Henley and Harrison’s.2 In addition to the statistics mentioned above, they also report that the national age-standardised rate of non-traffic transport injuries was 66.5 per 100 000 population. In the previous year, this rate was 67.2 per 100 000 population.3 The next report in this series, to be published shortly, will include analysis of national trends in the rate of non-traffic transport injuries over the period 2000–01 to 2007–08.

Clare E Bradley · James E Harrison · Geoffrey I Henley

In reply: We acknowledge our error in reporting Henley and Harrison’s findings,1 and commend Bradley and colleagues for providing information about traffic and non-traffic transport injuries separately. We are also pleased that the National Injury Surveillance Unit will soon publish a report including analysis of trends in non-traffic transport injuries, extending our analyses beyond New South Wales. This is consistent with our conclusion that more needs to be done to understand non-traffic crashes.2 We defend our claim that the statistics in many reports and articles often do not clearly distinguish between traffic and non-traffic crashes and injuries.

Shanley S S Chong · Wei Du · Julie Hatfield

To the Editor: Flitcroft and colleagues’ discussion of the National Bowel Cancer Screening Program provides a useful reminder of how political, institutional and financial issues can affect evidence-based policy.1 Bowel cancer is second to prostate cancer as the biggest cause of cancer death in Australian men, and men are more likely than women to be diagnosed with bowel cancer. There are no indications, however, that the screening program has sought to engage men as a target group. Men and women think about and act on their health in different ways and respond differently to messages, sources of information and modes of information delivery.2 Men are less likely than women to undergo preventive screening and are more likely to seek treatment at a later stage in a disease. A report for the Australian Government noted that, before receiving the Bowel Cancer Screening Pilot Program material, men were less likely to have been aware of preventive or pre-emptive behaviours “unless their GP had actually raised the subject with them, or a close friend had suffered, bringing the issue to a more personal level”.3 Further evidence indicated that fewer than one-third of men participated in the screening from mid 2006 to mid 2007, despite men aged 55 and 65 years being more likely than women to return positive results; among men aged 55 years, only 28% chose to participate.4 Participation rates during the 2-year screening period ending August 2008 were estimated to be 39.2% for men and 46.7% for women.5 Despite the considerable evidence that the “doing of health” is a highly sex-dependent activity, a population-based, “one size fits all” approach appears to have been adopted. Adding further insult to injury, men were blamed for their lower participation rate and for failing to understand “that screening for cancer saves lives”.6 A disappointing response to a free breast cancer screening initiative, on the other hand, prompted an investigation into the relationship between the wording of the screening invitation letter and the level of screening attendance.7 With around one in 19 men predicted to develop bowel cancer before the age of 75 years, men’s under-representation in bowel cancer screening is a serious problem. There is a need for more attention to be given to men’s attitudes and beliefs about risk and prevention, with a view to developing specific approaches to increase men’s participation in screening.8 It should not be too much to expect that Australia’s first National Men’s Health Policy, and an updated National Women’s Health Policy, will result in sex being taken into account in the design and implementation of national health initiatives.

Margo H Saunders · Anita Peerson

To the Editor: Flitcroft and colleagues’ historical report of bowel cancer screening in Australia is helpful to those new to this internationally accepted life-saving practice.1 One inaccuracy needs correcting. Lung cancer is the leading cause of cancer death in Australia — not prostate or breast cancer. Flitcroft et al appear to have quoted the Australian Institute of Health and Welfare data for new diagnoses, not cancer deaths.2 This error reflects the general lack of community focus or interest in the more than 7000 Australians who die each year from smoking-related lung cancer.3 An update is also warranted. Since submission of their article, once-only flexible sigmoidoscopy screening has joined faecal occult blood test (FOBT) screening in having randomised controlled trial evidence. Results of a recent British study point to the necessity of looking for this occult disease with flexible colorectal endoscopy.4 The study showed a massive 43% reduction in colorectal cancer mortality and a 50% reduction in incidence of invasive rectal cancer, owing to early flexible sigmoidoscopic diagnosis of colonic polyposis followed by polypectomy performed at subsequent colonoscopy. These techniques save thousands of lives worldwide each year. Flitcroft et al state that “A staged roll-out is a sensible approach”, but many of us who perform colonoscopic polypectomies on a weekly basis strongly disagree. Which is better — to be on a waiting list for a colonoscopy with a positive FOBT result, or to be ignorant of the possibility of a growing cancer in the colon? It is time to give people the opportunity of FOBT with or without further investigations. Flitcroft et al rightly point out that the National Health and Medical Research Council recommended that we should have at least biennial FOBT screening for individuals over 50 years of age.5 Australians have been very tardy in terms of adopting this recommendation. We don’t need an “age-specific cost-effectiveness analysis”. The argument should be about introducing flexible sigmoidoscopy. Like Semmelweis and hand washing back in 1847, history will judge our current generation harshly for ignoring the original life-saving FOBT research that was published in 19936 and allowing thousands of Australians to die unnecessarily from bowel cancer since then. It is time for us to take our heads out of the sand and introduce a proper national bowel cancer screening program. Thank you to Flitcroft and colleagues for helping us take another step in this direction.

Guy R Hingston

To the Editor: As public health professionals, we strongly support Givney’s call for the creation of an Australian national authority for disease prevention and control.1 This proposal is by no means a new one,2 but its relevance has, if anything, increased with time. Such an authority would structure and coordinate responses to emerging disease threats, as well as ensure that Australia has the national public health infrastructure required to coordinate the increasingly complex strategies needed for disease surveillance more generally. Human papillomavirus (HPV) surveillance is a recent case in point. Between 2007 and 2009, Australia delivered what remains the world’s most widely targeted HPV vaccination program, offering free vaccination with quadrivalent HPV vaccine to all girls and women aged 12 to 26 years. Australia’s excellent cancer registries will be able to accurately monitor the anticipated decline in cervical cancer incidence, but it will not occur for decades. In the meantime, we need to track more immediate vaccine impacts, such as the incidence of genital warts, incident Pap smear abnormalities and type-specific HPV infection. Specialist groups are initiating their own studies in these areas, with funding from a combination of government and industry sources, but there is no coordinated system for bringing together the key components of surveillance, and for ensuring that they are properly funded and analysed. The surveillance requirements for an HPV vaccination program are complex because of the multiple outcomes of vaccination, varying time scales over which these outcomes are expected, and the range of stakeholders involved in the fields of immunisation, cancer control and sexual health. No clear ownership or responsibility for comprehensive surveillance is apparent in Australia. In the United States, the Centers for Disease Control and Prevention have taken responsibility for coordinating HPV surveillance,3 and in the United Kingdom efforts are led by the Health Protection Agency, with planning and funding for comprehensive surveillance having been established at the outset of the immunisation program. The creation of an independent, well resourced body that is expert in disease control and prevention will ensure that Australia is best placed to respond to emerging disease threats as well as able to obtain maximum value from the implementation of prevention strategies.

Julia M L Brotherton · John Kaldor · Marion Saville

To the Editor: Givney’s recent letter restated the case for a national centre for disease control.1 His arguments for national planning, and particularly for a non-politicised approach to coordination and modification of responses to public health threats based on evidence, will be welcomed by many. A clear example of the validity of his case is provided by the recent pandemic (H1N1) 2009 influenza. In hindsight, despite certain risk groups being severely affected,2 the 2009 influenza season was generally mild.3,4 However, the public health response, based on the agreed pre-pandemic plans, was personnel-intensive and long-lasting.5 Crucially, there was a need for a well trained, flexible epidemiological workforce to rapidly analyse data to inform any response. Here, we highlight the contributions of Master of Applied Epidemiology (MAE) staff and students to this component of the response. The MAE program has operated as Australia’s only field-based epidemiology training program since 1991. MAE staff and students were enlisted to the response within days of the pandemic alert, as they constitute the only readily available epidemiological capacity in Australia. A survey conducted in February 2010 indicated that between April and December 2009, 18 students and five MAE staff members contributed 1159 person-days (3.2 person-years) to the response at local, state and national levels and internationally in New Zealand and with the World Health Organization. Contributions included establishing and evaluating surveillance systems, data analysis and reporting, training and supervision, rapid assessment and longer-term research projects. Areas covered included: border screening; investigation of clusters of cases related to air arrivals; school, prison and household transmission studies; analysis of state and national data; and establishment of a hospital-based sentinel surveillance system. Research findings have been disseminated widely via government reports, seminars, conference presentations and peer-reviewed publications. During the pandemic, the MAE program provided epidemiological “surge capacity”. This vital technical input to higher-level analysis allowed policy responses to changing evidence, a contribution that needs to be maintained and strengthened if Australia is to respond appropriately to future emerging disease threats. A logical home for a field epidemiology training program such as the MAE would be a national centre for disease control, with strong linkages to one or more academic institutions. We therefore echo Givney’s call for the establishment of an Australian centre, providing independent, evidence-based advice to governments, and incorporating a strong commitment to workforce capacity building and sustainability.

Paul M Kelly · Kamalini Lokuge · Hassan Vally · Alexander S Cameron

Objective: To determine whether changes in 24-hour average background ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO) and particulates < 10 μm (PM10) increase the risk of hospital emergency department (ED) presentations for asthma among children.Design, setting and subjects: A time-stratified case-crossover method was used to analyse data of 603 children and young adults aged 0–19 years who were resident in a south-west metropolitan area of Perth, Western Australia, and who had presented with asthma at any public ED within Perth between 1 January 2002 and 31 December 2006. Effect sizes were assessed in relation to age group, sex and season of exposure. City-wide background air pollution was estimated from air monitoring network data.Main outcome measures: ED presentation with asthma.Results: Patients 0–4 years with 1-day lagged exposure to NO2 and CO showed the most significant risk of ED presentation for asthma. An interquartile range (IQR) increase in NO2 resulted in an odds ratio (OR) of 1.70 (95% CI, 1.08–2.69). An IQR increase in CO resulted in an OR of 1.40 (95% CI, 1.06–1.84).Conclusions: The effect sizes observed in this study were higher than those of past studies, and indicated that children aged 0–4 years were the most vulnerable to the effects of air pollution. The period of exposure most clinically relevant is the day before ED presentation.

Gavin Pereira MAppStats, BCM, GCResCom · Angus Cook MB ChB, PhD · Annemarie J B M De Vos PhD, MPH, RN · C D’Arcy J Holman MB BS, MPH, PhD

The Australian Government has committed to reducing Indigenous disadvantage, including closing the life-expectancy gap within a generation, and to halving the gap in mortality rates for children under 5 years of age within a decade. Sixty per cent of the health gap between Indigenous and non-Indigenous Australians is attributable to the health of Indigenous people living in non-remote areas of Australia. We conducted a brief review of recent Australian original research publications on the health of the 53% of Indigenous people who live in urban areas, and found that data are sparse; there were only 63 studies in the past 5 years (11% of all articles about Indigenous health during this period). Although Indigenous Australians living in remote areas experience greater health disparity, the government will not achieve its aims without paying due attention to the non-remote-living population. More research is required, and particularly research that actually tests the impact of policies and programs.

Sandra J Eades BMed, PhD · Bronwen Taylor BTech, MSc · Sandra Bailey LLB · Anna B Williamson BPsych(Hons), PhD · Jonathan C Craig MB ChB, FRACP, PHD · Sally Redman BA(Hons), PhD

Trevor Beard was born on 11 May 1920 in Gloucester, United Kingdom. He studied medicine and surgery at the University of Cambridge and worked as a Resident Medical Officer at St Bartholomew’s Hospital and the City of London Maternity Hospital. In 1951, he moved from the UK to Australia and began general practice at Campbell Town in Tasmania. During this time, he vigorously spearheaded a successful campaign to eliminate human hydatid disease in Tasmania — the first jurisdiction in the world to declare provisional eradication of hydatid disease. He was formally recognised for this work when he was made an Officer of the Order of the British Empire (OBE) in 1966. Trevor devoted his life to improving public health. In the 1970s, he joined the Department of Health in Canberra in a senior public health policy role, and in the early 1980s, he moved into cardiovascular research at Canberra’s Woden Valley Hospital. After his official retirement in 1986, Trevor returned to Tasmania in 1987 and took up an Honorary Research Fellowship at the Menzies Research Institute in Hobart. Right up to the end, he remained active in his research on hypertension and salt intake, and was involved in various research projects, including the first large community survey of sodium intake in Australia. He wrote a guide to adopting a low-salt diet,1 and went on to develop a related website (http://www.saltmatters.org). He passionately promoted the use of low-salt diets to prevent hypertension and vigorously lobbied many areas of the food industry and government, playing a pivotal role in persuading the government to lower the official sodium intake recommendations in Australia in 2005. At a local level, he advocated successfully for the Royal Hobart Hospital and Meals on Wheels to provide low-sodium meals. Trevor actively campaigned for the introduction into Australia of the UK’s “traffic light” food-labelling system (which uses colour-coding to designate low, medium and high levels of total fat, saturated fat, sugar and salt in foods). In 2010, at the age of 90, he set a challenge for Drysdale House in Hobart — training ground for future chefs in Tasmania — to reconcile gastronomy with health by providing monthly lunches that would meet low fat, sugar and salt requirements. In addition to his OBE, Trevor received many other honours. He was awarded a Winston Churchill Fellowship in 1966, the Johnston Medal from the Royal Society of Tasmania in 1987, honorary life membership of Nutrition Australia in 1997, and honorary Fellowship of the Royal Australian College of General Practitioners in 1995. He was declared Senior Australian of the Year 2006 for Tasmania. Trevor died on 2 September 2010 of acute myocardial infarction following a successful total knee replacement and is survived by his four children, Tony, Jane, Simon and Lily. One of the many privileges of working with Trevor was witnessing his passion for his work. He was a man of formidable intellect, tenacity, good humour and personal warmth. We have lost a truly remarkable colleague and friend.

Fiona A Horwood

Michael Rozalla was born in Simla, India, on 25 June 1920 and was schooled in Simla and Naini Tal, both situated in the foothills of the Himalayas. He obtained his degree in medicine in Calcutta in 1945, and then served as a medical officer during World War II on the North-West Frontier of India and in Burma. After his discharge in 1948, he worked in a number of hospitals in England and then applied to the British Overseas Civil Service and took up duties in the colony of Sarawak in 1950. In 1960, after a period in Brunei, Michael returned to Kuching, the capital of Sarawak, as Head of the Health Section of the Medical Department of Sarawak. In this capacity, he was instrumental in establishing a fully organised Health Division in the Sarawak Medical Services. Among his notable contributions to the service of public health was his drafting of the Malaria Eradication Scheme, the Tuberculosis Scheme, and the Public Health Ordinance of Sarawak. During his time in Sarawak, Michael was the recipient of several World Health Organization fellowships in the areas of cholera and malaria, and represented Sarawak at various international disease conferences. In 1964, Michael was promoted to Deputy Director of Medical Services of Sarawak and, in the normal course of events, would have been recommended for promotion to Director in 1967, had he not elected to stand down in the interests of “Malaysianisation” (the Malaysian Government policy of replacing expatriate officers with local people where possible). He was made an Officer of the Order of the British Empire in 1969 for his service in Sarawak and Brunei. Michael migrated to Australia in 1970 and, in due course, was proud to become an Australian citizen. He joined the New South Wales Department of Health and took up the position of Deputy Director of Health in Bathurst. When the Department of Health was restructured in 1974, he was appointed Deputy Regional Director of Health, which included the duties of Medical Officer of Health. During this time, he set up the Community Health Programme in the Central West Region. Although Michael officially retired in 1980, he accepted a request from the Department to resume work as a Senior Medical Officer on a part-time basis. He worked on hospital disaster programs and completed a handbook for government medical officers working in NSW. He also prepared a booklet entitled Notes on triage and emergency treatment, which was incorporated into the NSW Disaster Medical Response Plan. He retired from part-time duties in 1990. Michael died on 18 April 2010 from complications of chronic renal failure and cerebrovascular disease. He was a scholar and a gentleman, and is sorely missed by all who knew and cared for him. He is survived by his wife Thea, son David and daughter Teen.

Thea J Rozalla

The recent review of taxation in Australia — the Henry tax review — has recommended that the federal government increase the taxes already levied on tobacco and alcohol. Tobacco and alcohol taxes are put forward as the best way of reducing the social harms caused by the use and misuse of these substances. Junk foods have the same pattern of misuse and the same social costs as tobacco and alcohol. The Henry tax review rejects the idea of taxing fatty foods, and to date the government has not implemented a tax on junk food. We propose that a tax on junk food be implemented as a tool to reduce consumption and address the obesity epidemic.

Molly E Bond BBiotech(Hons), DipLang · Michael J Williams BA(Hons), LLB(Hons) · Brad Crammond MA(Hons), LLM · Bebe Loff LLB, MA, PhD

To the Editor: Children have been seen as a key priority group for pandemic (H1N1) 2009 influenza (“swine flu”) vaccination. In Australia and New Zealand, children aged 0–4 years had the highest population rate of intensive care unit admissions for swine flu.1 From 3 December 2009, the Australian Government provided free H1N1-specific influenza vaccine for all Australians aged 6 months and older. However, it was not known how parents and other caregivers would respond to the offer of vaccination. We sought to determine caregivers’ intentions regarding whether their child would receive the pandemic vaccine. The study was approved by the human research ethics committee of the Children’s Hospital at Westmead and was conducted in November and December 2009, immediately before, and alongside, the commencement of the pandemic vaccination program for children. A paper-based questionnaire (with an alternative web-based option) was sent to caregivers of children aged 6 months to 5 years who were attending 16 long-day-care centres across metropolitan Sydney. It included questions about attitudes, behaviour, intentions and beliefs regarding swine flu, seasonal influenza and vaccines. We analysed responses using SPSS, version 17 (SPSS Inc, Chicago, Ill, USA) and conducted univariate analysis (as factors had high collinearity) to search for factors associated with caregivers’ intention for their child to receive the pandemic vaccine. The response rate was 44% (431/972). Most respondents had families of two children (47%) or one child (41%); 90% were mothers; and 48% had a postgraduate education. Caregivers were asked to report in relation to their eldest child attending the day-care centre (mean age, 38 months). Three children (out of 427 responses; 0.7%) had already received the pandemic vaccine; 23% of caregivers (92/400) said they would have their child vaccinated; 54% (217/400) were unsure; and 22% (87/400) would not. Intentions regarding seasonal influenza vaccination were similar. Factors associated with caregivers’ intention to have their child vaccinated with pandemic vaccine are shown in the Box. Those with the strongest associations included caregivers’ intention to have their child vaccinated against seasonal influenza in 2010 and belief that seasonal influenza vaccine is completely safe or only a slight risk. Factors not significantly associated with respondents’ intention to have their child vaccinated with the pandemic vaccine were the respondent’s age group, sex, education level, language spoken at home, and number of children in the household. The study indicated that at the commencement of the Australian pandemic influenza vaccination program for children, there was significant uncertainty among this sample of relatively highly educated respondents. The proportion of respondents intending to have their children vaccinated was far lower than recent Australian estimates (6% of children aged 4 years and under).2 Our findings suggest that, despite the acknowledged severity of pandemic influenza, respondents’ concerns about vaccine safety were influencing their intentions. Indeed, the program commenced in a context of public debate about the response to the influenza pandemic and the vaccination program, including concerns about the safety of using multi-dose vials for vaccine delivery.3,4 Among respondents intending for their child to have the pandemic vaccine, the association with the child having had a previous influenza vaccination suggests that, having once taken up vaccination, respondents were more likely to intend to do so again. More recent events in Australia leading to suspension of use of all three 2010 seasonal influenza vaccines for children under 5 years of age are likely to further increase safety concerns.5 While two vaccines have since been reinstated, these events present a significant challenge for future influenza vaccination programs. Providers are likely to have an important role in communicating recommendations and addressing caregivers’ concerns. Factors associated with caregivers’ intentions for their child to receive the pandemic (H1N1) 2009 influenza vaccine Survey responses Intention “yes” (n = 92) Number OR (95% CI) Would you have your child vaccinated against seasonal flu in 2010? (n = 396) No 8 1.00 Unsure 33 2.29* (1.11–5.15) Yes 51 17.49* (7.55–40.50) How safe do you think the seasonal flu vaccine is for children aged 1 to 5 years? (n = 396) Moderate/high risk 7 1.00 Don’t know 19 2.04 (0.82–5.07) Completely safe/slight risk 66 6.64* (3.00–15.22) How safe do you think the seasonal flu vaccine is for babies aged 6 to 11 months? (n = 395) Moderate/high risk 21 1.00 Don’t know 36 1.35 (0.75–2.44) Completely safe/slight risk 35 4.32* (2.27–8.22) Did your child receive seasonal flu vaccination in 2009? (n = 394) No 77 1.00 Yes 15 3.48* (1.65–7.36) How concerned do you feel about your child catching the flu? (n = 396) Not at all/ a little/ moderately 31 1.00 Very/extremely 61 2.46* (1.46–4.17) Does your child have any medical conditions requiring ongoing visits to a health care professional? (n = 396) No 76 1.00 Yes 16 2.00† (1.03–3.87) The flu vaccine can give you the flu. (n = 396) Agree 24 1.00 Don’t know 23 1.18 (0.62–2.23) Disagree 45 1.82† (1.04–3.20) OR = odds ratio. * P ≤ 0.01. † P ≤ 0.05.

Julie Leask · Maria Yui Kwan Chow · Catherine King · Robert Booy

Objective: Design, setting and participants: Vaccination data for Western Australians aged 10 years and older were obtained from two sources: the WA Pandemic Influenza Vaccination Database (PIVD; which collected reports of pandemic influenza vaccinations from vaccination providers statewide) for the period 30 September 2009 to 31 January 2010, and the WA Health and Wellbeing Surveillance System (HWSS; a continuous population-based telephone survey) for the period 1 December 2009 to 31 January 2010. Data from the PIVD was used to impute vaccination coverage estimates for at-risk subpopulations not assessed in the HWSS interviews.Main outcome measures: Vaccination coverage of Western Australians aged 10 years and older and of subgroups targeted by the national pandemic (H1N1) 2009 influenza vaccination campaign.Results: A total of 171 789 pandemic influenza vaccinations were reported to the PIVD by 31 January 2010 and 88% of these were administered by 1 December 2009. Based on HWSS data, vaccination coverage of persons aged 10 years and older was 14.5% (95% CI, 12.6%–16.6%) and of persons aged 18 years and older was 15.3% (95% CI, 13.3%–17.6%). Based on PIVD data, coverage in adults ranged from 10.3% in pregnant women to 52.8% in health care workers.Conclusions: Our estimate of pandemic influenza vaccination coverage in the adult population of WA is comparable to the national estimate of 19%, but it did not reach levels considered sufficient to interrupt community transmission. Future influenza vaccination programs should target groups at increased risk of severe influenza, such as pregnant women.

Donna B Mak MB BS, MPH, FAFPHM · Alison M Daly BA(Hons), BA(Ed) · Paul K Armstrong MBBS, MAE, FRACP · Paul V Effler MD, MPH, FAFPHM

Objective: Design, setting and participants: Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010.Intervention: Audit of uptake of the H1N1-specific vaccine.Main outcome measures: Rate of H1N1-specific vaccination, and reasons for not being the vaccinated.Results: 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33 (6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns.Conclusions: Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns — of both the women and their GPs — about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers.

Scott W White MB BS · Rodney W Petersen MB BS, MBA, FRANZCOG · Julie A Quinlivan MB BS, PhD, FRANZCOG