Environmental health

Incorrect author affiliation: In the letter “Avoiding the tragedy of another balcony collapse” in the 1 June 2009 issue of the Journal (Med J Aust 2009; 190: 651-652), James W Nixon was incorrectly described as a paediatrician at the Royal Children’s Hospital, Brisbane. James W Nixon is Chair of Kidsafe Queensland, Brisbane, QLD. The html and pdf versions of the article published online were corrected on 5 June 2009.

Shinichiro Sakata · Craig A McBride · James W Nixon · Roy M Kimble

With the recent outbreak of swine influenza, the world may be facing this century’s first influenza pandemic. In Mexico, around 2000 patients have been hospitalised with respiratory illness and almost 150 people have died. Several other countries have reported smaller numbers of suspected and confirmed cases of swine influenza. This 2009 influenza A virus is a strain of the H1N1 subtype, and appears to be a human–avian reassortment swine virus influenza. It is likely that sustained human-to-human transmission of swine influenza has occurred, at least in Mexico. Despite there being so many hospitalised patients in Mexico, cases outside Mexico have demonstrated a mild influenza-like illness, with only one fatality to date. In contrast to the 1918 influenza pandemic, we now have a more robust public health system, with widespread global networks; vaccines can be developed rapidly; and there are antiviral medications to which the swine influenza A(H1N1) virus is sensitive. Many resources have been invested in pandemic preparedness programs in the health care and public health systems in Australia over the past few years.

Sanjaya N Senanayake MB BS, MAppEpid, FRACP

To the Editor: We concur wholeheartedly with Gill and colleagues1 in support of recognising obesity as a public health issue, and we dispute claims that the current problem of obesity is being exaggerated. Gill and colleagues point out that obesity trends have climbed over decades, and state that 6%–8% of Australian school children are affected.1 While this is a substantial burden of over a quarter of a million children, we also consider that restricting definitions of obese to arbitrary cutoff points may underestimate the problem, given that the entire distribution of childhood weight is increasing, not just the extreme group classified as obese. Adiposity is related to cardiovascular outcomes such as myocardial infarction and stroke in a (curvi)linear fashion. Defining obesity by arbitrary cutoff points is vulnerable to differences between sexes, ethnicity and age, and limits our understanding of obesity-related diseases. It is well known that cardiovascular risk factors cluster, particularly the adiposity-driven components of the so-called metabolic syndrome. In the Western Australian Pregnancy Cohort (Raine) Study, we have used cluster analysis to identify a group of children at risk of future cardiovascular disease with features of the metabolic syndrome.2 The differences in characteristics are shown in the Box. The “high risk” and “low risk” cluster groups differ widely in terms of not only body mass index, the most widely used measure of obesity, but also waist circumference (a measure of central adiposity), insulin resistance, blood pressure, and levels of triglycerides, high-density lipoprotein cholesterol, total cholesterol (data not shown) and low-density lipoprotein cholesterol (data not shown). Not only the conventionally used 95% confidence intervals, but also the 99% confidence intervals do not overlap for any of these intermediate cardiovascular risk factors. We found that 29% of children were in the high-risk cluster at the age of 14 years2 and a similar analysis suggested that even at age 8 years, 25% of children were at increased risk of future obesity, cardiovascular disease and diabetes.3 C-reactive protein (CRP) level is known to be associated with future cardiovascular diseases in adults,4 and with an adverse metabolic profile in children.5 The “high risk” children had significantly higher CRP levels at the age of 14 years than their low-risk counterparts. Certainly, the magnitude of this problem, affecting up to a third of our youth, needs to be addressed by government and health-planning bodies. We suggest our approach of cluster analysis will help identify earlier those children at substantially increased risk of cardiovascular and other adiposity-related disorders in Australia. Features of the cluster groups with respect to components of the metabolic syndrome, showing 99% CIs* BMI = body mass index. HOMA = homeostatic model assessment (for quantifying insulin resistance). SBP = systolic blood pressure. HDL = high-density lipoprotein cholesterol. * From Huang et al.2 Reprinted with permission from the American Diabetes Association.

Rae-Chi Huang · Fiona J Stanley · Lawrence J Beilin

To the Editor: There is a substantial volume of evidence from a range of national and state-based surveys illustrating increases in the rates of obesity and overweight among Australian children over the past two decades,1 concurring with trends observed in most developed countries.2 The recent article by Gill and colleagues highlighted questions that have been raised publicly regarding the extent and impact of levels of obesity and overweight among Australian children, including whether trends have been exaggerated.1 To examine these issues using the latest data available, we present data from the three most recent national surveys in which weight and height of Australian children were measured: the Australian Health and Fitness Survey (1985),3 the National Nutrition Survey (1995),4 and the Australian National Children’s Nutrition and Physical Activity Survey (2007).5 We examined overweight and obesity levels among young Australians from comparable age groups at three time points over more than 20 years, using the same internationally accepted definitions of childhood overweight and obesity. For 1985 and 1995 data, we used the figures reported by Magarey et al in 2001,6 which compared results from the 1985 and 1995 surveys using new standard international definitions to classify overweight and obesity among Australian children and adolescents.7 We calculated body mass index for the 2007 Australian National Children’s Nutrition and Physical Activity Survey using the raw data file obtained through the Australian Social Science Data Archive,8 categorising children as overweight or obese based on the same international definitions used by Magarey et al.6 We based our calculations on the age group common to each of the three surveys: 7–15-year-olds. As shown in the Box, the prevalence of overweight and obesity in boys aged 7–15 years has risen from 11.0% (95% CI, 10.99%–11.01%) in 1985 to 20.0% (95% CI, 19.97%–20.03%) in 1995 and 23.7% (95% CI, 23.68%–23.72%) in 2007. In 7–15-year-old girls, the prevalence of overweight and obesity has increased from 12.2% (95% CI, 12.19%–12.21%) in 1985 to 21.5% (95% CI, 21.47%–21.53%) in 1995 and 25.8% (95% CI, 25.78%–25.82%) in 2007. While data from additional time points are required to map national trends more comprehensively, our analysis clearly indicates an upward trend in overweight and obesity levels in both boys and girls aged 7–15 years between 1985, 1995 and 2007. This trend is cause for alarm, given the widely recognised body of evidence on the significant short-term and long-term consequences of childhood obesity.9 Prevalence of overweight and obesity in Australian children aged 7–15 years, 1985–2007 * Data weighted for age, sex and region with the weighting variable in the raw data file obtained from the Australian Social Science Data Archive.8

Lyn M Roberts · Tessa R Letcher · Alexandra A Gason · Tim Lobstein

Australia can benefit from lessons learned in the epidemic of C. difficile infection in Europe and North America It is 30 years since Clostridium difficile was shown to be the cause of pseudomembranous colitis and many cases of antibiotic-associated diarrhoea in humans. In the interim, C. difficile has risen from relative obscurity to become a major hospital pathogen. Two factors were particularly important in its emergence during the 1980s. First, increased and inappropriate use of some broad-spectrum antibiotics, particularly cephalosporins, predisposed more patients to infection with C. difficile. Second, contamination of the hospital environment with C. difficile spores was, and remains, a significant problem, as the spore is likely to be the infective particle. The epidemiology of C. difficile infection continues to evolve, and developments overseas in the past decade threaten not only parts of Australia’s vast agricultural sector but also the country’s health care system. Since 2002, rates of C. difficile infection have escalated, with outbreaks of severe infection in North America and Europe caused by an epidemic strain — polymerase chain reaction (PCR) ribotype 027 (also known as North American pulsed-field type 1 [NAP1]). This strain is characterised by the production of greater amounts of toxins A and B and an additional, binary toxin, as well as resistance to fluoroquinolone antimicrobials.1 When this editorial was submitted for publication in January 2009, there was no evidence that this epidemic strain was present in Australia. However, C. difficile PCR ribotype 027 has now been isolated for the first time in Australia, as reported in this issue of the Journal2 (Riley et al). Although the patient most probably acquired the organism while travelling in North America, this case illustrates the ease with which it could be introduced into Australia. Thought to be driving the epidemic in humans in North America and Europe are the overuse of fluoroquinolones and fluoroquinolone resistance, but the ageing population and improved case ascertainment may also be contributing to the dramatic increase in cases. Other factors may also be important, such as the increase in prescription of proton-pump inhibitors, which coincided with the emergence of epidemic C. difficile.3 Several recent observations from overseas have broad relevance for Australia. First, there has been an apparent increase in community-acquired C. difficile infection in the absence of classic risk factors such as antibiotic exposure, leading to suggestions that all patients with community-acquired diarrhoea should be tested for C. difficile.4 Assertions that community-acquired C. difficile infection is a new disease4 are not correct — it has been recognised in Australia for over 15 years but is underdiagnosed.5 Therefore, it is difficult to determine whether this increase is a true increase or rather reflects better case ascertainment. Nonetheless, the suggestion that C. difficile infection should be considered more than just a hospital problem is valid, and general practitioners need to be aware of this change in epidemiology. The prevalence of binary toxin-producing C. difficile in human disease is also increasing, and there is an association between binary toxin-producing isolates and community acquisition.6 Second, it is speculated that C. difficile is part of a zoonosis, and that transmission of infection via spores may be foodborne.7 There is compelling evidence for the former, but none for the latter. C. difficile is known to colonise many animals.8 Indeed, as in humans, it probably colonises the gastrointestinal tracts of most infant animals until weaning. There was alarm at a report that 20% of a small sample (n = 60) of retail beef in Canada contained C. difficile.9 Equally disturbing are reports that many pig herds in the United States are infected with C. difficile. The overall prevalence of C. difficile in piglets from 10 herds in North Carolina was 48%, and ranged from 0 to 97% across the herds. Mortality for piglets with C. difficile infection is 15%, and animals that survive are 10% underweight when they go to market.10 Most animal isolates of C. difficile produce binary toxin, and both pigs and cattle harbour PCR ribotype 078 — a strain that, like ribotype 027, produces increased amounts of toxins A and B, in addition to binary toxin. In the Netherlands, the prevalence of human C. difficile infection with ribotype 078 strains has increased since 2005; these infections were in a younger population and more frequently community-acquired than infections with ribotype 027 strains. In the eastern Netherlands, where more than 90% of the country’s pig farms are located, over 20% of human isolates are now ribotype 078, and human and pig strains of C. difficile are highly genetically related.11 In Australia, little is known about the prevalence of C. difficile in pigs. A small study in 2007 found C. difficile in 10 of 37 samples (27%) from piglets with diarrhoea, but none of the isolates were ribotype 078 (unpublished data). Why is C. difficile infection increasing in pigs in Europe, and what are the implications for Australia? The use of antimicrobials for growth promotion was banned from 2006 in Europe, and even earlier in Denmark, starting in 1995. However, since 2000, the use of therapeutic antimicrobials in production animals has increased in Europe in general, and specifically in Denmark, a big producer of pork. Of real concern is evidence of greater use of cephalosporins in animals. While the number of pigs in Denmark increased by 50% in the past 15 years, the amount of penicillinase-susceptible penicillins used increased by 400%, and cephalosporins by 1000%. Most of this increase was in piglets and sows.12 Although the total amount of cephalosporins used remains small, this is a worrying trend. If the situation is similar in the Netherlands, and anecdotal evidence suggests that it is, then this may be analogous to the situation in humans in the 1980s when there was a dramatic increase in C. difficile in many hospitals, driven by cephalosporin use.13 The overlap between the location of pig farms in the Netherlands and the occurrence of human ribotype 078 infections suggests a common source.11 This is likely to be the environment. The Netherlands has one of the highest population densities in the world. If infection rates in pig farms in the Netherlands are as high as those in the US,10 then it is likely that a large proportion of the Dutch population comes into contact with C. difficile spores every day. Individuals are at risk of infection if they are taking antimicrobials or any other medication that perturbs the gut flora. The good news for Australia is that, with our very low population density, a similar risk to humans is unlikely to develop. However, this is no reason for complacency. Every effort should be made to stop epidemic C. difficile from becoming established in our production animals. Unfortunately, the mere perception of C. difficile infection as a foodborne disease will damage the industry. Even before the first isolation of C. difficile PCR ribotype 027 in a patient in Australia, health care practitioners were becoming justifiably concerned. A proposal for C. difficile to be made notifiable in all states and territories of Australia was approved at the Australian Health Ministers’ Advisory Council meeting in November 2008. Australia’s conservative policies on fluoroquinolone use in humans and animals may offer some protection. However, if cephalosporin use is driving C. difficile infection in animals overseas, then additional efforts to target cephalosporin use in veterinary medicine may be needed in Australia. The solution to these problems continues to lie in surveillance for the emergence of virulent strains of C. difficile, promotion of judicious use of antimicrobials in both human and veterinary medicine, and environmental cleanliness, the latter perhaps easier said than done outside health care facilities.

Thomas V Riley MAppEpid, PhD, FRCPath

Reintroducing the alcopops tax is important, but more comprehensive reform of alcohol taxation and other broader measures are needed To those Australians who believe that alcohol consumption in this country is causing too much damage, and that a public health-focused, evidence-based alcohol policy can make a difference, the defeat of the “alcopops” legislation in the Senate in March this year was a disappointment. However, this is no reason to stop national action to reduce damage from alcohol. The thousands of Australians whose lives are damaged by alcohol, and the hundreds each year whose deaths could be prevented, are too important.1 Concerned organisations need to collaborate and advocate for a comprehensive, evidence-based approach to reducing the alcohol toll. Their ultimate goal should be to move to a more moderate and responsible drinking culture in Australia. The first question is what to do with the more than $400 million raised from the alcopops tax. Our elected representatives are to be congratulated on voting in May to retain it, rather than handing it back to the alcohol industry. Judging by past performance, had it gone to DrinkWise, it would have been spent on soft-sell advertising, which the great body of evidence suggests has no impact on alcohol consumption or consequent harms.2,3 The alcopops revenue should be directed to independent public health agencies to develop evidence-informed interventions that aim to reduce consumption and consequent harms. The Alcohol Education and Rehabilitation Foundation is one such entity, established using tax revenues generated in similar circumstances from beer sales. The national Preventative Health Taskforce has already developed a framework to prevent alcohol-related harms,4 and will soon deliver a final report and recommendations for action, including an overarching National Prevention Agency, which will need funds. With additional funding, the National Health and Medical Research Council (NHMRC) could give special priority to alcohol-related research. Funding of agencies such as VicHealth and Healthway in Western Australia, which were originally supported by tobacco revenues, could also be considered. The Royal Australasian College of Physicians welcomes the federal government’s initiative to reintroduce the alcopops tax legislation in the current sitting of Parliament, but encourages the government to go further. Although there was evidence the alcopops tax was followed by reduced overall alcohol consumption,5 if the government wishes to address the full range of alcohol-related harms — which include much more than binge drinking in young people — it should comprehensively reform alcohol taxation. Controlling price is by far the most effective, and cost-effective, single intervention available to control consumption and consequent harms.2,3,6 A comprehensive reform of alcohol tax is needed, with public health as a principal objective. Specific elements could include: taxing beverages on the basis of their alcohol content — a volumetric system; a minimum price per standard drink; and additional taxation based on evidence of harm associated with particular beverage types. A proportion of alcohol-related tax revenues should be directed towards prevention and treatment of alcohol-related problems. The Australian public will probably support such taxes.7 Taxation policy is crucial but must be part of a broader approach. There is good evidence for the effectiveness of controlling the availability of alcohol by regulating the number, nature and opening hours of alcohol venues.2,3,8 The forthcoming review of the Northern Territory’s Liquor Act provides an opportunity to encourage alcohol legislation to genuinely focus on preventing alcohol-related harms, and not just on regulating the sale of alcohol. The role and practice of alcohol promotion should also be closely examined. Loosening the link between alcohol advertising, sponsorship and sporting organisations may be an important way to encourage Australian drinking culture to evolve in a healthier direction. Some alcohol tax revenues could be directed towards replacing alcohol-industry sponsorship, as was done for tobacco in several states, or buying back alcohol advertising during sports programs, as suggested by the Australian Medical Association.9 Although prevention is essential, many people and their families are already suffering from the effects of alcohol. More treatment programs are urgently needed, particularly in rural and remote areas, where alcohol problems are even more common than in the cities, and for groups with particular needs, such as Aboriginal people, who need tailored programs. Finally, a strong vision and framework would bind all these strategies together. The National Alcohol Strategy10 expires this year, and another is needed: one that more closely follows the evidence of what really works in reducing harm. Much good work to reduce the harms from alcohol has been done in Australia by individuals and organisations such as the Public Health Association of Australia and the Australian Drug Foundation. However, much more is needed, as the level of harm is still unacceptable, especially among young people. We in the health profession need to play a greater advocacy role, in partnership with others within and beyond the health sector, such as the Cancer Councils, and social welfare and community organisations. The Royal Australasian College of Surgeons Trauma Committee, with its experience in road trauma and interpersonal violence, has indicated a strong interest in being involved. We need to be part of, and to help build, active coalitions. We should heed the lessons learned from the fight against tobacco. Although there are important differences between alcohol and tobacco, much is similar in the need to change the culture surrounding their use, and in the large and powerful industries that profit from their sale. Overcoming these obstacles will require an alliance of organisations, with a common understanding of the key issues, goals and ways to achieve them, and persistence in their pursuit. With thousands of lives lost or damaged, and billions of dollars wasted every year,1 this is our challenge and our responsibility.

on behalf of the Royal Australasian College of Physicians Alcohol Advisory Group.*

To the Editor: The federal government is to be applauded for its decision to re-introduce the “alcopops” tax Bill to Parliament and to try to retain the $300 million raised so far for expenditure on services, programs and research to reduce alcohol-related harm in Australia. The alcopops tax was paid by consumers in the form of higher retail prices, which will fall dramatically if the government again fails to pass legislation to retain the tax. If it transpires that the government cannot retain the revenue already raised, it should be given to an independent public health body (such as the National Health and Medical Research Council [NHMRC]) and not to DrinkWise via distillers and distributors, as has been suggested.1 DrinkWise is a “putatively independent body that was originally funded by the alcohol industry”;2 six of the 11 current members of its board are senior alcohol industry figures. The alcohol industry profits from drinking that contributes significant harm to individuals and communities,2 and it can be relied upon to oppose policies that are known to reduce alcohol consumption across the population.3,4 DrinkWise and similar industry-backed organisations around the world promote industry-friendly programs that do not have an evidence base or are ineffective (such as education campaigns or tepid television advertising),5 while lobbying against the adoption of effective evidence-based interventions, such as higher taxes on alcohol, as these would affect profits.2-4 The Chief Executive of DrinkWise, Chris Watters, recently revealed the organisation’s position on the alcopops tax, reportedly asserting that it did not recommend “fiddling with alcohol tax” because it was “old thinking” and that “the facts just don’t stand up”, and noting that DrinkWise funds many educational programs across the country.6 There is a clear consensus among public health experts worldwide that increasing the price of alcoholic beverages is one of the most powerful and cost-effective strategies that governments have at their disposal to reduce unhealthy alcohol use.7-10 Other effective strategies include drink-driving legislation, random breath testing, increasing the minimum legal age for drinking or purchasing alcohol, restrictions on trading hours and numbers of licensed premises, and better enforcement of existing liquor laws. In contrast, comprehensive reviews of the evidence show that, by themselves, alcohol education programs are ineffective.11,12 Alcohol industry-sponsored agencies have adopted similar public relations strategies to those used by the tobacco industry.3 These strategies distract attention from their concurrent lobbying against the adoption of policies that would actually make a difference. The laudable policy action taken thus far by the government in its attempt to implement the alcopops tax would be enhanced by supporting an independent body, such as the NHMRC, that has transparent funding strategies and criteria, based on an independent peer-review system, to distribute funding for alcohol-related research. We, along with the more than 50 other scientists and health experts listed at <http://www.webcitation.org/5gbwQWf9J> who endorse and are signatories to this letter,13 will not seek or accept funding from DrinkWise. We call on other researchers and community agencies to consider their positions.

Peter G Miller · Kypros Kypri · Tanya N Chikritzhs · Steven J Skov · George Rubin

In reply: I write in response to the letter from Miller and colleagues, recently published online.1 Their letter is an attempt to influence non-government senators as the Australian Government reintroduces the Bill to increase the tax on some alcoholic beverages. There must have been a better way to do this than by besmirching the good work of DrinkWise and its directors. DrinkWise Australia is not an industry-dominated body. It has a balanced board of six members from the alcohol industry and six distinguished community members. Miller and colleagues should know that, in criticising DrinkWise, they also attack the reputations of board members Professor Ross Kalucy, Chair of Psychiatry at Flinders University; Noel Turnbull, Adjunct Professor in Communications at the Royal Melbourne Institute of Technology; Neil Comrie, former Chief Commissioner of Victoria Police; and Terry Slater, who led the Australian Government’s public health programs before heading up the National Food Authority and the Therapeutic Goods Administration. The sixth community representative position on the board is currently vacant and has been offered to the federal health department. DrinkWise does not advocate for or lobby government in respect of alcohol taxation policy for a very sensible reason — alcohol industry leaders advocating for or agreeing on matters affecting price could constitute a breach of the Trade Practices Act 1974 (Cwlth). DrinkWise programs are strictly evidence-based, drawing on specifically funded high-level independent research executed by leading academics at universities including Griffith, Macquarie, Monash, Deakin, Flinders, and the Hunter New England Institute. Moreover, the DrinkWise “Kids Absorb Your Drinking” advertising campaign was developed through qualitative, quantitative and ethnographic research, as well as the findings of an extensive literature review by child heath experts and academics.2-9 Campaign tracking results show that 28% of adults surveyed in March 2009 reported having reduced the amount of alcohol they drink in front of their children in the previous 12 months. When parents who had seen the DrinkWise advertising were asked about its impact on their drinking behaviour, 39% said they were more self-conscious of how they drink in front of their children, 18% had changed their drinking patterns, and 14% had actually cut down how much alcohol they consume when their children are around.10 DrinkWise Australia: receives funding from the federal government and the alcohol industry for the development of both its evidence base and its programs; has no associations with any international alcohol or tobacco lobby groups; undertakes research through Australian universities to develop the evidence base for its interventions; does not interfere with specification of the research hypotheses, research design and techniques, or publication of results; ensures that the research it funds is undertaken in accordance with the universities’ protocols for conducting independent research; and grants the researchers it funds a “non-exclusive, royalty-free, perpetual license to use, reproduce, adapt and publish Project IP [intellectual property] for research, education, academic and consulting purposes”.11 I was particularly surprised that the letter’s authors would trivialise the importance of education in successful drug intervention programs and instead advocate for increased reliance on supply-side strategies. DrinkWise delivers interventions in a variety of settings, not only through the Kids Absorb Your Drinking campaign, but also through practical tools such as a website (http://www.drinkwise.com.au), information materials and discussion forums, as well as working at the grassroots level with groups such as local government, school organisations, community newspapers, Sports Challenge Australia and the Good Sports program. Educational programs informed by scientific literature, that are implemented and evaluated effectively and not used as a standalone intervention strategy, can work.12 We at DrinkWise hope that anyone with a strong commitment to public health will be able to work with us and not against us. This will ensure that we will be able to continue to run evidence-based initiatives to reduce alcohol-related harm in Australia.

Trish M Worth

To the Editor: Climate change has an adverse impact on health.1 Procurement, waste production, transport, and energy and water consumption (ie, the ecological “footprint”) all contribute to climate change. If the principle underpinning the work of all health professionals is “do no harm”, addressing the harmful effects of the health care industry on the natural environment must become a priority. We argue that one way to rapidly achieve this would be to mandate more sustainable practices as part of hospital accreditation. The United Kingdom has specifically targeted its health system to reduce its large ecological footprint,2 but in Australia, progress towards environmental sustainability within health care is uncertain and unmonitored. The contribution by health care to Australia’s national carbon emissions is unclear, but we do know that, for example, Victoria’s public hospitals consume 60% of the total energy used by the state’s government departments,3 so we have the opportunity to make a major impact. There are excellent examples of hospital energy- and water-saving projects with financial recovery within 10 years.2,4 The Environment Protection Authorities of several Australian states are now mandating that heavy users of energy and water (including larger hospitals) have Environment and Resource Efficiency Plans to reduce their footprints,5 but action from hospitals has been unclear. Progress has typically been made on an ad-hoc basis by hospitals acting in isolation, although the Institute of Hospital Engineering, Australia is facilitating a more systematic approach.4 The Australian Council on Healthcare Standards (ACHS), through its Evaluation and Quality Improvement Program (EQuIP)6 accredits Australian hospitals against mandatory and preferred criteria. However, EQuIP does not currently include mandatory criteria that address issues such as energy, water and waste auditing, energy efficiency and the presence of a hospital environmental committee. The accreditation process offers an opportunity to encourage hospitals to prioritise these issues. The ACHS has awarded hospitals in the past for “environmental excellence”, but without a solid framework from the ACHS, the goal of all of our hospitals pursuing sustainability seems unlikely. In 2009, it is out of step with Australia’s shift to a low-carbon future that there are no requirements that hospitals achieve more sustainable use of energy, water and transport, and improve procurement and waste reduction. The introduction of broad environmental standards as part of the accreditation process could be a vehicle for achieving rapid improvements in sustainability across the hospital sector and shift our health system to one that “does no harm”.

Forbes McGain · Grant A Blashki · Kevin P Moon · Fiona M Armstrong

Objective: To determine whether there is an association between compensation factors and health care utilisation following major trauma.Design and setting: Retrospective cohort study within a major metropolitan trauma centre in New South Wales.Participants: Major trauma patients aged ≥ 18 years, admitted between May 1999 and April 2004. Patients were included if they had an accidental injury and an Injury Severity Score > 15. In total, 355 of 582 potentially contactable patients returned completed questionnaires (response rate, 61%).Main outcome measure: Health care utilisation, defined as the number of times patients visited specified health care professionals (general practitioners, medical specialists, psychiatrists, physiotherapists, chiropractors and massage therapists) in the previous 3 months. For statistical analysis, health care utilisation was dichotomised into low and high (0–3 or ≥ 4 health care visits over the previous 3 months).Results: Health care utilisation was significantly higher for patients engaging the services of a lawyer (odds ratio, 3.3; 95% CI, 2.0–5.5; P < 0.001) after allowing for time since injury, chronic illness, presence of a head injury and employment status. Having a head injury and increased time since injury were significantly associated with lower health care utilisation, whereas being unemployed and having a chronic illness were associated with higher health care utilisation.Conclusion: Compensation-related factors are significant predictors of health care utilisation in a major trauma population.

Ian A Harris MB BS, MMed(ClinEpid), PhD · Darnel F Murgatroyd MScHSci(ManipPhysio), DipPhysio · Ian D Cameron MB BS, PhD, FAFRM · Jane M Young MB BS, MPH, PhD · Michael J Solomon MB ChB, MSc, FRACS

Objective: To determine the frequency of smoking on The Simpsons television show, and the relationship with the sex and age groups of characters shown smoking, and with positive, negative and neutral connotations associated with instances of smoking.Design and setting: Content analysis (performed from January to October 2008) of instances of smoking that appeared in the first 18 seasons of The Simpsons television show, which aired from 1989 to 2007.Main outcome measures: Frequency, impact (positive, negative, neutral) of instances of smoking; and frequency associated with age (child or adolescent versus adult characters), sex and types of characters on the show.Results: There were 795 instances of smoking in the 400 episodes observed. Most (498; 63%) involved male characters. Only 8% of instances of smoking (63) involved child or adolescent characters. Just over a third of instances of smoking (275; 35%) reflected smoking in a negative way, compared with the majority, which reflected smoking in a neutral way (504; 63%) and the minority, which reflected smoking in a positive way (16; 2%). Child and adolescent characters were much more likely to be involved in instances of smoking reflected in a negative way compared with adult characters (odds ratio, 44.93; 95% CI, 16.15–172.18).Conclusions: There are a large number of instances of smoking in The Simpsons television show. Child and adolescent characters are much more likely to be portrayed in instances of smoking reflected in a negative way than adult characters. Viewing The Simpsons characters smoking may prompt children to consider smoking at an early age.

Guy D Eslick PhD, MMedSc(ClinEpi), MMedStat · Marielle G Eslick

To the Editor: In November 2008, a residential balcony collapse in Brisbane, Queensland, resulted in one person killed and 25 injured.1 Moments after the accident, tertiary hospitals across the city were placed on alert. Valuable hospital resources, including intensive care beds and staff, were allocated to the care of potential casualties; surgical theatres were kept on standby; and elective operating lists were cancelled. In 2008, injuries in more than 40 people across Australia and New Zealand were caused by residential balcony collapses.1-3 About 8000 Australian timber balconies are considered at risk of collapsing and potentially causing human fatality.4 Timber balconies constructed between 1970 and 1990 are at most risk of collapse.4 Many were constructed with inappropriate timber, without building approvals, and by unqualified tradespeople. When properly constructed, a well maintained timber balcony generally lasts for about 20 years.4 Collapse is not limited to timber balconies. In February 2002, a concrete cantilever balcony on a Sydney apartment fell under its own weight, shearing off the balcony under it.5 According to the Australian Concrete Repair Association (ACRA), many concrete balconies appear “safe” but have never been loaded to their maximum capacity, giving residents a false sense of security.5 As balcony parties and outdoor living become more popular, the ACRA believes that it is only a matter of time before more balconies collapse.5 A well maintained concrete balcony can be expected to last for about 40 years.4 In April 1995, the Cave Creek disaster in Pararoa National Park, NZ, resulted in the deaths of 14 people when an unstable wooden viewing platform, unable to support the weight of the 18 park visitors who had crammed onto it, collapsed into a gully.6 Following the accident, the NZ Department of Conservation made it mandatory that warning signs, indicating the maximum number of people permitted, be installed at every public viewing platform in the country.6 Why do suspended structures and public transport vehicles (such as viewing platforms, elevators and buses) have clearly displayed maximum capacity warning signs, but not balconies? Warning signs showing maximum capacity and recommended inspection dates would remind people to maintain and use their balconies safely. A prospective buyer of a home with a balcony should find out when the balcony was built and check local government records for building approvals. If no record exists, a balcony should be professionally inspected. We believe regular safety inspections and clearly displayed maximum capacity warning signs should be mandatory for all balconies. We also believe a review of building codes and standards is needed to protect residents of older homes and apartments — perhaps with an initial amnesty on unapproved balcony constructions — to encourage owners to seek professional inspections and have structural deficits corrected so that future tragedies need not occur.

Shinichiro Sakata · Craig A McBride · James W Nixon · Roy M Kimble

Textbook of disaster psychiatry. Robert J Ursano, Carol S Fullerton, Lars Weisaeth, Beverley Raphael, editors. Cambridge: Cambridge University Press, 2007 (xii + 346 pp). ISBN 978 0 521 85235 7. Disasters, by their nature, are unexpected and often occur when services are least able to respond, such as the tsunami on Boxing Day in 2004. Therefore, the ready availability of resource material is particularly important in disaster management. Due to recognition of the importance of well coordinated and planned recovery programs, there is also growing interest in providing structured academic courses in the disaster field. For these activities, the Textbook of disaster psychiatry is a high-quality, welcomed edition to an already competitive stable. The editors are doyens of the field and bring together a richness of experience, knowledge, and anecdote that combine to provide a text of unusual depth. They focus not only on the challenges facing clinicians, but also on the obstacles the broader systems confront in the face of disasters. A text providing an integrative methodology for a broader public health approach is a valuable tool to ensure optimal long-term outcomes. This is not simply a disguised textbook on post-traumatic stress disorder; it has relevance beyond mental health practitioners. Despite the fact that individuals’ adaptive behaviour determines the success or otherwise of physical disaster relief programs, mental health programs are often seen as a low priority in disaster management. As a consequence, this text will be valuable to coordinators of medical services and those involved in community and social reconstruction. While the editors are truly an international group, the authors of the text are all, bar one, from the United States. Nevertheless, this does not detract from the international applicability of the content and approaches that it espouses. This is a book to have on the shelf for the day when the sky falls in.

Alexander C McFarlane

The goal of “closing the gap” in life expectancy between Indigenous and non-Indigenous people by 2030 is probably unattainable. Despite our best efforts, it is implausible that, within 21 years, preventive strategies, social or medical, will extinguish all excess expression and risk of chronic disease, the greatest contributor to excess Indigenous deaths. Developing systems to supply optimal primary care, as we currently know it, will take time. In addition, we have an incomplete understanding of the nature of excess risk, and lack remedies to totally contain it. Furthermore, vertical imprinting of excess risk will take some generations to ameliorate. To avoid failure by specifying unattainable goals, emphasis should be given to process measures that will lead to better outcomes. It is self-evident that sustained change requires better education, nutrition, employment opportunities and infrastructure. Within the health system, access to good quality, integrated primary care, needs-based health services funding, and an urgent and intensified focus on areas with the highest mortality rates, are top priorities.

Wendy E Hoy BScMed, MB BS, FRACP

Economic interventions to improve access to healthy food Poor nutrition is a major determinant of excess morbidity and mortality among Aboriginal and Torres Strait Islander peoples,1 contributing to over 16% of the burden of disease.2 In this issue of the Journal (page 549), consistent with the “economics of food choice” theory,3 Brimblecombe and O’Dea report that the diet of a remote Aboriginal community was high in energy-dense, nutrient-poor foods — the cheapest options to satisfy hunger.4 This energy–cost differential restricts access to healthy food, and helps explain the persistently poor dietary patterns and deplorable health status of remote Indigenous communities.4 Placing nutrition issues in an economic framework highlights the investment required to improve Indigenous nutrition.4 But what has been learned to date about where resources should be directed? Despite the high costs and limited availability of healthy foods in remote community stores, surprising achievements have been made in some areas. Community dietary patterns were found to respond directly to improved stock management and food supply,5,6 and multistrategy, community-directed nutrition programs in some remote communities resulted in marked and sustained improvements in anthropometrical, biochemical and haematological risk factors for chronic disease.7,8 Knowledge gained from such studies has broadened the focus of Indigenous nutrition initiatives to include the “supply side” (improving food quality and access to healthy food in remote communities) as well as the “demand side” (promoting nutrition through behaviour change). In 2003, the FoodNorth study provided a comprehensive analysis of remote food supply issues, barriers and leverage points for improvement.9 More recently, the Remote Indigenous Stores and Takeaways Project developed nine practical resources, including a freight-improvement toolkit and a buyer’s guide, to assist remote stores to stock, promote and monitor the sale of healthy food.10 A major barrier is that community stores are seen as small businesses rather than as essential services, like health and education. Encouragingly, several submissions to the recent House of Representatives Inquiry into community stores in remote Indigenous communities detail specific approaches to secure both health and viable business outcomes.11 Remote store groups that combine buying power and operational efficiency (eg, the Arnhem Land Progress Association and the Retail Stores group in Queensland) have shown the benefits of store nutrition policies.9 Outback Stores, a company established by Indigenous Business Australia in 2006, included provision of nutritious food as a key goal, and provides one potential model to support sustainable employment and economic development in independent remote stores.12 The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000–2010 provided a broad framework for nutrition interventions, addressing both supply and demand issues.13 However, implementation of the strategy has neither been sustainably nor well resourced and remains fractured and opportunistic. Therefore, what is still urgently required is systematic, widespread, sustained implementation of evidence-based nutrition interventions. Brimblecombe and O’Dea now rightly highlight the need to also include innovative economic interventions.4 In Northern Territory communities, it has been estimated that up to 36% of the family income is needed to purchase food,14 which is at least double the proportion required by non-Indigenous Australians.15 One of the proposed “Close the Gap” equity targets was that, by 2018, 90% of Indigenous families could access a healthy food basket for under 25% of their income.16 However, nutrition issues were not included in the final National Indigenous Reform Agreement of the Council of Australian Governments. Globally, the dominant economic intervention affecting food pricing is national taxation on food to raise general revenue.17,18 In Australia, the basic foods required to maintain health were mostly exempted from the Goods and Services Tax (GST), and the price of these foods was expected to fall after the introduction of the new tax system in 2000.19 However, in Queensland from 2000 to 2001, the price of a basket of healthy foods increased by 12%, more than twice that of less healthy options.20 This highlights the unpredictability of complex economic systems and the need for rigorous testing of economic solutions to increase access to healthy food.18 Such testing is imperative within remote communities, but baseline data are not readily available as Australia lacks a comprehensive food and nutrition monitoring and surveillance system. It is also crucial that economic interventions support broader models of sustainable development in remote communities. Potential economic instruments include greater differential national taxation on energy-dense, nutrient-poor food (the “fat tax”), and subsidisation of healthy food through freight, in-store pricing and/or direct commodity subvention systems. There is a case for combining both approaches17 to better influence diet among lower socioeconomic groups18 and within relatively closed systems, such as schools and workplaces.17 The provision of free fruit in such settings has also produced sustained benefits in some countries.21 Improving remote area housing to include infrastructure for storage and preparation of food is also vital; in one study, this was serviceable in less than 6% of houses.22 Local food production, including that of traditional foods, may hold promise in some areas. Training and employment of Indigenous nutrition workers23 to deliver services, including budgeting programs like Indigenous FOODcents,24 are also required. Welfare reform and income management programs have great potential in some areas. However, in communities where incomes are quarantined and welfare recipients are required to spend a significant proportion of their income on food and other essentials, good public policy dictates that governments must also ensure that a healthy food supply is actually available and affordable in those communities. For the most vulnerable, food supplementation programs,25,26 if desired and controlled by the community, are warranted. The value of such assistance is greatly increased where food costs are high, and can immediately improve recipients’ dietary quality.19 Within a multistrategy approach, economic interventions tailored to community needs will assist low-income Indigenous Australians in remote communities to obtain the food they need for good health. “Best buys” of such an approach are listed in the Box. Solutions must involve sectors beyond health, including food producers, transporters and retailers, educators, economists and policymakers. “Best buys” to improve Indigenous nutrition and health 1. Continue and expand the reach of successful interventions Increase demand for healthy food Brief nutrition interventions and early interventions in primary care, including “well persons” health checks and follow-up action Prenatal, antenatal and postnatal nutrition programs; culturally appropriate infant growth assessment and action programs; and promoting breastfeeding and appropriate introduction of solid foods27 School-based nutrition-promotion projects, and community food-literacy and budgeting projects Improve supply of healthy food Use of resources developed by the Remote Indigenous Stores and Takeaways Project10 to improve store management practices, and transport and stocking of healthy food Local food gardens and traditional food procurement projects Increase capacity to achieve the interventions given above Train and employ an Indigenous nutrition workforce Improve housing, including food-storage, preparation and cooking facilities Develop a national, coordinated monitoring and surveillance system for food and nutrition 2. Trial economic interventions for widespread roll-out, if successful Food supplementation for women, infants and children Free fruit and vegetables for remote schools and other settings Freight subsidies for getting basic healthy foods to remote areas In-store price “mark-up” of less healthy items, and lower price margins on healthier foods Expansion of the current national differential taxation system to further favour competitive retail pricing of healthy foods

Amanda J Lee PhD, BSc(Nutr), GradDipDiet · Dympna Leonard MPH, BSc(Diet) · Aletia A Moloney MCommNutr · Deanne L Minniecon MHSc(HealthProm)

Objective: To investigate associations between “caring for country” — an activity that Indigenous peoples assert promotes good health — and health outcomes relevant to excess Indigenous morbidity and mortality.Design, setting and participants: Cross-sectional study involving 298 Indigenous adults aged 15–54 years in an Arnhem Land community, recruited from March to September 2005.Main outcome measures: Self-reported involvement in caring for country, health behaviours and clinically measured body mass index (BMI), waist circumference, blood pressure, type 2 diabetes status, albumin to creatinine ratio (ACR), levels of glycated haemoglobin (HbA1c) and high-density lipoprotein (HDL) cholesterol, lipid ratio, score on the five-item version of the Kessler Psychological Distress Scale (K5), and 5-year cardiovascular disease (CVD) risk.Results: Controlling for sociodemographic characteristics and health behaviours, multivariate regression revealed significant and substantial associations between caring for country and health outcomes. An interquartile range rise in the weighted composite caring-for-country score was significantly associated with more frequent physical activity, better diet, lower BMI (regression coefficient [b] = − 2.83; 95% CI, − 4.56 to − 1.10), less abdominal obesity (odds ratio [OR], 0.43; 95% CI, 0.26–0.72), lower systolic blood pressure (b = − 7.59; 95% CI, − 12.01 to − 3.17), less diabetes (OR, 0.12; 95% CI, 0.03–0.52), lower HbA1c level (b = − 0.45; 95% CI, − 0.79 to − 0.11), non-elevated ACR (OR, 0.28; 95% CI, 0.13–0.60), higher HDL cholesterol level (b = 0.06; 95% CI, 0.01–0.12), lower K5 score (b = − 0.97; 95% CI, − 1.64 to − 0.31) and lower CVD risk (b = − 0.77; 95% CI, − 1.43 to − 0.11).Conclusions: Greater Indigenous participation in caring for country activities is associated with significantly better health. Although the causal direction of these associations requires clarification, our findings suggest that investment in caring for country may be a means to foster sustainable economic development and gains for both ecological and Indigenous peoples’ health.

Christopher P Burgess FRACGP, MPH · Fay H Johnston PhD, FAPHM · Helen L Berry PhD · Joseph McDonnell MSc · Dean Yibarbuk · Charlie Gunabarra · Albert Mileran · Ross S Bailie MB ChB, FAPHM

Objective: To describe the natural history of vitamin D deficiency in an at-risk population of African migrants living in Sydney.Design, setting and participants: Opportunistic study of 25-hydroxyvitamin D [25(OH)D] concentrations over time in a community-based cohort of North African refugee families living in south-western Sydney. As part of a health-screening program, serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphate (PO4) and alkaline phosphatase (ALP) were measured in September 2006 (end of winter, T1). Results for 25(OH)D were made available, and treatment was recommended as appropriate. In February–March 2007 (end of summer, T2), in the setting of a separate study of high-dose vitamin D (stoss) therapy, the same cohort was contacted, and measurements were repeated.Main outcome measures: Changes in 25(OH)D, PTH, ALP and PO4 concentrations between T1 and T2 in those who had not received vitamin D supplementation in the intervening period.Results: We collected data from 149 participants at T1; by T2, 58 participants (39%) had been excluded or lost to follow-up. Data from 91 participants (46% female), all of whom had Type VI (very dark) skin pigmentation, were included in the analysis. All 91 were 25(OH)D deficient at T1. Between T1 and T2, mean 25(OH)D serum concentration increased from 19 nmol/L (SD, 5.6 nmol/L) to 36 nmol/L (SD, 12.4 nmol/L) (P < 0.001). Of the 91 participants, 79 (87%) remained vitamin D deficient at T2. Serum PTH and ALP activity decreased between T1 and T2 (P < 0.05).Conclusion: Despite a significant increase in 25(OH)D serum concentration over the study period, most participants (87%) remained 25(OH)D deficient at the end of summer. Our results support the current consensus that recommends annual screening for vitamin D deficiency and routine vitamin D supplementation in at-risk populations, such as dark-skinned or veiled groups.

Paul Z Benitez-Aguirre MB BS, BSc, MPH · Nicholas J Wood MB BS, FRACP · Cornelis Biesheuvel PhD · Conrad Moreira MB BS, MPH, FAFPHM · Craig F Munns MBBS, PhD, FRACP

The Australian Government's “alcopops” tax legislation will soon be voted on by the Senate. This is the first time in memory that an alcohol taxation measure has been informed principally by public health concerns. Much debate surrounds the utility of alcohol taxation as a measure to reduce alcohol-related harm. However, the harms resulting from alcohol misuse in Australia are at unacceptable levels and action to reduce them is overdue. There is good evidence from Australia and internationally that taxation and price measures are among the most effective and cost-effective in reducing alcohol consumption and related harms. Recent alcohol sales data give an early indication that the alcopops tax is being effective in reducing consumption. Current alcohol tax policy is unwieldy and not well directed towards improving public health. A proportion of tax revenues dedicated to alcohol programs would assist public acceptance of the measures. A broad review of alcohol taxation policy is needed as part of a comprehensive approach to alcohol problems in Australia.

for the Royal Australasian College of Physicians Alcohol Advisory Group

To the Editor: More than 1000 sunscreen products are marketed in Australia, and an increasing proportion (about one-third) incorporate engineered nanoparticles (ENPs). Defined as manufactured particles having one or more dimensions less than 100 nm (0.00001 cm), ENPs exploit the altered chemical reactivity and other changes that reduction to nanosize elicits. ENPs in sunscreen, such as titanium dioxide (TiO2) and zinc oxides, constitute effective broad-spectrum ultraviolet radiation (UVR) blocking agents with enhanced cosmetic transparency. The Australian Therapeutic Goods Administration (TGA), in approving such products, has stated that “there is no evidence that sunscreens containing these materials pose any risk to the people using them”.1 Similarly, authors of a recent article (written in collaboration with representatives of a cosmetic company) interpret the evidence as confirming that ENPs do not penetrate below the stratum corneum, or only in small amounts, producing limited cellular toxicity.2 Information on sunscreen packaging is not required to disclose the presence of ENPs. Yet, when TiO2 nanoparticles are incorporated into human cells in vitro, mobilisation of electrons by absorption of ultraviolet A (UVA) light produces reactive oxygen species and causes DNA damage (strand breakage and base modification). In fact, TiO2 has been used in this way to kill cancer cells in vitro.3 In sunscreens and cosmetic preparations, TiO2 is often coated to reduce this photocatalytic activity because over 90% of ambient UVR is UVA. However, evidence has now emerged that TiO2 in uncoated anatase form has been added to a marketed but as yet undivulged Australian sunscreen — in this form, TiO2 is capable of producing damaging photocatalytic free-radical reactions on particular steel roofing materials.4 Likewise, zinc oxide ENPs manufactured for use in sunscreens are potent biocides and subject to disposal restrictions in most countries. Despite the TGA’s stance, existing research does not comprehensively ensure the safety of all ENPs in sunscreens, particularly ENPs less than 40 nm in size applied long term to human skin that is immature, aged, diseased, damaged, hairy or covering flexural creases.5 The non-government organisation Friends of the Earth has compiled a list of sunscreens available in Australia that are claimed by the manufacturers to be free of nanoparticles.6 A New South Wales Government committee has recommended that, for regulatory purposes, ENPs be considered new chemical entities that require increased safety data.7 Policymakers should increase funding for objective research in this area (such as that by Macquarie University and the flagship project in nanotechnology of the CSIRO [Commonwealth Science and Industry Research Organisation]). Until such safety data are available, the TGA should apply the “precautionary principle”5 and, at a minimum, increase packaging information about nanoparticles in sunscreens.

Thomas A Faunce

Cycling is an affordable, convenient and achievable form of physical activity for all Australians Cycling, the fourth most popular physical recreation in Australia, is increasingly being used as a means of transport. As a form of regular physical activity, it confers substantial health benefits that are accessible to people of all ages.1 The epidemiological evidence is growing that cycling has health-enhancing effects, independent of other leisure-time physical activity. In a large Danish cohort followed up for 15 years, a 39% reduction in all-cause mortality was observed in those who cycled to work, and this was independent of participation in sport and other physical activity.2 Other large population studies have shown the effects of commuting by bicycle on reducing mortality and cardiovascular risk among Finnish women,3 and similar risk reductions for Chinese adults in Shanghai.4 Ecological observations have noted lower rates of obesity in regions with high rates of cycling.5 The article by Sikic and colleagues in this issue of the Journal describes cycling-related injuries in Victoria, and shows a 5-year increase in emergency department presentations, hospital admissions and major trauma among cyclists.6 This increase is of concern, and the authors reasonably call for preventive approaches. For many years, cycling advocates have called for a greater investment in cycling infrastructure, and studies overseas have demonstrated the potential for this investment to reduce injury outcomes. For example, cycling injuries are between eight and 30 times more common in the United States compared with the Netherlands or Germany.7 Similarly, rates of cycling-related deaths are much lower in Western Europe and declined by 60% between 1975 and 2000, compared with a much smaller decline in the US.5,8 Importantly, as Sikic et al acknowledge, their analyses do not adjust for the population denominator.6 More people are cycling now than 5 years ago — there are about a million new bicycles sold in Australia each year, and more people are cycling to work, with the greatest increases occurring in Victoria where the study by Sikic et al was conducted.1 Although there is a positive correlation between numbers of cyclists and injuries, the association is not simply linear. Known as the “safety in numbers” phenomenon, when more people cycle, collectively it becomes safer, and the injury rate per kilometre cycled decreases.9 Sikic et al suggest that people who ride bicycles should be registered,6 but requiring registration for all cyclists would not provide an accurate measure of cycling “exposure”, such as time spent cycling and distance travelled. It would cost more to administer than it would recoup, and it would likely act as a significant deterrent to casual or occasional cycling. In particular, cyclist registration would make it more difficult to encourage populations to shift to trial spontaneous recreational cycling. Research to calculate cycling times and distances as a population denominator for risk assessment should be a priority. In the Victorian data reported,6 most cycling injuries occurred on streets or highways where bicycles share the road with cars. Even though the absolute risk is still low, these injuries are mostly preventable. Making cycling safer requires better infrastructure and facilities for cycling, especially the provision of separated bicycle paths and cycle lanes.1,7 At the same time, driver attitudes and behaviour must be addressed. Strategies include enforcing lower driving speeds, traffic calming, parking restrictions, and community support for a safer road environment. Further, integrating cycling into public transport schedules and systems, including simple measures such as bicycle parking at train stations, would make cycling easier and give cyclists more options for safe commuting. In London, after the introduction of a “congestion tax” restricting car use into the city centre, combined with new bicycle lanes, cycling education and better public transport, many more cycling trips were made, and yet the overall number of cyclists injured actually declined between 2001 and 2004.10 It is generally understood what needs to be done to increase cycling participation levels. Better urban design, such as higher density development, mixing residential and commercial land use, and shorter trip distances, will facilitate more cycling.1 Other strategies to encourage cycling include behaviour change programs such as TravelSmart, Ride to Work, and Ride to School initiatives, public bicycle events to encourage infrequent and novice riders to cycle in a supportive social environment, and bicycle education programs for both children and adults.1 A dominant car culture and concerns about safety are the main reasons people give for not cycling in Australia.11 Mass media marketing campaigns are needed to help legitimise the value of cycling as transport, and advise drivers about relevant cycling road rules. Despite the perceived risks of cycling, the absolute magnitude of the risk is low, and the benefit-to-risk ratio is overwhelmingly positive; for chronic disease prevention, obesity reduction and mental health, the benefits are substantial.12 Cycling provides an affordable, convenient and achievable form of physical activity for all Australians, including children and youth, through to older adults with chronic conditions. As a physical activity, it also meets transport and traffic management needs, and is eco-friendly. Much more needs to be done in Australia to provide an environment that encourages people to cycle safely. This means giving greater funding and community priority to allocating road space for cycling. It also means physicians recommending that suitable patients consider cycling, and supporting efforts to improve the urban environment for cycling.12

Adrian E Bauman PhD, FAFPHM · Chris Rissel PhD

How can we ensure colonoscopy services are available to those who need them most? Bowel (colorectal) cancer is the most common cancer affecting both men and women in Australia, with 13 076 cases diagnosed and 4164 deaths reported in 2005.1 It is the second commonest cause of cancer-related death, behind lung cancer. The incidence of bowel cancer increases exponentially after 50 years of age, with a lifetime risk of about one in 17 among men and one in 26 among women.1 Bowel cancer satisfies most of the World Health Organization criteria for population cancer screening.2 Specifically, it is a common, serious cancer, and its natural history is reasonably well understood. It arises from precursor adenomas, and removal of these prevents cancer development. Importantly, most adenomas and early cancers are asymptomatic. Detection at early stages confers an excellent prognosis, and there are numerous tests for early detection and intervention, with the potential to reduce the incidence, morbidity and mortality of the disease. Cancer screening aims to identify affected individuals who do not suspect they have the disease. This is in contrast to performing diagnostic investigations for symptomatic patients, or targeting individuals with a significant family history of bowel cancer, a history of inflammatory bowel disease, previous adenomatous polyps or previous bowel cancer. However, bowel cancer screening recommendations can be confusing for medical practitioners. Numerous tests of varying performance levels are available, and it is difficult to separate recommendations for the population from those targeted towards individuals. There are also significant differences between the Australian recommendations endorsed by the National Health and Medical Research Council (NHMRC)3 and two recently published American guidelines, from the United States Preventive Services Task Force (USPSTF)4 and from a collaboration of the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer (representing the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Gastroenterology and American College of Physicians) and the American College of Radiology.5 Interestingly, these guidelines differ due to differing interpretations of essentially the same evidence. It is important to note that the newer American guidelines are less relevant to the Australian health care environment, and should not usurp the existing NHMRC recommendations in Australia. The NHMRC guidelines strongly recommend screening from the age of 50 years, by performing a faecal occult blood test (FOBT) at least every second year. The strength of this recommendation arises from three large, population-based, prospective randomised controlled trials demonstrating a mortality reduction of 15%–33%.3-5 No other cancer screening strategy is based on such strong evidence. Flexible sigmoidoscopy performed 5-yearly receives an equivocal recommendation, whereas colonoscopy and computed tomographic (CT) colonography are not recommended because of insufficient evidence. In contrast, the American guidelines recommend presenting information to patients, who then choose from the options, including high-sensitivity FOBT, flexible sigmoidoscopy or colonoscopy.4,5 The American recommendations diverge on CT colonography: the USPSTF does not recommend it on the basis of unknown long-term harm,4 while the collaborative joint guidelines endorse 5-yearly examinations.5 Unlike the US, Australia has moved beyond making passive recommendations to become one of a few countries actively implementing a nationwide population-based bowel cancer screening program — the National Bowel Cancer Screening Program (NBCSP) — although, currently, only individuals aged 50, 55 or 65 years are invited to participate (http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about). The NBCSP, which uses a high-sensitivity immunochemical FOBT, began in 2006 after a pilot program (2002–2004) found that bowel cancer screening would be acceptable, feasible and cost-effective.6 The age restriction for invitees is part of a phasing-in process designed to enable resources to cope with increased downstream demand, especially for colonoscopy, which is the recommended investigation for participants with a positive FOBT result. About 7.5% of NBCSP participants have a positive FOBT result, and 5% of these are found to have cancer.7 Although the federal government has made no commitment to the NBCSP beyond June 2011, it is inconceivable that the program will simply be terminated, given the strong evidence basis for its function. The problem facing Australian medical practitioners is what to do in the face of the various disparate guidelines. A simple approach is to recommend participation in the NBCSP for all invitees. Increased awareness of bowel cancer will also cause some individuals outside the eligible ages to enquire about screening. In these cases, the NHMRC recommendations are most appropriate: for medical practitioners wishing to encourage opportunistic screening, an immunochemical FOBT can be recommended for patients aged between 50 and 75 years. Patients with positive FOBT results will then require follow-up colonoscopy. However, these recommendations ignore the growing tendency, often driven by patients, for screening with colonoscopy. In the absence of symptoms, about 500 colonoscopies need to be performed on 50–75-year-olds to identify one cancer,7 with an associated one in 1000 risk of serious complications.8 This contrasts with one cancer found for every 20 colonoscopies in the NBCSP.7 Of course, many patients will have premalignant adenomas that would be found with colonoscopy screening, which in turn creates a substantial requirement for long-term surveillance colonoscopies. Yet the vast majority of patients with adenomas will never develop bowel cancer, even without future intervention.9 Finally, the imperfections of colonoscopy are becoming increasingly recognised, reducing the ratio of its potential benefits to high cost.10,11 Thus, “indiscriminate” use of colonoscopy diverts availability of this expensive resource away from those most in need of it, especially in the public health system. As a step towards improving colonoscopy access, the Western Australian Department of Health will introduce a Colonoscopy Services Model of Care, scheduled for implementation over the next 2 years in the public hospital system, that prescribes appropriate use and referral processes. This will be supported by trained clinical staff and computerised referral systems to improve the quality and triaging of referrals in the public sector. Patients will also be informed of the priority level of their case, and the appropriate waiting time. Other states in Australia should strongly consider implementing similar strategies. Bowel cancer is common, serious and largely preventable. Medical practitioners should be encouraged to refer individuals for bowel cancer screening in compliance with the current Australian NHMRC recommendations and the NBCSP. Such practice will ensure that colonoscopy resources are available to those most in need in our community.

Hooi C Ee MB BS, FRACP, PhD · John K Olynyk MB BS, FRACP, MD

A stringent, preventive risk-management approach could ensure potable reuse is a safe option As a result of prolonged drought, Australians are increasingly relying on alternative water sources — including rainwater, greywater, and water recycled from stormwater or sewage — for many community and household uses. Health professionals therefore need to be aware of the likelihood, if any, of illness related to water usage. In particular, careful consideration should be given to the safety of water recycling, especially as, at face value, it seems to represent a backward step from John Snow’s mid 19th century discovery of the importance of keeping drinking water and sewage separate.1 The obvious question is: is water recycling safe? There are different types of recycling, and different end uses for recycled water. In Australia, recycled water is currently used for irrigation of parks, golf courses and certain crops, and by various industries. Increasingly, new housing developments are incorporating separate pipes to distribute two grades of water: drinking water, supplied to kitchens and bathrooms; and recycled water for outdoor purposes (garden watering, car washing) and limited indoor use (toilet flushing, sometimes in laundries). As these uses of recycled water should not involve intimate human exposure, they are generally considered to incur negligible health risks. However, plumbing errors or use of recycled water for unendorsed purposes could result in intentional or unintentional ingestion. Fortunately, no recognised disease outbreaks associated with these schemes have so far occurred, and the public seems to be tolerant of these forms of water recycling. The more controversial issue relates to the potential health consequences of using treated recycled water to augment drinking water supplies (also called “potable reuse”). Australian water and health agencies have recognised the need for detailed technical guidance on minimising health risks from reuse schemes, resulting in production of the Australian guidelines for water recycling (AGWR).2,3 Phases 1 and 2 of these guidelines have been endorsed by the Australian Health Ministers’ Conference, and Phase 2 by the National Health and Medical Research Council (NHMRC). The AGWR recognise that the health consequences of system failure in a water recycling scheme could be catastrophic, with the potential for large gastroenteritis outbreaks, and that the greatest threat to public heath is from poor maintenance or poor quality control of water treatment processes. Consequently, the guidelines recommend proactive identification and management of risks, and include a “framework for management of recycled water quality and use”.2,3 One of the framework’s 12 elements involves undertaking a comprehensive risk assessment of each reuse scheme to determine the appropriate type and number of treatment steps required to “clean” the water. Another fundamental aspect of the framework is continuous monitoring of operational characteristics such as disinfection (chlorine concentration) and filtration (turbidity) that indicate water treatment processes are functioning efficiently. In other words, assuring adequate water quality is best achieved by monitoring the performance reliability and integrity of water treatment systems, and not by testing for all possible microbial or chemical contaminants.2,3 This lack of reliance on water quality testing is likely to seem counterintuitive to clinicians; however, the degree of assurance provided by negative test results is constrained by detection limits and the representativeness of small water sample volumes. Water quality testing is thus better suited to providing verification of system performance rather than being used as a routine management tool. There are two main issues raised by opponents of recycling schemes. First, they question whether water treatment processes can be guaranteed to always function effectively. This is a key focus of the AGWR, and it is essential that operators of potable reuse schemes have adequate skills and resources to provide the high level of quality control required to ensure safety. The second issue relates to adequate removal of chemical contaminants, given the large number of substances present in sewage (eg, hormones, pharmaceuticals, personal care products). This is a complex issue, particularly as the health consequences of low-level exposure to many of these substances are currently ill defined by toxicological and health data. The AGWR take a conservative approach to this issue and are consistent with international practices. Moreover, any incremental risks associated with potable reuse are likely to be negligible compared with other sources of direct exposure to these chemicals and with exposure from conventional drinking water supplies. So what is the bottom line? Evidence shows that current public supplies of drinking water in Australian cities do not incur an increased risk of gastroenteritis.4,5 Potable reuse is not yet occurring in Australia, but such water recycling schemes have existed internationally for more than 30 years, with schemes in Europe, the United States and Singapore having no recognised adverse health outcomes.6 Gastroenteritis outbreaks are unlikely when water treatment processes are well managed, so clear guidelines supporting prospective implementation of a preventive risk-management framework are fundamental to ensuring the safety of potable reuse.2,3 Health surveillance, although a relatively insensitive marker, can provide a retrospective indication of health outcomes associated with such schemes. The AGWR acknowledge that safety is not predicated on achieving zero health risk, but that there is an upper limit of tolerable risk (10-6 disability-adjusted life-years per person per year).3 The Australian drinking water guidelines, although now under review, currently contain no health-based target for microbial risk.7 This means that more stringent requirements for water quality are currently applied to potable reuse schemes than to conventional drinking water. While not advocating for or against potable reuse, it is thus paradoxically possible that planned potable reuse could be among the safest approaches to the provision of drinking water.

Karin S Leder MB BS, FRACP, PhD · Joanne E O’Toole BAppSc, MBA · Martha I Sinclair BSc(Hons), PhD

Objective: To assess the change in birth rates, both overall and in age, parity, socioeconomic and geographical subgroups of the population, after the introduction of the Baby Bonus payment in Australia on 1 July 2004.Design and setting: Population-based study using New South Wales birth records and Australian Bureau of Statistics population estimates for the period 1 January 1997 – 31 December 2006.Participants: All 853 606 women aged 15–44 years with a pregnancy resulting in a birth at ≥ 20 weeks’ gestation or a baby ≥ 400 g birthweight.Main outcome measure: Change in birth rate in 2005 and 2006 compared with the trend in birth rates before the introduction of the Baby Bonus.Results: The crude annual birth rate showed a downward trend from 1997 to 2004; after 2004 this trend reversed with a sharp increase in 2005 and a further increase in 2006. All age-specific birth rates increased after 2004, with the greatest increase in birth rate, relative to the trend before the Baby Bonus, being seen in teenagers. Rates of first births were not significantly affected by the bonus; however, rates of third or subsequent births increased across all age, socioeconomic and geographical subgroups.Conclusions: In the first 2 years after the introduction of the Baby Bonus, birth rates increased, especially among women having a third or subsequent birth. This could represent an increase in family size and/or a change in the timing of births.

Samantha J Lain BComm, BHlthSci(Hons), MPH · Jane B Ford BA(Hons), PhD · Camille H Raynes-Greenow BA, MPH, PhD · Ruth M Hadfield BSc, DPhil(Oxon), GCBiostat · Judy M Simpson BSc, PhD · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, MPH, DrPH

Dengue transmission in Australia is currently restricted to Queensland, where the vector mosquito Aedes aegypti is established. Locally acquired infections have been reported only from urban areas in the north-east of the state, where the vector is most abundant. Considerable attention has been drawn to the potential impact of climate change on dengue distribution within Australia, with projections for substantial rises in incidence and distribution associated with increasing temperatures. However, historical data show that much of Australia has previously sustained both the vector mosquito and dengue viruses. Although current vector distribution is restricted to Queensland, the area inhabited by A. aegypti is larger than the disease-transmission areas, and is not restricted by temperature (or vector-control programs); thus, it is unlikely that rising temperatures alone will bring increased vector or virus distribution. Factors likely to be important to dengue and vector distribution in the future include increased dengue activity in Asian and Pacific nations that would raise rates of virus importation by travellers, importation of vectors via international ports to regions without A. aegypti, higher rates of domestic collection and storage of water that would provide habitat in urban areas, and growing human populations in northern Australia. Past and recent successful control initiatives in Australia lend support to the idea that well resourced and functioning surveillance programs, and effective public health intervention capabilities, are essential to counter threats from dengue and other mosquito-borne diseases. Models projecting future activity of dengue (or other vector-borne disease) with climate change should carefully consider the local historical and contemporary data on the ecology and distribution of the vector and local virus transmission.

Richard C Russell MSc, PhD, FACTM · Bart J Currie FRACP · Michael D Lindsay PhD · John S Mackenzie PhD · Scott A Ritchie PhD · Peter I Whelan BSc

To the Editor: We evaluated follow-up by SMS (short message service) text messaging of contacts of a patient with meningococcal disease. An 18-year-old woman from south-western Sydney was diagnosed with invasive meningococcal disease in July 2008 after presenting to hospital with a rash that appeared after a 2-day prodromal illness. The Sydney South West Public Health Unit identified the patient’s household and similar contacts, and arranged for these individuals to be treated with clearance antibiotics. The patient had visited a bar with friends 3 days before symptom onset. The extent of contact with people in this social network did not warrant treating them with clearance antibiotics. However, it was appropriate to warn them about meningococcal disease as recommended by national guidelines.1 A list of mobile phone numbers of 14 people who visited the bar with the patient was compiled by one of her friends. A text message was sent 2 days after the patient’s diagnosis to everyone on the list via a broadcast messaging service: Message from public health. A friend of yours has meningococcal disease. Watch out for symptoms. Please read the fact sheet at http://www.health.nsw.gov.au/factsheets/infectious/meningococcal.html or call 9515 9420. The message sender appeared as “SMS4U”. Two weeks later, one of us (J E C) made up to three attempts to telephone each of the contacts, explaining that this was a follow-up about a text message they may have received from the Public Health Unit. Contacts were asked whether or not they remembered receiving the message, had viewed the website, and found the information helpful. Twelve were contacted (six men, six women; age range, 18–24 years); all remembered receiving the message, nine looked at the website, and 11 found the message helpful. All were happy to receive the information this way. Some knew of their friend’s illness through other social contacts. This is the first time we have used SMS to communicate information to social contacts of a patient with meningococcal disease. To our knowledge, this is the first reported use of SMS for this purpose, although email and the Internet have been used previously.2 SMS communication appeared highly acceptable to these young people and provided useful information, but it may be less useful in other age groups. SMS has been used successfully in other health contexts — appointment and vaccination reminders3,4 and diabetes education.5 It enables delivery of a concise, timely and consistent message that can easily be broadcast to large groups. There are potential pitfalls: limited information can be conveyed; there is uncertainty regarding whether the message is received (the broadcast service we used provided a “successful send” receipt but not a “message opened” receipt); those without mobile phones cannot be contacted; those without Internet access cannot access web-based resources; and some recipients may not understand the message. The authority of a message from SMS4U (the only available option) was also of concern. We did not exploit the capability of forwarding an SMS message and, by doing so, “snowballing” the information. This could be valuable for alerting large contact networks. Our study was small, and we recommend further evaluation of SMS communication in larger groups.

Johanne E Cochrane · Chris Lowbridge · Patrick Maywood · Stephen J Conaty