Environmental health

Objective: To explore 5 years of drowning deaths in Australia compared with a previous Australian study a decade earlier, and to assess the feasibility of achieving a 50% reduction in unintentional drowning deaths by 2020.Design and setting: An audit of all unintentional drowning deaths in Australia using data from the National Coroners Information System for 1 July 2002 to 30 June 2007.Main outcome measures: Number and rate of drowning deaths, by age, sex, location, activity, place of birth, visitor status, and involvement of alcohol or drugs.Results: There were 1452 drowning deaths during the study period (76.4% male). The age-adjusted rate per 100 000 people ranged from 1.61 in 2002–03 to 1.23 in 2006–07. Children aged 0–4 years had the highest rate (2.63 per 100 000 people), and 29% of deaths were of people aged 55 years or older. Over half of all deaths occurred in rivers (20.3%), at beaches (18.3%), or in swimming pools (13.3%). Alcohol was involved in 21.6% of all drowning deaths, although this varied by age.Conclusions: This audit suggests that a 50% reduction in drowning fatalities by 2020 may be achievable using current knowledge and preventive systems in certain types of immersions. However, further research and new initiatives will be required, particularly to prevent drowning deaths in rivers and of older people.

Richard C Franklin BSc, MSocSc, PhD · Justin P Scarr BEd, MBA · John H Pearn MD, FRACP, FRCP

Objective: To compare the weight status of women and children living in socioeconomically disadvantaged rural and urban neighbourhoods in Victoria.Design, setting and participants: Cross-sectional study of data collected between August 2007 and July 2008 as part of the Resilience for Eating and Activity Despite Inequality (READI) study. Women aged 18–45 years living in 40 rural and 40 urban socioeconomically disadvantaged Victorian areas were surveyed by postal questionnaire. Data from a subset of their children aged 5–12 years were also analysed. Weight and height were self-reported for women and measured for children.Main outcome measures: Women’s weight status based on body mass index (BMI): underweight; healthy; overweight; or obese Class I, II or III; children’s weight status based on International Obesity Taskforce BMI cut-off points.Results: Of 11 940 women randomly selected, 4934 (41%) replied to a postal invitation to participate. After exclusions for various reasons, data were available on 3879 women and 636 of their children. Twenty-four per cent of urban and 26% of rural women were classified as overweight; a further 19% of urban and 23% of rural women were classified as obese. Twenty per cent of both urban and rural children were classified as overweight; a further 10% of urban and rural children were classified as obese. In crude analyses, rural women had higher odds of Class I and II obesity (odds ratio [OR], 1.34 and 1.72, respectively) compared with urban women. After adjusting for sociodemographic factors (age, number of children, country of birth, education level, employment status and marital status), there was no difference between urban and rural women in odds of overweight or obesity Class I, II or III. No significant urban–rural difference in odds of overweight/obesity was evident among children.Conclusions: The higher prevalence of obesity in rural women compared with urban women was largely explained by individual-level sociodemographic factors, such as age, number of children, country of birth, education level, employment status and marital status. This suggests that higher obesity levels among women in rural areas may be attributable to the sociodemographic composition of these areas.

Verity Cleland PhD · Clare Hume PhD · David Crawford PhD · Anna Timperio PhD · Kylie Hesketh PhD · Louise Baur MB BS, PhD · Nicky Welch PhD · Jo Salmon PhD · Kylie Ball PhD

From the recognition of the swine flu pandemic in late April 2009, health professionals, politicians and the public needed to know how serious pandemic (H1N1) 2009 influenza (swine flu) was in relation to other seasonal strains of influenza. The Victorian experience suggests that the circulation of pandemic (H1N1) 2009 influenza in the community was at most like influenza circulation in a season of moderate seasonal activity. We have no estimate of the total case count, but we know most infections have been mild. However, while disease in the community appears mild, and the risk of hospitalisation is low, a high proportion of patients hospitalised with swine flu required intensive care. Deaths from swine flu have not been as numerous as the modelled deaths from seasonal influenza, although people dying from swine flu are younger. Because we do not understand the laboratory-confirmed burden of disease due to seasonal influenza (as opposed to the modelled burden of disease), we could not base our response to the pandemic on an informed comparison of seasonal and pandemic influenza. We may not have needed a pandemic response to a disease that, although it has a different footprint, has been predominantly of seasonal intensity. It is critical to accumulate quality evidence about laboratory-confirmed influenza to guide our intervention policies for both seasonal and pandemic influenza.

Heath A Kelly BSc, MB BS, MPH

Objective: To describe the case characteristics and outcomes of patients hospitalised with pandemic (H1N1) 2009 influenza infection during the first 2 months of the epidemic.Design, participants and setting: Prospective case series of 112 patients admitted to seven hospitals in Melbourne with laboratory-confirmed pandemic (H1N1) 2009 influenza between 1 May and 17 July 2009.Main outcome measures: Details of case characteristics, risk factors for severe disease, treatment and clinical course.Results: Of 112 hospitalised patients, most presented with cough (88%) and/or fever (82%), but several (4%) had neither symptom. A quarter of female patients (15) were pregnant or in the post-partum period. Patients presenting with multifocal changes on chest x-ray had significantly longer hospital lengths of stay, and were more likely to require intensive care unit admission. Thirty patients required admission to an intensive care unit, and three died during their acute illness. The median length of intensive care admission was 10.5 days (interquartile range, 5–16 days).Conclusions: This study highlights risk factors for severe disease, particularly pregnancy. Clinical and public health planning for upcoming influenza seasons should take into account the spectrum and severity of clinical infection demonstrated in this report, and the need to concentrate resources effectively in high-risk patient groups.

Justin T Denholm BMed, MBioethics · Claire L Gordon MB BS, BMedSci · Paul D Johnson MB BS, PhD, FRACP · Saliya S Hewagama MB BS · Rhonda L Stuart MB BS, FRACP, PhD · Craig Aboltins MB BS, FRACP · Cameron Jeremiah MB BS · James Knox BSc(Med), MB BS, DTM · Garry P Lane MMed(ClinEpi), MQIHC, FRACP · Adrian R Tramontana MB BS · Monica A Slavin MB BS, FRACP · Thomas R Schulz BSc, MB BS · Michael Richards MBBS, FRACP, MD · Chris J Birch PhD · Allen C Cheng FRACP, MPH, PhD

Pandemic (H1N1) 2009 influenza has generated many controversies in Australia around case definitions, laboratory diagnosis, case management, medical logistics and travel restrictions. Our experience as clinical advisers in the Victorian Department of Human Services Emergency Operations Centre suggests the following: Case definitions may change frequently, and will tend to become more clinically specific over time. Early in a pandemic, laboratory diagnosis plays a critical role in case finding and pathogen identification. Later in the pandemic, standardised case management applied to well crafted case definitions should reduce reliance on the diagnostic laboratory in clinical management. The diagnostic laboratory will remain critical to monitoring disease surveillance, pathogen virulence, and drug susceptibility. Medical logistics will continue to challenge pandemic managers as the health sector struggles to do the most good for the greatest number of people. Travel restrictions remain scientifically controversial public health recommendations. Issues of scalability (escalation and de-escalation of the response) relating to virus lethality need to be resolved in current pandemic planning.

David A Bradt MD, FACEM, FAFPHM · Joseph Epstein FRACS, BA(Hons), FACEM

Objective: To compare the patient characteristics, clinical features and outcomes of adult patients hospitalised with pandemic (H1N1) 2009 influenza and seasonal influenza.Design and setting: Retrospective medical record review of all patients admitted to Liverpool Hospital, Sydney, with laboratory-confirmed influenza from the initiation of the “PROTECT” phase of the pandemic response on 17 June until the end of our study period on 31 July 2009.Main outcome measures: Severity of illness; requirement for admission to the intensive care unit (ICU) and/or invasive ventilation; mortality.Results: Sixty-four adults were admitted to Liverpool Hospital with influenza, 48 with pandemic (H1N1) 2009 influenza and 16 with seasonal influenza. Thirteen patients were admitted to the ICU. Seven required invasive ventilation, with 2 patients requiring ongoing extracorporeal membrane oxygenation (ECMO). Five patients died (mortality rate, 8%) with two deaths occurring after the study period. Patients with pandemic (H1N1) 2009 influenza were younger and less likely to be immunocompromised than patients with seasonal influenza. However, the clinical features of pandemic (H1N1) 2009 influenza and seasonal influenza were similar.Conclusions: Our findings show that the clinical course and outcomes of pandemic (H1N1) 2009 influenza virus are comparable to those of the current circulating seasonal influenza in Sydney. The high number of hospital admissions reflects a high incidence of disease in the community rather than an enhanced virulence of the novel pandemic influenza virus.

Ya-Shu Chang MB ChB · Sebastiaan J van Hal MB ChB, FRACP, FRCPA · Peter M Spencer MB BS · Iain B Gosbell MD, FRACP, FRCPA · Peter W Collett MB BS, PhD, FRACP

A graded public health response was implemented to control the pandemic (H1N1) 2009 outbreak in Queensland. Public health measures to contain the outbreak included border control, enhanced surveillance, management of cases and contacts with isolation or quarantine and antivirals, school closures and public education messages. The first confirmed case in Australia was notified on 8 May 2009, in a traveller returning to Queensland from the United States. In Queensland, 593 laboratory-confirmed cases were notified with a date of onset between 26 April and 22 June 2009, when the Protect phase of the Australian Health Management Plan for Pandemic Influenza was implemented; 16 hospitalisations and no deaths were reported during this time. The largest number of confirmed cases was reported in the 10–19-years age group (167, 28% of cases), followed by the 20–29-years age group (153, 26% of cases). With ongoing community transmission, the focus has shifted from public health to the clinical domain, with an emphasis on protecting vulnerable groups. Considerable resources have been invested to prevent and control the spread of disease in Indigenous communities in Far North Queensland. The capacity of clinical services to cope with increased admissions, the potential for widespread antiviral resistance, and rollout of mass vaccination campaigns remain future challenges.

Ranil D Appuhamy BSc, MB ChB, MIPH · Frank H Beard MB ChB, FAFPHM · Hai N Phung MD, MPH, PhD · Christine E Selvey MB BS, MSc · Frances A Birrell MPH, MAppEpid, GCSc(Stats) · Terry H Culleton GradCertMgmt, BHlthServMgmt, RN

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social “vitamins” of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

Mark F Harris FRACGP MD · Elizabeth Harris MPH, BA, DipSocWk · Timothy D Shortus MPH, PhD, FRACGP

Good-quality data on tobacco sales are vital for evaluating tobacco control interventions The prevalence of smoking in Australia is among the lowest for high-income countries. In 2007, 17.9% of Australians aged 14 years or older were current smokers, compared with 23.6% in 1998. Yet tobacco remains Australia’s leading risk factor for premature death and disability, accounting for 7.8% of the total disease burden,1 nearly twice the combined burden caused by alcohol (2.2%) and illicit drugs (2.0%). Tobacco is still big business in Australia. In 2004, an industry-commissioned report estimated that the retail value of the Australian tobacco market was about $9.3 billion, and tobacco products accounted for 4.7% of retail sales through about 35 000 retail outlets.2 The federal government also derived an estimated $5.6 billion in tobacco excise taxes for the financial year 2008–09.3 Despite the substantial harm that smoking causes, the sale of tobacco products is minimally regulated in Australia. There are few restrictions on where tobacco can be sold — some states (Queensland and Victoria) do not require tobacco sellers to obtain a tobacco retail licence, or even maintain a register of tobacco sellers.4 Governments increasingly demand good evidence that proposed tobacco control policies will work. National and state-based population surveys are the main source of smoking prevalence data, which are needed to determine whether tobacco control policies are having the desired impact. Although the information that these surveys provide is valuable, it has serious limitations. The collection of self-reported smoking status data in population surveys is costly, and is also increasingly hampered by low response rates caused in part by the uptake of unlisted mobile phone use and the proliferation of call screening and answerphones.5 In addition, self-reported smoking data may have become less reliable as smoking has become increasingly stigmatised in Australian society — fewer people, especially those who smoke occasionally, may be willing to disclose that they smoke. Furthermore, tobacco control interventions are likely to have small, but nonetheless important, effects on smoking in whole populations, which are difficult to detect in yearly or less frequent surveys because of statistical power problems. At the same time, ever greater sensitivity is needed to satisfy the requirement for evaluation of effectiveness of tobacco control interventions at the population level. A comprehensive ongoing data series on tobacco sales would facilitate evaluation of tobacco control policies at national, state or regional levels by taking into account variations in the timing of policy implementation. As suggested in the National Preventative Health Taskforce’s final report,6 state and territory governments or the federal government should require Australia’s three major tobacco manufacturers — Philip Morris (Australia), British American Tobacco Australia and Imperial Tobacco — to provide auditable, postcode-identified monthly data on all tobacco products supplied for retail sale. Data on supply of tobacco products are collected by manufacturers on a daily basis as retailers place tobacco orders. The three manufacturers supply almost all cigarettes sold to Australian retailers.7 Several small importers supply “boutique” brands, but these have negligible brand share. Tobacco sales data would be extremely valuable in monitoring trends in tobacco use and in evaluating the effectiveness of current and proposed tobacco control interventions, such as “quit” campaigns, pack warnings, retail display bans and mandatory plain packaging for tobacco products. Because of its geographic isolation, Australia has a relatively small illicit tobacco market compared with most other countries (Euromonitor International estimates that 3.5% of cigarettes consumed in Australia in 2007 were illicit).8 Therefore, retail data are likely to provide a reasonably accurate estimate of total tobacco consumption in Australia and an unbiased benchmark against which household survey data can be evaluated. Data on tobacco products supplied to retailers on a month-by-month basis are not the same as data on the volume of tobacco excised because of the common habit of manufacturers warehousing large amounts of excised tobacco. This was demonstrated in 2006, when pictorial pack warnings were introduced from March. After this time, it was illegal for any company to manufacture tobacco packaging with the old text-only warnings; but old stock was being sold by retailers 6 months later because manufacturers had over-produced the old packaging and warehoused it.9 The tobacco industry is highly effective at mobilising retailers to lobby against tobacco control strategies, so moves to require provision of tobacco sales data will be opposed. There are no good reasons for opposition. These data are already collected by commercial market research companies on behalf of the tobacco industry and are available for purchase; however, researchers have been denied access to this information when they have attempted to purchase it. The tobacco industry should be legally required to provide governments with data on the sales of a commodity which is more addictive and harmful to population health, and much less regulated, than alcohol.

Coral E Gartner PhD · Simon F Chapman PhD · Wayne D Hall PhD · Melanie A Wakefield PhD

Objective: To investigate the Australian public’s expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine.Design, setting and participants: A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza.Main outcome measures: Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents’ willingness to share Australian vaccine with neighbouring developing countries.Results: Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region.Conclusion: Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.

Keith Eastwood MApplEpid · David N Durrheim MBChB, DrPH, FAFPHM · Alison Jones MD, FRCP · Michelle Butler MSc

Clinical record A 66-year-old woman was brought to the emergency department at the Alfred Hospital in Melbourne with severe headache and confusion after 2 days of a “flu-like illness”. Her medical history was significant only for rheumatoid arthritis, for which she was prescribed low-dose methotrexate. On initial assessment, she was found to be febrile (38°C) and agitated, and quickly required intubation for decreased consciousness. Full peripheral blood examination showed a total white blood cell count of 35.4 × 109/L (reference range, 4.5–11.5 × 109/L) and acute renal impairment (creatinine concentration, 169 μmol/L, reference range, 45–80 μmol/L). Lumbar puncture performed after intubation showed turbid cerebrospinal fluid (CSF), with 198 × 106/L polymorphs and no lymphocytes seen on microscopy. A Gram stain of her CSF showed gram-positive cocci, which were subsequently confirmed to be Streptococcus pneumoniae. S. pneumoniae was also cultured from blood taken at presentation. Intravenous therapy with vancomycin, benzylpenicillin, ceftriaxone, and dexamethasone was commenced initially, and the patient was transferred to the intensive care unit for ongoing management, including inotropic support. After antibiotic susceptibility testing, benzylpenicillin therapy alone was continued. The patient became afebrile and haemodynamically stable after 48 hours, but her neurological recovery was prolonged. She remained intubated for 10 days after admission, and required a tracheostomy for respiratory weaning. Films from blood taken shortly after admission showed target cells, acanthocytes and Howell–Jolly bodies, raising the possibility of anatomical or functional asplenia. Her family and general practitioner were questioned, but they were unaware of previous splenic surgery, or surgical scars or abdominal trauma, and did not believe that the patient had ever received pneumococcal vaccination or prophylactic antibiotics. After extubation, the patient revealed that an absent spleen was noted many years previously when she had a laparoscopic cholecystectomy, but that she was unaware of any implications or required management of asplenia. After the discovery of her (presumed congenital) asplenia, she was referred to the Victorian Spleen Registry for vaccination, commencement of antibiotic prophylaxis, and ongoing education. During her subsequent hospital stay, it became apparent that the patient had persistent neurological deficits, in particular, unilateral sensorineural hearing loss and difficulty with cognitive tasks and concentration. She spent a total of 19 days in an acute-care hospital and a further 50 days in a rehabilitation centre, and has since returned home with ongoing support from allied health professionals and carers. Overwhelming postsplenectomy infection (OPSI) is a well recognised long-term risk in patients who have undergone splenectomy. In addition, there are patients who are asplenic for other reasons, including congenital asplenia or medical conditions such as coeliac or sickle cell diseases.1 The incidence of OPSI can be reduced by instituting a suite of preventive measures,2 although auditing has shown that adherence to recommendations is poor, both in Australia and elsewhere.3-5 Partly in response to these studies, a number of national and international guidelines have been published, including recent guidelines produced by the Australasian Society for Infectious Diseases.6 In Victoria and elsewhere, there have been more systematic efforts, including the establishment of registries for people who are asplenic. Our case illustrates the risk of OPSI, and, below, we describe how this risk can be minimised. Although an individual’s risk for OPSI is only in the order of one in 500 patients per year, this carries a 50% chance of mortality for those affected,6 and a risk of significant morbidity. The cost to the health system of an individual case of OPSI can be significant, and systematic approaches to prevention are cost-effective.7 Guidelines based on the limited evidence available usually recommend a combination of vaccination and long-term antibiotic prophylaxis, plus the supply of emergency antibiotics and, possibly most importantly, patient and family education about health after, and the possible consequences of, splenectomy.1,6,8 In retrospective studies, adherence to these guidelines appeared to reduce the rate of OPSI by about 50%.2 As was the case in our patient, most cases of OPSI are due to S. pneumoniae.6 Vaccination against this organism is important, as is vaccination against Neisseria meningitidis and Haemophilus influenzae type b, and vaccination with the influenza vaccine (Box 1). Prophylactic long-term antibiotic therapy is also recommended (Box 1), on the basis of a similar level of evidence. Lack of antibiotic prophylaxis is associated with increased risk.2,3 If patients cannot tolerate long-term prophylaxis, an emergency supply of antibiotics and information on when to take these may be an appropriate alternative.6,8 Education is also important in recognising signs of infection and the need for early presentation to medical care. Insufficient medical advice to patients and their treating medical practitioners, and forgetting this advice, have been purported to be responsible for cases of OPSI occurring decades after the original splenectomy.3 Education also includes the need for travel advice, especially to areas where malaria exists, and consideration of antibiotic therapy after animal bites or other trauma. Poor adherence to guidelines has given rise to the suggestion that an active spleen registry may be the best option to ensure adherence to best-practice recommendations.9 There are few previous reports of spleen registries, and those that exist show that registries vary in their methods of operation.10 Lessons from practice Overwhelming postsplenectomy infection occurs in one in 500 patients per year, but the associated mortality rate is 50%. This risk can be reduced by about half with education, vaccination and antibiotics. Systematic approaches to postsplenectomy care are likely to be more efficient than ad-hoc approaches. The Victorian Spleen Registry was established in 2003 with funding from the Victorian Government Department of Human Services for an initial 18-month period. The registry team includes the registry coordinator, infectious disease physicians, clinical haematologists and a clinical immunologist, with additional advice received from surgeons, pharmacists and anatomical pathologists. The registry actively enrols asplenic patients; referral and patient consent are required for inclusion. Patients enrolled on the registry are provided with written information about the management of asplenia, and provided with memory aids such as refrigerator magnets and wallet-sized cards. More than 1000 patients are now enrolled. However, continuing funding for the registry is an ongoing problem. This case and others, like the one illustrated in Box 2, show the severity of even non-fatal OPSI when it occurs, and the real need to minimise the risk to patients by ensuring that they receive regular vaccination, appropriate antibiotic advice and education, as provided in a registry setting. 1 Summary of current recommendations for adult patients who are asplenic Recommendation Frequency Vaccination Pneumococcal conjugate Consider at baseline Meningococcal conjugate C Baseline Haemophilus influenzae type b Baseline Pneumococcal polysaccharide (23 valent) Baseline + 5 year Quadrivalent polysaccharide meningococcal vaccine Baseline + 5 year Influenza Annual Antibiotic prophylaxis Amoxycillin 250 mg orally or Daily, lifelong penicillin 250 mg orally Twice daily, lifelong Roxithromycin 150 mg (if allergic to penicillin) Daily, lifelong Amoxycillin 3 g (if prophylaxis not tolerated) In emergency (eg, febrile illness when unable to access medical care) Enrolment in a spleen registry where one is available 2 Middle-aged woman after overwhelming postsplenectomy infection This patient had not had all the necessary vaccinations; she survived, but required amputation of all four limbs.

Justin T Denholm BMed, MBioethics · Penelope A Jones RN, GradDipEpi · Denis W Spelman MPH, FRACP · Paul U Cameron PhD, FRACP · Ian J Woolley MB BS, FRACP

Incorrect author name: In the letter “Invasive pneumococcal disease in Western Australia: emergence of serotype 19A” in the 2 February 2009 issue of the Journal (Med J Aust 2009; 190: 166), there was an error in one of the author's names. The name “Keil D Anthony” should have been “Anthony D Keil’.

Carolien M Giele · Anthony D Keil · Deborah Lehmann · Paul G Van Buynder

Although it is imperative to keep trying, the fight against obesity is unlikely to be successful until economists, politicians and health scientists agree on similar goals Consider this: the world has just been through one of the worst economic crises since the Great Depression, yet Australia seems to have come through it swimmingly — at least for the moment. How did we do it? The government gave us money to help us consume. Synonyms for “consume” in Roget’s thesaurus include: “eat”, “drink”, “get through”, “devour”, “put away”, “munch through”, “chomp through”, “guzzle”.1 With not a tinge of irony, the Australian Government Senate report, Weighing it up: obesity in Australia2 (and most other obesity reports), advises us to take stock of ourselves, not to be such pigs, to stop overeating, leave the SUV (sport utility vehicle) at home and walk, or ride a bicycle — in other words, to stop consuming! Is this schizophrenic government policy? No, it’s sensible, post-Keynesian economics, currently being applied around the world. But how sensible is a system that puts vast amounts of money into treating a problem that it puts vast amounts of money into creating? Obesity depends on overconsumption — of food, drink and effort-saving technology; hence, the fatter the population, the fatter the economy. A spoof “pitch” on a recent ABC television program on advertising cleverly illustrates this. Asked to develop a campaign to reduce prejudice against obesity, the competing agency came up with an advertisement praising fat people for their overconsumption for being heroes in the battle to reverse the 2008–2009 global financial crisis. The catch phrase of this spoof, “Australia: our success depends on your excess”, sums up the modern conundrum. Reporting in the journal Health Affairs,3 researchers calculated that obese individuals in the United States pay US$1400 per year more for their health (or lack thereof) than their lean counterparts. This adds an extra $47 billion per year to the US budget, or about 10% of all health spending, which, ironically, all goes to the measure of economic health, or gross domestic product (GDP). People with diabetes spend US$4100 more per year on medical care in their first year of detection than people without diabetes, and each incurs an extra $158 of medical expenses each year, which is also added to GDP.4 Currently, these physically sick but economically valuable people make up 7% of all Australians. However, there are another 15% with prediabetes, lining up to contribute to the nation’s coffers.5 Such a vital economic segment of the population could easily be doubled within a generation, with money to consume more fatty foods, use gas-guzzling cars rather than walk or cycle, and watch televised activity rather than actively participating. If the economy remains sluggish, smoking, and alcohol and drug use, which currently add about 9% to GDP directly, and a similar amount from dealing with the consequences, could be increased overnight with a further government bailout. While health experts decry these costs as evidence of health system failure, economists rub their hands together to the tinkle of money that is keeping the GDP in the black. Politicians, of course, are the meat in the sandwich. Without labouring the point (ie, the economic benefits of fast food, obesity surgery, weight-loss programs, etc), it should be obvious that there is now a disconnection between the modern system of economic growth and human health. This is not to suggest that this has always been the case. There is no doubt that economic growth has been the greatest single contributor in history to improving human health.6 But even the early architects of economic growth — Mill, Keynes and others — foresaw a time when growth would pass its use-by date, when the returns on further investment would start to decrease and then become negative. As pointed out by one commentator: “after maturity, continued growth is either obesity or cancer”.7 In his Principles of political economy, written in 1848, John Stuart Mill states: It must always have been seen, more or less distinctly, by political economists, that the increase in wealth is not boundless: that at the end of what they term the progressive state lies the stationary state, that all progress in wealth is but a postponement of this, and that each step in advance is an approach to it.8 In health terms, it seems this time may have arrived. Data from Sweden over the past 200 years show an initial close relationship between health and economic growth, but then in recent years, a reversed relation in which faster growth implies less progress in improving health.9 Diminishing returns in health, as reflected by increases in obesity, disability-adjusted life-years, and health costs (although not yet by decreases in longevity), have also been linked with climate change,10 making an alternative to our current growth fetish even more crucial. For most people, of course (including those in the health professions), this is all too hard, along with its correlates in water shortages, species extinction, freakish weather events, and global warming. So, we tend to ignore it, hoping it will go away. But without considering the macroeconomic system’s dynamic influence on human health, and the fact that economic growth has largely finished its work in developed countries and we now need to pay greater attention to reducing inequity,11 obesity and its related chronic diseases will continue their onward march to becoming the only human epidemic to approach affecting 100% of the population. Let’s hope economists, health scientists and politicians can agree on similar goals before that happens.

Garry J Egger MPH, PhD

Climate change is weakening Earth’s life-support systems The United Nations Climate Change Conference in Copenhagen (7–18 December) will soon be behind us. Climate change, however, continues to progress more rapidly and disruptively than climate scientists foreshadowed only 5 years ago. Recent peer-reviewed reports of climate change processes and impacts show, among other effects, an increased rate of greenhouse gas accumulation in the lower atmosphere, and an accelerating sea level rise. This has prompted a worrying reappraisal of where we might now be heading. Earlier this decade, there were hopes of limiting the global temperature increase to about 2°C. There is now growing scientific recognition that we need to prepare for an even more disrupted world with temperature rises of up to 3–4°C.1-3 Most political institutions have short-term priorities. These impede the urgent, enlightened and unselfish collective action needed to respond to this unprecedented global environmental challenge.3,4 Despite the rapid maturation of climate change science and the wonders of global sensing technology and electronic connectivity, we collectively fail to understand the full extent of the risks we face. Something fundamental is missing. Preoccupation with the technical details of climate change science, and with economic costs, property protection and the politics of shared responsibility, has overshadowed full appreciation of the consequences for human health and survival. Despite the growing recognition of the risks posed by climate change to social and economic wellbeing, the risks to human health are mostly viewed as regrettable, and hopefully tolerable, collateral damage. This view is very naïve. It fails to recognise the profound significance of the risks posed to the biology and health of plant and animal species everywhere, including our species. Christmas joys aside, this situation signals a Red Alert. Climate change is weakening Earth’s life-support systems, and, if not reversed, portends a disastrous outcome. This is no longer a matter of speculation or theoretical modelling. The number of people affected annually by heatwaves and other extreme weather events has risen in several countries over recent decades. For example, the average annual number of excess deaths associated with heatwaves has increased markedly over the past two decades in Hungary, commensurate with a threefold increase in the average annual frequency of heatwaves.5 Food yields have recently decreased in some regions, including parts of Asia, southern Africa and the eastern Sahelian region of Africa, in association with a range of environmental stresses that include warming, drying and severe flooding.6 Some infectious diseases have changed their geographic range and seasonal duration, in association with regional warming. This includes northward extensions in Sweden of tick-borne encephalitis and its tick vector, and in China of the critical winter survival zone for water snails that transmit schistosomiasis. Similarly, malaria has been occurring at higher altitudes in highland regions in parts of eastern Africa.7 Despite current evidence, such as the marked ecosystem changes and accelerated ice losses in the Arctic, human-driven climate change is still at an early stage; excessive greenhouse gas emissions will continue for (at least) decades, and the full realisation of their effect on climate will be drawn out over time.8 The momentum of change in the climate system is huge and protracted, especially for sea level rise. Hence, most current climate “mitigation” actions will have limited immediate effect, and further delay and attenuation of emission reduction targets by governments will invite disaster. Adverse impacts on human health can be expected to rise over coming decades — particularly in vulnerable populations in low-income and poorly resourced countries, such as Bhutan and Nepal, and in geographically exposed locations, such as river delta populations, and small island states, and south-eastern Australia. Meanwhile, the unequivocal detection of climate-related health impacts at this early stage presents a research challenge. The health effects of climate change coincide with various non-climate-related causal factors — so, for example, an upwards trend in excess deaths during heatwaves may also be due to population ageing and a greater prevalence of underlying cardiovascular disease. Further, human vulnerability (unlike that of all other species) is typically cushioned by culture, technology, trade and aid. However, this difference in vulnerability between Homo sapiens and other living organisms is less than we might imagine. The natural environment, the biosphere, furnishes all of Nature’s processes and the products upon which our health and survival depend: food, fresh water and fibre (including timber, firewood and cotton), natural constraints on pathogens, access to natural medicines and a relatively stable climate. These things, rather than hospitals, doctors, genetic testing and dietary advice, are the true foundations of population health. Climate risks to health are both direct and indirect. Direct risks include deaths and physical injury from extreme events, such as increasingly frequent and intense bushfires, cyclones and floods; and deaths and hospitalisations from extreme heat. Indirect risks include changes in the range and seasonality of various infectious diseases, and impaired food system productivity on both land and sea, productivity in the latter being compounded by oceanic acidification due to greater uptake of carbon dioxide. Mental and physical health problems can result from the social disruption and dislocation caused by weather extremes that are bringing drought and long-term regional drying out to parts of rural Australia. A likely increase in the flow of climate refugees, here and elsewhere, will also have consequences for health and health care systems. Climate change will act primarily by amplifying and extending the rates and ranges of existing health problems. Hence, to minimise climate change impacts, it is crucial to reduce the high background rates of poor health in vulnerable populations. Many low-income countries are already struggling to meet the UN’s Millennium Development Goals.9 Their populations face great health threats from climate change, including exacerbations of infectious disease (including water-, food- and vector-borne disease); higher rates of maternal and child mortality (particularly if basic health services are disrupted by environmental stresses); and undernutrition, with impairment of children’s physical and intellectual development. This year has seen a heightened awareness of the significance of the health risks from climate change. In May, the cover of the Lancet announced that “Climate change is the biggest global health threat of the 21st century” — a bold statement, but consistent with the emerging evidence. In that same month, the congress of the Royal Australasian College of Physicians devoted a full plenary session to the topic, as did the 2009 annual conference of the Health Ministers of Commonwealth countries in Geneva. In September, leaders of 18 national bodies of medicine, from low- and high-income countries, published a letter in both the Lancet and the BMJ stressing the potential for a worldwide health disaster from climate change.10 Health professionals, as citizens, will have concerns in relation to climate change as communities increasingly seek an effective policy response. Meanwhile, the specific professional challenges for medical practitioners include: reducing the carbon footprint of clinics, clinical practice and the overall health care system; providing appropriate public education via the clinical setting; setting personal examples (eg, bicycles rather than BMWs); assisting research that elucidates the health risks posed by climate change; and contributing, via professional organisations, to public education and to policy advocacy. We are now all participants in the world’s most important debate on the primary determinants and sustainability of population health.

Anthony J McMichael FAFPHM, MB BS, PhD · Colin D Butler BMed, MSc, PhD

Conference delegates workshopped a realistically staged disaster scenario in which they were completely isolated from outside resources If you have to have a disaster, Broome, on the remote Kimberley coast of Western Australia, seems a good place to be; that is, until you take a closer look at what it would be like at the centre of the action. And this is exactly what delegates did during the inaugural conference on Tropical, Emergency and Disaster Medicine (TED-MED), held in Broome on 22–24 May 2009. The conference was attended by 81 delegates, including 28 general practitioners, eight tropical medicine specialists, six emergency medicine specialists and five disaster medicine specialists, plus representatives of government agencies, rural and remote nurse paramedics, clinical laboratory scientists and environmental health and industry participants. In this conference, we used the scenario of a tropical cyclone to move conference attendees outside their comfort zones and draw them into the reality of health crisis management in regional Australia. As it happened, Broome turned out to be an excellent location for the TED-MED conference because of a series of recent events, including the explosion of a refugee boat off the north-west coast of Australia and a tourist vehicle rollover on the Mitchell Plateau to the north-east. To add further realism to the program, there was severe wind damage caused by storms hitting Perth the day before visiting speakers flew into Broome, and the nation was on the verge of moving from the “Delay” phase to the “Contain” phase of the response to pandemic (H1N1) 2009 influenza. There were two triggers for a broad-based conference such as this. One was a renewed emphasis on regional development, particularly in WA’s north-west, where the expansion of the Ord River Irrigation Scheme, mining and petrochemical industries, and tourism are expected to drive a threefold to fourfold expansion of the regional population over the next decade. The second trigger was the Government of WA’s Royalties for Regions policy, under which some of the revenue generated by the mining and resources industry is returned to regional WA in the form of infrastructure funding, and is expected to add impetus to the population growth in the north of the state. In his opening address, WA Director General of Health Peter Flett emphasised the challenges of providing health care to such a thinly spread population in a tropical environment. He said that there was an urgent need to tackle the declining professional population as the baby boomer generation goes into retirement. David Atkinson, from the Kimberley Aboriginal Medical Service Council, compared his extensive experience in remote Aboriginal communities with indigenous communities in remote Canada. The extremes of hot and cold were explored further by retired remote and rural general surgeon Val Lishman AM, who spoke on his work in northern Australia and as an Australasian Antarctic Expedition doctor. Val’s moving snapshot of wilderness medicine in extreme environments was a profound reminder of the importance of resourcefulness and unquenchable optimism in the face of adversity. At the centre of the conference program was a carefully researched disaster scenario (Cyclone TED). Delegates prepared for an extended problem-solving activity through a series of lectures. Major-General Paul Alexander (Australian Defence Force [ADF] Surgeon General) gave the initial plenary session on ADF health capability, reflecting on the role Defence personnel often play in disaster response. He usefully clarified what the Defence Force can do and under what circumstances they would be tasked to assist. Highlights of subsequent parallel sessions were a vivid description by plastic surgeon Fiona Wood of the management of patients with burns who were injured in the Bali bombing, the challenges to medical evacuation from a combat zone by David Werda (former ADF paramedic during United Nations deployment to Somalia), and tag-team presentations on snakebite and emergency resuscitation by George Jelinek and Steve Dunjey (both from the Emergency Department at Sir Charles Gairdner Hospital). Steve’s recent high-profile resuscitation success in outback WA led him to comment that medicine is full of surprises. “You can see unexpected survival in patients under 50 after over 20 minutes’ resuscitation.” The closing straight was led by a relay team of experts. Juliet Hubbard, speaking for Indigenous communities, advocated much wider training of health professionals in cultural safety, particularly in managing major community crises. Alison McMillan (Department of Human Services, Victoria), speaking on the Victorian bushfire disaster, reminded us how quickly local emergency services can be overwhelmed. She gave delegates a sense of the confusion that arises as responding agencies piece together a picture of a disaster. Finally, Brad Santos, a severe-weather expert from the Bureau of Meteorology, left the storm damage in Perth behind him and showed how cyclones behave, with specific reference to their severity and time course. Having given us a taste of what to expect, he introduced the disaster scenario with a scene-setting severe-weather warning. Unlike in many tabletop exercises that aim to advertise the capabilities of host agencies, the details of the scenario were not disclosed to participating agencies. Michael Watson (Clinical Microbiologist, Perth), who led the team of scenario writers, said that he wanted a realistic challenge. As it happened, the date of the conference coincided with peak high tides, enabling Michael and his team to design a realistic scenario in which cyclonic winds caused a storm surge and significant flooding. They envisaged power, telecommunications, the airport, and road links being out of action for 48 hours. To the frustration of health administrators, there was no phone-a-friend-in-Perth option. Police, fire and emergency services, ambulance services, the Royal Flying Doctor Service, the Water Corporation, the Department of Housing and the Department for Child Protection (which is responsible for resettling displaced people) had to rely on what was available locally. There was a lot of tension in the room in the early stages of the disaster scenario as participants grappled with conflicting priorities. In the wrap-up session, table after table recounted tales of resources they discovered when they started to reach out to other groups. Some discovered leadership skills they didn’t know they had. Others showed a natural talent for critical thinking under pressure. One of the conference highlights was a vivid description by Phil Kuhne (Department for Child Protection) of what it would be like in an overcrowded cyclone shelter, and why there wouldn’t be any cyclone parties on his watch. Adding a little realism to the scenario, television crews from two competing channels arrived to interview organisers and speakers just after the scenario started, diverting critical expertise when it was most needed. Cyclone TED was full-on; a draining experience for all those involved. However, there was little rest for the delegates. While the lessons of the disaster scenario were still fresh in their minds, participants split into three parallel skills-development workshops on practical aspects of disaster response, life support with particular emphasis on failed intubation drills, and deployable molecular diagnostic laboratories. Ronan Murray brought the more esoteric aspects of laboratory diagnostic support down to earth by reminding participants of the potential role of the molecular diagnostics laboratory in assisting with front-line clinical decision making in remote or rural regions. The Australasian College of Tropical Medicine took the opportunity to consult on the practical needs of health practitioners in tropical Australia, convening a small group to write up the lessons learned and condense them into a regional development framework — as one delegate put it, the “where we are, where we need to be and how we’re going to get there” of health care in tropical Australia. This process generated the action statement that was presented at the conclusion of the conference. The document, known as the Broome Declaration (Box), captured the spirit of the meeting and provided a sense of direction. In the final discussion of the conference, converting the Declaration into action was debated. There was uncertainty over where resources could be found for infrastructure development, and some scepticism over anything resembling a centrally driven capital project, but there was considerable enthusiasm for local ownership of the process from local delegates. The TED-MED Conference demonstrated that there are people who work at the hot and dusty end of health care who are willing to provide professional leadership. The Broome Declaration represents a benchmark for health development in tropical and regional Australia. It remains to be seen whether there is a substantive political commitment to support front-line health care professionals in developing health capability for regional Australia. The Broome Declaration 1. On this day, 24th May 2009, in Broome, Western Australia, we, the participants in the first consultative tropical medicine summit convened under the auspices of the Australasian College of Tropical Medicine, hereby recognise that the following 10 themes are essential to the development of tropical health: holistic, one health;* collaborative intersectoral partnership; primacy of prevention, early intervention; cultural safety;† subsidiarity;‡ leadership development; proximity of services; immediate availability; effective communication; and strategic urgency. 2. Recognising the current shortfall in health capability in this region as typical of many parts of the tropics, we commit to: establishing tropical health development priorities based on the above themes; informing health authorities of our conclusions; and working toward practical development outcomes within our immediate areas of professional influence. 3. We therefore propose the following specific priorities for north-west Australia: developing a remote access tropical medicine training program; establishing a regional development centre for all stakeholder groups in the Kimberley and the rest of the north-west; and forming a steering group to identify governance and resource support for these outcomes. * A reference to the concept of health as a state of physical, mental and social wellbeing, rather than an absence of disease, first articulated in the Declaration of Alma-Ata.1 † Achieved in a health care setting when carers and providers are attuned to the cultural context of the individuals and communities, and are sensitive to culture-specific vulnerability. ‡ The principle of devolving responsibility for decision making to as close as possible to the level of community at which action is taken.

Timothy J J Inglis DM, FRCPA, FACTM · Ronan J Murray FRCPA, FRACP, FACTM · Michael Watson FRCPA, FRACP, FACTM

Objective: To examine the nature of disease awareness advertising (DAA).Design: Therapeutic advertisements in six popular Australian women’s magazines were monitored between April 2006 and March 2007. A subset of advertisements was included in the study based on criteria derived from a definition of DAA. Unique advertisements were analysed by four independent coders.Main outcome measures: Types of advertisements and their sponsors, the types of disease information present, and the persuasive techniques utilised.Results: Of 711 advertisements identified, 60 met the inclusion criteria for DAA, and 30 of these were unique. Over one-third of the advertisements were classified as “unbranded product advertisements”, which promote a product without referring directly to a brand. DAA sponsored by pharmaceutical companies most often provided treatment and prevalence information. Most (22/30) advertisements used emotional appeals; 15 of these used “happiness/healthiness/wellbeing”.Conclusions: The educational value of industry-sponsored DAA could be improved if regulations and guidelines stipulated disease information requirements, such as inclusion of risk-factor and symptom information. Regulators should provide guidelines for “unbranded product advertisements” and the acceptability of other persuasive techniques. Further research into DAA is required and should consider advertisements in a range of media, and behavioural responses.

Danika V Hall MEd, BA · Sandra C Jones MBA(Marketing), MPH, PhD · Donald C Iverson BSc, MSc, PhD

Incorrect order of authors: In “ASID (HICSIG) position statement: infection control guidelines for patients with influenza-like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities” published online on 21 September 2009 and in the 19 October 2009 issue of the Journal (Med J Aust 2009; 191: 454-458), John K Ferguson was incorrectly listed as the first author of the article. The correct order of authors is: Rhonda L Stuart, Allen C Cheng, Caroline L Marshall and John K Ferguson.

Rhonda L Stuart FRACP, PhD · Allen C Cheng FRACP, MPH, PhD · Caroline L Marshall FRACP, PhD, GradDipClinEpi · John K Ferguson FRACP, FRCPA, DTMH

Two sisters aged 6 and 11 years presented with pruritic inflammatory lesions, one on the arm and one on the shoulder (Figure). The lesions appeared 72 hours after the girls had black henna tattoos applied while they were on holiday in Egypt. On examination, each girl had eczematous eruptions that perfectly outlined the tattoo. Patch tests were positive for paraphenylenediamine, a known potent contact allergen. Black henna tattoos are a frequent source of sensitisation to paraphenylenediamine among Australian tourists to South-East Asia.1 Potential significant consequences include allergic reactions to hair dyes, textile dyes, anaesthetics, sulfonamides and sunscreens containing p-aminobenzoic acid.

Pablo J Almeida · Leopoldo Borrego

Vaccinia vaccine is used to immunise against smallpox, which is caused by the orthopoxvirus, variola. A 26-year-old laboratory worker was inoculating mice with vaccinia vaccine as part of research into cross-reactivity among poxviruses. This particular vaccine contained a live attenuated strain of vaccinia (Western Reserve). The laboratory worker had himself received vaccinia vaccine in 2004 because of the nature of his work. On this occasion, after inoculating two mice, he suffered a needlestick injury to the left index finger. Two days later, a cloudy vesicle, typical of vaccinia virus,1 appeared at the inoculation site (Figure, arrow). After 3 more days, the finger became acutely inflamed, with secondary lymphangitis and axillary lymphadenitis. After antibacterial therapy, the lymphangitis and lymphadenitis rapidly resolved and the vesicle disappeared within 10 days. The man remains well. Infection with vaccinia usually follows vaccination or needlestick injuries. Although this is usually mild and self-limiting, certain conditions (eg, immunocompromise, pregnancy, eczema) predispose to more severe and even fatal illness. Prior immunisation with the vaccinia vaccine is thought to prevent or reduce the severity of such infections, and it is recommended that people working with vaccinia or related orthopoxviruses be vaccinated every 10 years.1 Vaccinia immunoglobulin and certain antiviral agents have been used to treat severe infections.2 Given the potential dangers from accidental exposure and the fact that the last documented case of smallpox (in 1978) was related to a laboratory incident,3 strict infection control measures are paramount, including disinfection after injury, prompt reporting, urgent medical review, and measures to minimise secondary spread to contacts.1

Sanjaya N Senanayake

To empower patients, we need to apply the knowledge gained from research The final report of the National Health and Hospitals Reform Commission, A healthier future for all Australians, has rightly stimulated debate in Australia about what it takes to create an equitable and sustainable health care system.1 The report draws attention to the importance of strengthened consumer engagement, boldly described as “giving people real control and choice about whether, how, where and when they use health services, supported by access to evidence-based information that facilitates informed choices”, as a platform for creating an “agile and self-improving health system”.1 Building health literacy is identified as a key strategy that will underpin strengthened consumer engagement. This ambitious commitment is long overdue. Research indicates that those who actively participate in health care decisions generally achieve better health outcomes compared with those who do not, and that most patients are not currently involved in health care decisions to the degree they would like to be.2 Those most likely to participate in health care decision making tend to be younger, female and educated. Regardless of personal preferences, not everyone is equally equipped to participate in health care decisions. The Commission’s report recognises this in its advocacy of action to build health literacy. Health literacy can be simply defined as the capacity to acquire, understand and use information for health. A 2006 Australian Bureau of Statistics survey examined health literacy in Australia using data derived from the Adult Literacy and Life Skills Survey, which assessed respondents’ prose and document literacy, numeracy, and problem-solving skills.3 From these data, information relating to respondents’ health literacy was derived, using specific questions related to health issues. The study found that 60% of Australians lack basic health literacy, described as the “minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy”.3 In a country that prides itself on achieving high rates of functional literacy, this is surprising, and indicates that individuals with higher levels of general literacy may not be able to consistently apply it in situations requiring specific content knowledge, or in an unfamiliar environment. For many individuals, as patients, carers and members of the public, health care settings are unfamiliar environments in which alien vocabulary and concepts are used. The relationship between literacy and the quality and outcome of health care has gained increasing attention, especially in the United States.4 Research shows that people with poor health literacy are less responsive to health education and use of disease prevention services, are less able to successfully manage chronic disorders such as diabetes and asthma, and incur higher health care costs.5 This has led to progressive testing of interventions designed to mitigate the effects of poor health literacy through modified communication and improved health service organisation.6 The limited research on health literacy conducted in Australia, such as the article by Adams and colleagues in the current issue of the Journal, confirms both the findings of the Australian Bureau of Statistics survey on the extent of the problem, and the established link between poor health literacy and poor health outcomes.7 Research from New South Wales provided insight to the needs and preferences of people with low literacy in the development of clinical decision aids.8 Given the policy recommendations and potential importance of their impact, this remains an underdeveloped area of research.8 Although the Commission’s attention to health literacy is encouraging, the practical actions proposed in its report are underdeveloped and will require early attention to seize this opportunity for action. Health literacy is best developed through education that is customised to individuals and their specific priorities. The recommendation that health literacy be incorporated into the National Curriculum for school children is commendable; however, the educational needs of a person with diabetes who is receiving patient education, or a pregnant woman attending antenatal classes, or a carer of a person with long-term mental illness will be greatly different. School health education will not prepare us for the different individual health challenges we may face. If we are to see “real control and choice about whether, how, where and when [people] use health services”,1 three strategies are required. First, health care providers and those responsible for patient management and administration need to demonstrate greater sensitivity to the needs of patients with poor health literacy by creating a less alienating health care environment that is more responsive to patient needs. Second, greater care needs to be taken to improve the quality of patient communication and the materials that support it. Both of these strategies require further research, and both can be achieved in part through modification of basic and continuing education. Third, outside the health care system, as well as investing in school education, Australia would do well to follow the lead of the United Kingdom in adopting innovative adult education programs such as the Skilled for Health program, which brings health content into an adult basic skills program.9 It is over 15 years since national goals and targets for health literacy were first proposed in Australia.10 Since then, our understanding of health literacy has grown considerably. If this knowledge is not applied, the policy goal of achieving meaningful control and choice by patients is unlikely to be met. Worse, increasing patient participation without specific interventions to address low health literacy could exacerbate existing health inequalities by further alienating those with poorer literacy skills and less confidence in using the health care system.

Don Nutbeam PhD, FFPH (UK)

Objective: To measure the level of functional health literacy (FHL) in an Australian population, and to explore the level of risk associated with level of FHL.Design, setting and participants: Cross-sectional, random population survey administered to 2824 South Australians aged ≥ 15 years, September – October 2008.Main outcome measures: Newest Vital Sign as a measure of FHL, self-reported general health status, and use of health services.Results: 24% of respondents were at risk of limited FHL, and 21% had a high likelihood of inadequate FHL; this increased with age (≥ 65 years, 50% v 25–44 years, 11%). In multiple logistic regression models, a high likelihood of inadequate FHL was significantly more common among those with lower education (left school ≤ 15 years of age, odds ratio [OR], 8.1; 95% CI, 4.8–13.6); with lower annual income (< $20 000, OR, 4.1; 95% CI, 2.3–7.4); who were born in countries other than Australia, New Zealand, the United Kingdom and Ireland; and with poorer health status (OR, 1.6; 95% CI, 1.2–2.2). Inadequate FHL was significantly less common among females (OR, 0.6; 95% CI, 0.5–0.8). People with inadequate or at-risk FHL were significantly more likely to report having diabetes, cardiac disease or stroke, and significantly less likely to have recently attended a doctor. Respondents aged ≥ 65 years with inadequate FHL were more likely to have been admitted to hospital (OR, 2.2; 95% CI, 1.1–4.5).Conclusion: Many Australians are likely to have limited health literacy, and this is a risk to effective health care delivery and health improvement across the community.

Robert J Adams MD, FRACP · Sarah L Appleton BSc · Catherine L Hill MD, BS, FRACP · Mark Dodd BEc · Christopher Findlay BEc, MEc, PhD · David H Wilson MPH, PhD

To the Editor: Finally! An article in the Journal about health reform that carries no spin and decries further futile experimentation in management. Lewis and Leeder are to be congratulated on their insightful review.1 As they point out, social and environmental determinants of health are far more important to a community’s well-being. This was recognised intuitively as long ago as 1986, with the promulgation of the Ottawa charter,2 and its recommendation that health services be reoriented primarily toward promoting heath rather than delivering acute care per se. As Lewis and Leeder articulate, the evidence in favour of this line of thinking is actually quite potent.1 However, as they point out, the thing that surprises students and practitioners in public health is why the “bigger picture” has been so difficult to comprehend and act on. Rather than a need for the “stars to be aligned”, perhaps this is the time for stronger advocacy? And while we’re at it, evaluation tools for health promotion programs need to become more sophisticated if we’re going to convince our colleagues, politicians and the community that we’re spending their money wisely. The transformation that Lewis and Leeder recommend is likely generational in its span, but what better time to make a start?

George Larcos

Objective: To identify individual and household factors associated with violence among Australian Indigenous women with dependent children.Design and participants: Univariate and multivariable analysis of data from the 2002 National Aboriginal and Torres Strait Islander Social Survey, stratified by area.Main outcome measure: Self-reported experience of being a victim of violence in the previous year.Results: One in four Indigenous women living with dependent children younger than 15 years reported being victims of violence in the previous year; this corresponds to an estimated 24 221 Indigenous mothers (95% CI, 21 507–26 935) nationwide. Violence was more prevalent in regional areas and cities than remote areas. In remote areas, mothers who had been removed from their natural families during childhood had nearly threefold greater odds of being victims of violence (odds ratio [OR], 2.90; 95% CI, 1.82–4.61); in non-remote areas, the odds were 72% greater (OR, 1.72; 95% CI, 1.23–2.39). Older maternal age (≥ 45 years) was associated with lower odds of experiencing violence in both non-remote areas (OR, 0.39; 95% CI, 0.25–0.60) and remote areas (OR, 0.46; 95% CI, 0.30–0.70). Women with partners residing in the household faced lower odds of violence in both non-remote areas (OR, 0.54; 95% CI, 0.41–0.72) and remote areas (OR, 0.46; 95% CI, 0.32–0.67).Conclusions: The prevalence of violence against Indigenous mothers with young children is alarmingly high across remote and non-remote areas. This study identified distinctive characteristics of victims, but further research is needed to assess potential risk factors, such as history of removal from natural family.

Kyllie Cripps BA(Hons), PhD · Catherine M Bennett PhD, MAppEpid · Lyle C Gurrin PhD · David M Studdert LLB, ScD

Objective: Design and setting: Prospective modelling with the tools FluSurge 2.0 and FluAid 2.0 (developed by the United States Centers for Disease Control and Prevention) over 12 weeks from when the pandemic “Contain” Phase was declared on 22 May 2009, compared with data obtained from daily hospital reports of pandemic (H1N1) 2009 influenza-related admissions and transfers to intensive care units (ICUs).Main outcome measures: The effect on hospitals as projected by the FluAid 2.0 model compared with observed hospital admissions and ICU admissions.Results: Prospective use of the FluAid 2.0 model provided valuable health intelligence for assessment and projection of hospitalisation and critical care demand through the first 10 weeks of the pandemic in Victoria. The observed rate of hospital admissions for pandemic (H1N1) 2009 was broadly consistent with a 5% gross clinical attack rate, with 0.3% of infected patients being hospitalised. Transfers to ICUs occurred at a rate of 20% of hospital admissions, and were associated with vulnerable patient groups, and severe respiratory failure in 82% of patients admitted to ICUs. Most patients treated in ICUs (85%) survived after an average ICU length of stay of 9 days (SD, 6.5 days). Mechanical ventilation was required by 72% of patients admitted to ICUs, and extracorporeal membrane oxygenation (ECMO) was used for 7%. Pre-existing haematological malignancy accounted for half of all the deaths in patients admitted to ICUs with pandemic (H1N1) 2009 influenza.Conclusions: Prospective use of modelling tools informed critical decisions in the planning and management of the pandemic. Early estimation of the clinical attack rate, hospitalisation rates, and demand for ICU beds guided implementation of surge capacity. ECMO emerged as an important treatment modality for pandemic (H1N1) 2009 influenza, and will be an important consideration for future pandemic planning.

Martin E Lum MB ChB, FANZCA, MBA(Exec) · Alison J McMillan CCN, BEd, MBA · Chris W Brook FRACP, FAFPHM, FRACMA · Rosemary Lester MPH, MS(Epid), FAFPHM · Leonard S Piers MD, PhD, MPH

To the Editor: A previous report from our institutions identified a steady increase in the prevalence of paediatric treadmill friction burn injuries, from three in 2001 to 17 in 2006.1 We sought to determine whether there was any change in this trend during the past 2 years. Children younger than 16 years with treadmill-related injuries were identified from prospectively collected data from burns and trauma databases maintained by the trauma research nurses at two paediatric tertiary trauma centres in Sydney (the Children’s Hospital at Westmead and Sydney Children’s Hospital) between January 2007 and December 2008. Sixty-five children sustained treadmill-related injuries (17 in 2007 and 48 in 2008); 43 were boys. The mean age at the time of the injury was 3.7 years (range, 9 months to 14 years). Friction burns ranged from less than 1% to 7% of total body surface area, and most patients sustained a total body surface area burn of 1% or less (58 patients). The most common site of injury was fingers and/or hand (49), followed by forearm or upper arm (6), and torso (5). In most cases, a limb or part of a limb was trapped between the rear roller and the treadmill belt. Fourteen patients required surgery, including 13 who underwent a skin grafting procedure. Most injuries occurred while the treadmill was in use by others, with the children approaching unnoticed from behind (46). In nine cases, the injury happened when the patients themselves, at a mean age of 7.8 years (range, 2–12 years), were using the treadmill. The substantial increase in prevalence of treadmill injuries in children during the past 2 years may be related to increased sales of treadmills as the community becomes more conscious of obesity. The data also reflect other Australian studies that show that children younger than 5 years are at greatest risk, accounting for 90% of paediatric treadmill injuries during the period January 2004 to June 2007.2 Despite the risk of injury, particularly for children, there appears to be no current national regulations governing the supply of treadmills or advice that should be given to customers at the point of sale. The New South Wales Government introduced legislation in June 2009 mandating prominent permanent warning labels to be affixed to all new treadmills — the Fair Trading Amendment (Treadmills) Regulation 2008 (NSW). The NSW Office of Fair Trading, with assistance from the NSW Severe Burn Injury Service and Kidsafe NSW, has developed an alert poster (copies of which may be downloaded or ordered from their website) for display at childcare centres, playgroups and places where domestic treadmills are sold.3 The Australian Competition and Consumer Commission recently published a safety alert brochure on domestic treadmills, which contains a safety checklist.4 Although helpful, the brochure does not include previous recommendations such as caution with headset use (ie, decreased awareness of children near the treadmill), and the use of mirrors or alternative positioning to ensure children approaching the treadmill can be seen.1 As most injuries occur within the first 6 months of purchase of the treadmill,5 educating parents seems to be most important around the time of purchase. Design modifications could also reduce the risk of entrapment of a digit or hand.2 It is likely that, without better application of current injury prevention strategies, the prevalence of these injuries will continue to increase.

Lawrence H Kim · Deborah A Maze · Susan Adams · Sarah Guitonich · Siobhan Connolly · Anne Darton · Andrew J A Holland