Environmental health

Objective: To describe changes in the iodine status of Tasmanians following voluntary fortification of bread with iodine in October 2001.Design and setting: Post-intervention, cross-sectional urinary iodine surveys of Tasmanian schoolchildren aged 8–11 years were used to assess population iodine status. Participants were selected using a one-stage cluster sampling method. The sampling frame comprised classes containing fourth-grade children from all Tasmanian government, Catholic and independent schools. Results were compared with pre-intervention survey results.Main outcome measures: Median urinary iodine concentration (UIC) and percentage of UIC < 50 μg/L ascertained from spot urine samples.Results: Median UIC was 75 μg/L in 1998, 72 μg/L in 2000, 105 μg/L in 2003, 109 μg/L in 2004 and 105 μg/L in 2005. Median UIC in post-intervention years (2003–2005) was significantly higher than in pre-intervention years. The percentage of UIC results < 50 μg/L was 16.9% in 1998, 18.7% in 2000, 10.1% in 2003, 10.0% in 2004 and 10.5% in 2005.Conclusion: Despite methodological differences between the pre- and post-intervention surveys, switching to iodised salt in bread appears to have resulted in a significant improvement in iodine status in Tasmania. Given iodine deficiency has been identified in other parts of Australia and in New Zealand, mandatory iodine fortification of the food supply in both countries is worthy of consideration. As voluntary fortification relies on industry goodwill, mandating fortification could be expected to enhance population reach and give a greater guarantee of sustainability in Tasmania.

Judy A Seal MPH, AdvAPD · Zelda Doyle BSc(Hons), MSc(Epid) · John R Burgess MD, FRCAP · Roscoe Taylor MB BS, FAFPHM, GradDipEpid · Angus R Cameron BVSc, MVS, PhD

Getting the message right will help the public reduce their risk of mental illness In the 2006–07 budget, the Australian Government announced expenditure of $21.6 million over 4 years to improve community awareness of the link between using illicit drugs and the development of mental disorders. Community awareness programs to reduce the prevalence of unhealthy behaviours are nothing new; they have been around for decades for cancer, heart disease and infectious diseases. While campaigns focusing on the negative effects of drug misuse have already been delivered, this initiative breaks new ground. It will be the first large-scale campaign in Australia to tell the public what actions they can take to reduce their risk of developing mental disorders. Australia is not alone in this area, with both France and the United States launching campaigns in 2005 to alert the public to the potential link.1,2 However, it is too early to know whether these campaigns have had any effect. Probably the main reason that there have not been earlier campaigns on how to reduce the risk of mental disorders is a lack of evidence for causal links. How good then is the evidence that illicit drugs cause mental disorders? First, there is substantial agreement that an association exists between early onset of cannabis use and later psychotic symptoms or disorder,3 but there is ongoing disagreement regarding the causal basis of this association.4 Clearly, cannabis use is “neither a sufficient nor necessary cause for psychosis”,3 but it may “unmask” psychotic disorders in individuals who are vulnerable. The timing of drug exposure may be particularly critical here, especially given recent evidence that a specific polymorphism of the COMT (catechol-O-methyltransferase) gene conveyed increased risk of later psychosis only if cannabis was consumed during adolescence.5 Second, a number of studies have reported a modest association between early onset of regular cannabis use and later depression, although further research is required to determine whether this relates to a direct causal role or common psychosocial factors.6 The evidence implicating other illicit drugs is more limited. Methamphetamine, which is rapidly growing in popularity in Australia, has been consistently associated with a transient psychotic state that is more common in people dependent on this drug.7 A growing body of literature suggests that a significant minority of those regularly using methamphetamine are also at risk of more entrenched patterns of psychosis.8 While there is currently limited evidence of a direct causal relationship between illicit drug use and mental disorders, the issue becomes whether we can afford to wait and see if increasing early use of illicit drugs actually does lead to a rise in the incidence of mental disorders. If a community awareness campaign is to be effective, it needs to be appropriately targeted. Initiation of illicit drug use typically starts in adolescence, and the evidence points to those with the earliest onset of drug use as being at greatest risk of subsequent mental disorders. A campaign targeting an early adolescent audience requires clear, coherent and credible evidence-based messages that are balanced and free from political dogma. The messages must also be delivered in a format that is appealing and meaningful to adolescents and informed by current trends in media and information technology. This might include web-based campaigns and the development of related Internet sites. Whether the campaign also focuses on providing information for parents will need to be determined, as this would require a complementary set of relevant information and materials. Mass media campaigns in other areas of health have typically had very little effect, including when drug misuse prevention has been the goal.9 In many cases, the weak effect has been due to campaigns being insufficient in intensity. Nevertheless, there are lessons that can be learned from earlier campaigns and these need to be applied (see Box). Given that the campaign discussed here will be the first to address risk of mental disorders, it needs to be well evaluated, either through a staggered roll-out in which some regions serve as controls, or through a time-series analysis in which there are repeated measurements over time — before, during, and after the campaign. As the first of its kind in Australia, it is important that this campaign is done well. A bad start could set back a field with considerable potential. Reducing the prevalence of risky behaviours, like illicit drug use, is not the only approach. It is also possible to promote positive actions that all individuals can take to reduce their risk of mental disorders.12 Campaigns that focus on educating the public about other effective preventive strategies (eg, exercise) should also be a clear priority, similar to other areas of health policy. Indeed, we have good evidence regarding psychosocial factors that increase risk for both substance misuse and mental disorders, and we need to communicate this information to the wider community. We envisage a future in which the public will know as much about how to reduce their risk of mental disorders as they currently do about how to reduce their risk of cancer and heart disease. Principles of effective mass media campaigns9 and possible applications to a campaign promoting awareness of illicit drugs as a risk factor for mental disorders Carry out preliminary research with the target audience Carry out qualitative research with young people to help design the campaign and to get feedback about the effectiveness of messages. Use a theory to give the campaign a conceptual foundation There are several relevant theories of behaviour change, including the transtheoretical model (which specifies how to communicate with people who are at various stages of readiness to change)10 and the theory of planned behaviour (which looks at how behaviour is influenced by a person’s attitudes and those of the people closest to them, and whether the person believes that the behaviour is under volitional control).11 Segment the audience into subgroups of people whose message preferences are similar to one another Potential audience subgroups might include: young people currently using illicit drugs, adolescents not using drugs, people with a personal or family history of mental disorders, and parents. Design messages that are targeted to the audience subgroups Messages need to appeal to each group. For example, messages for young people might need to avoid preaching, use suitable role models, and include features such as humour, novelty and a fast pace. Place messages through appropriate media that are widely used by the audience The appropriate media may be quite different for each group (eg, the Internet or youth radio might be more appropriate for young people than for parents). Conduct a process evaluation to see that the messages reach the audience Surveys should be conducted to ensure that the messages have reached the target audiences with a high frequency of exposure. The approach should be changed if an audience is not being reached. Evaluate outcomes to find out whether the campaign caused any changes in target audience behaviour Measure changes in attitudes towards the link between drug use and mental disorders, as well as changes in drug use. Evaluate the effects using a staggered roll-out, with some regions used as controls, or a time-series design, which involves multiple measures before, during, and after the campaign.

Anthony F Jorm MPsychol, PhD, DSc · Dan I Lubman PhD, FRANZCP, FAChAM

Government, industry and the community can work together to reduce price disparities An Aboriginal Health Worker, Marinka Burton, shops at one of the Mai Wiru (good food) stores in the Pitjantjatjara Lands, South Australia. Details of the Mai Wiru program can be found at http://www.nganampahealth.com.au With the New Year come those grand statements of good intent — to eat less and live longer. But resolving to eat less is a luxury reserved for affluent people. This New Year, most of the world’s population will still be seeking to increase their food supply. This is not a matter irrelevant to Australia: Harrison and colleagues (page 9) remind us that not all Australians have an abundant, affordable and continuous supply of food.1 In their article, they report on a series of surveys — the Healthy Food Access Basket (HFAB) surveys — of selected food stores in Queensland. The surveys showed that, to meet their families’ basic food needs, Australian residents in very remote areas paid an average of about 30% ($114) more each fortnight than people living in cities. The price disparity was greater for basic, healthy food items than for “unhealthy” items such as takeaway food, soft drinks and tobacco. Moreover, at the time of the surveys, fewer of the basic healthy foods were available in remote stores than in city stores. Of particular concern were the higher increases in food prices over time in very remote areas — for example, between 2001 and 2004, the cost of the HFAB in very remote areas increased by 18% ($77.00), which was greater than the rise in the Consumer Price Index. Remote Australia is home to many Indigenous Australians. They are doubly disadvantaged, paying more for food and other essential goods, and having the lowest incomes of any population group. A detailed study of costs and incomes in a remote Indigenous community in South Australia found that basic living costs consumed up to 85% of family incomes, with food accounting for 35% of the total.2 In contrast, Australians in general spend less than 20% of the family income on food.3 Although remote Indigenous communities obtain their food from various sources, the local store remains the largest supplier of foods.4 Self-sufficiency in food (especially in the face of increasing drought) is not a viable option. Thus, inequitable food pricing is an issue for all remote communities. The poor health and nutritional status of Indigenous Australians, including extreme rates of obesity, diabetes mellitus, cardiovascular disease and end-stage renal disease, have been amply documented.5 The links between poverty, food insecurity and obesity have recently been outlined by Drewnowski and Specter,6 who argue that poor people all over the world maximise calories per dollar spent. Thus, less expensive, energy-dense foods with high fat and sugar content always win out in the shopping basket over more expensive, less energy-dense foods such as fruit and vegetables. Reducing the disparity between food prices in cities and remote areas would be one way to help Indigenous families make healthier food choices. Why are food prices higher in remote areas? Investigators have identified several reasons.7,8 Refrigerated road transport for food is expensive, and made more so by the goods and services tax (GST) and rising fuel costs. In addition, in the wet season, some communities rely on air transport for their supplies. Poor business and stock management practices, lack of accountability, and unusual or corrupt behaviour by store managers have meant higher mark-ups in stores. The lack of clear store governance roles and procedures set down by community committees has hindered attempts to improve store management practices. Store expenses, including managers’ salaries (set high to encourage recruitment to remote areas), electricity, shipping, refrigerated storage and stock spoilage costs, are often higher than those incurred by city retailers. Because of the small populations in remote areas, opportunities for achieving economies by bulk-buying from large wholesalers are limited. What is being done? An impressive array of local initiatives has been described in FoodNorth, a report commissioned by the Western Australian Government on behalf of the “Top End” states and the Northern Territory.7 The report investigated the issues of excessive food costs and limited availability, and documented examples of promising programs from remote Australia that address these problems. Recently, federal, state and territory agencies have initiated more expansive programs, including the Remote Indigenous Stores and Takeaways project and a new company, Outback Stores, established by Indigenous Business Australia with significant federal funding.9,10 These projects have been established in recognition that remote-area food stores are commercial enterprises (although in many cases community-controlled) and must make a profit to survive. At the same time, those concerned with the health and wellbeing of remote communities argue that remote stores have a social responsibility to supply healthy foods to communities that depend entirely on their stock. These dual, and potentially opposing, objectives of profit and social responsibility present a difficult, but not insurmountable, tension for food retail businesses in remote areas. Indeed, there have been considerable shifts in recent years in some communities, whose stores are pursuing better business practices for bigger profits, while improving the quality of the produce they sell — for example, by using multiple strategies that outline the roles and responsibilities of the store, the types of foods to be stocked and promoted, and the accountability requirements of managers to reduce store expenses. Improving retail management practices is expected to cut the need for high mark-ups on prices. Some communities are establishing buying groups to enable stores to bulk-buy at wholesale prices. Community stores are developing guidelines and manuals to improve training and industry practice. An example is the Freight improvement tool kit, which is designed to improve the efficiency of cold-chain perish-able food transport to remote areas.11 Schemes to recruit and train Indigenous people in retailing aim to improve the efficiency of store operations as well as providing employment opportunities. Leaders in the retail grocery industry, including Coles and Woolworths, are providing considerable pro bono support. In parallel, local communities are expanding and improving banking services to minimise stores’ financial losses from unofficial loans and credit lines. What can others do to help and support these heroic efforts? There is no shortage of ideas and plenty of work for us all — food retailers, bankers, food transport companies, land councils, Indigenous-run businesses, employment program managers, governments, health professionals, health-related data collection agencies, and academics. Public–private partnerships, particularly for retail and business training for Indigenous communities, need to be fostered and maintained. Government assistance to minimise GST costs and perhaps subsidise food transport costs is worthy of consideration. Continued support and investment in the current promising initiatives are required, including funding to evaluate programs and ensure they lead to reduced prices of healthy foods in remote areas, as well as other expected benefits such as improved employment rates, incomes and health of remote-dwelling Australians. To this end, several groups have argued for the development and maintenance of a system for routine monitoring of prices of selected foods, and a family food basket, Australia-wide.7,12,13 The HFAB surveys provide a useful model for further development of a national food price monitoring initiative. This New Year, let us resolve to help solve the problems of Australians living in remote areas who pay higher prices for food than we pay, but whose ability to pay is less than ours. Indeed, let us go beyond a resolution and — through greater citizen action, good business and a modicum of government intervention — assist our remote communities in righting this wrong.

Karen L Webb PhD, MPH · Stephen R Leeder AO, PhD, FRACP, FAFPHM

To the Editor: Australia has one of the highest levels of food advertising on television in the developed world,1 with most advertisements being for foods that are high in fat, sugar, and/or salt.2 Evidence from international reviews suggests that television food advertising has an independent effect on children’s food preferences and purchasing requests.3,4 While the size of this effect is indeterminate, and the evidence base is correlational and therefore inadequate for making causal inferences,5 there is a highly plausible link between television food advertising and overweight and obesity. It is important to examine whether current regulations protect Australian children from excessive exposure to advertisements for unhealthy food on television. Methods used by food advertisers to circumvent or exploit loopholes in section 16 of the Children’s Television Standards Method Example Showing an advertisement twice within 30 minutes over several consecutive 30-minute periods An advertisement for a brand of chocolate breakfast cereal was shown 12 times during a 3-hour period (two advertisements per consecutive 30-minute period) Advertising multiple variations of a product within a 30-minute period A confectionery company advertised four different chocolate bars within a 30-minute period Currently, Australian children’s television advertising regulations are based on three regulatory codes that ostensibly aim to prevent misleading and excessive advertising to children. However, these codes lack precise definitions, allowing for subjective interpretation and creating loopholes that make the regulations difficult to enforce. Here, we focus on one of these regulatory codes, the Children’s Television Standards (CTS), presided over by the Australian Communications and Media Authority (ACMA) and available on their website at http://www.acma.gov.au. There is currently no published information available regarding successful complaints about breaches of the CTS since its inception in 1990. Section 16 of the CTS specifies that an advertisement may be broadcast no more than twice within a 30-minute children’s viewing period (C period). We examined whether any food advertisements breached CTS 16 in a regular week on three Sydney commercial television channels. As C periods are nominated at the discretion of broadcasters and are therefore difficult to identify, we selected periods when a high proportion of children were expected to be viewing (determined from ratings data from OzTAM, the official source of television ratings for metropolitan areas) and during programs that we believed were appealing to children. In 357 hours of television viewing during the study week in May 2006, 14 breaches of CTS 16 were observed for food advertisements during surmised C periods. Most (80%) were for high fat and/or high sugar foods. While the number of breaches represents a small proportion of total advertisements, it is important to remember that these data correspond to only one CTS clause in 1 week of television broadcasting. In addition, we found that food marketers circumvented or exploited a loophole in this clause 26 times during the study week. Examples of this circumvention are presented in the Box. Although not outright breaches, these instances illustrate that there are loopholes in the CTS that allow constant repetition of advertisements to children. Although the letter of the code may not be contravened in these cases, the essence of the code certainly is. Other researchers have observed breaches of the CTS. For example, Chapman and colleagues identified 194 breaches of the CTS during 645 hours of commercial television across rural and urban locations. The majority of these were breaches of CTS 20(2)(a), relating to the misuse of premium offers to market a product.2 The ACMA is presently reviewing the CTS, with plans to issue a discussion paper for public comment. This review is well overdue. Under the Broadcasting Services Act 1992 (Cwlth), the ACMA has a responsibility to protect children from the possible harmful effects of television viewing. To do this, significant amendments to the CTS are needed. There is a need to improve the clarity of the code, to expand C periods to include viewing times when high numbers of children are actually watching, to actively monitor advertisements, to adopt clear procedures for complaints and investigation of alleged breaches, and to impose penalties for confirmed breaches.

Bridget P Kelly BSc(Nutrition)Hons · Josephine Y Chau MPH, BSc(Hons)

To the Editor: To control the modern epidemics of preventable disease, Australia’s dietary guidelines recommend moderation in four nutritional areas — fat, saturated fat, sugar and salt. In spite of this, the obesity and diabetes epidemics seem unstoppable.1 This is hardly surprising — these guidelines seldom reach the public, and they recommend “moderation” without defining it. Zimmet and James recommend “traffic-light” food labels (red, amber, green) as a way of educating shoppers in the nutritional quality of foods.1 Traffic-light food labels2 promote the moderation message, with moderation indicated by an amber colour. Shoppers can see at a glance a food’s profile of compliance with the guidelines for each of the four areas where they call for moderation. Thus, salt content is moderate when the light for salt is amber, high when it is red and low when it is green. The same applies to fat, saturated fat and sugar. The colour coding is based on concentration in grams per 100 g or per 100 mL, with arbitrary boundaries (Box 1 and Box 2). The more green lights a food has, the healthier it is. With the aid of these labels, health professionals can treat hyperlipidaemia by dietary restriction, giving patients advice to shop exclusively for foods with green lights for fat and saturated fat. They can treat prehypertension (blood pressure, ≥ 120/80 mmHg) and thereby prevent hypertension by advising patients to eat foods with green lights for salt and green or amber in every other area.3-5 With the intention being to “guide the traffic”, the best approach would be flexible, holistic and specific for each food. For example, an amber light could recommend olive oil in moderation, even though it happens to be 100% fat. The natural sugar content of fresh fruits is high enough to give many fruits an amber rating, but moderation is hardly the right message for fruit. Australian traffic-light labels could avoid this, as the Australian dietary guidelines speak only of added sugar. Australia might add a traffic-light label for energy density (showing the same three colours based on kJ/100 g), and expand the saturated fat category to include trans fat, with very low thresholds triggering automatic red lights. Many shoppers would be surprised to find several of Australia’s best-selling breakfast cereals carrying two red lights (for added sugar and salt) and many processed meats with three or four red lights (for energy density, fat, saturated fat and/or salt). The Council of Australian Governments has announced a national campaign to arrest the growing epidemic of childhood obesity. Traffic-light labels would enable parents to protect their families from obesity by shopping almost exclusively for foods with green and amber traffic-light labels for fat, saturated fat, and added sugar. Food choices to control obesity involve a radical change in shopping behaviour, and traffic-light labels are expressly designed to promote radical change. They need to be mandatory, and they need to replace industry-sponsored schemes, which we believe are less likely to alter a customer’s buying patterns. 1 Lower and upper boundaries for the moderate (amber “traffic light”) category set in 2006 by the UK Food Standards Agency2 Food component Boundaries Fat Solids 3–20 g/100 g Drinks 1.5–10 g/100 mL Other liquids 3–20 g/100 mL Saturated fat Solids 1.5–5 g/100 g Liquids 0.75–2.5 g/100 mL Sugar Solids 5–15 g/100 g All liquids 2.5–7.5 g/100 mL Salt Solids 0.3–1.5 g/100 g All liquids 0.3–1.5 g/100 mL (equivalent to sodium 118–590 mg/100 g) The UK traffic-light label boundaries shown above treat all sodium as sodium chloride. If 118 mg is rounded to 120 mg/100 g, the boundary between moderate- and low-salt foods agrees with the international definition of low-salt foods (sodium, ≤ 120 mg/100 g). Front-of-pack traffic-light labels do not replace the technical Nutrition Information Panel. Beneficial nutrients are best promoted in this panel and, where permitted, in nutritional claims. The website <http://www.saltmatters.org> carries a longer article on the basic issues (click on Traffic Lights). 2 Example of traffic-light labelling Food carrying this label would be high in fat and saturated fat, low in sugar and medium (moderate) in salt. Red lights flag nutrient excess which is associated with preventable health problems, including, in this example, obesity, heart disease, metabolic syndrome and diabetes.

Trevor C Beard · Caryl A Nowson · Malcolm D Riley

A recent conference raised issues about the environment in which lifestyle choices are made Even before it had started, the recent 1-day conference “Obesity: should there be a law against it?” provoked controversy. The very title of the conference, convened by the University of Sydney’s Centre for Health Governance, Law and Ethics and the Australian and New Zealand Institute of Health Law and Ethics, elicited outraged responses. The recipient of much of the outrage, Conference Convener, Roger Magnusson (Associate Professor, Faculty of Law, University of Sydney), explained to the conference attendees that law’s perceived role in society is all about coercion. While law is a potent tool for public health and disease prevention, it needs to be able to “justify its involvement and defend itself from ideological attacks”. The conference’s quirky title went to the very core of the issue. Surely, adults have a right to choose to be overweight if it fits with their desired lifestyle. Shouldn’t the law stay away from our refrigerators and couches? An insightful early question from the floor was, “How can the law help frame the debate which is now framed as freedom of choice versus paternalism?” A distinguished international group of speakers presented a range of approaches to this dilemma. The Australian context: Boyd Swinburn (Chair in Population Health, School of Exercise and Nutrition Sciences, Deakin University) considered obesity in terms of the conventional epidemiological triad, where host factors (human biology and behaviour) interact with vectors (excessive energy intake and inadequate expenditure) and the environment (physical, economic, policy and sociocultural). By far the major environmental drivers, said Swinburn, are economic ones, and these are weighted on the side of obesity. Products such as energy-dense foods and cars are heavily promoted, while others such as bicycles, the exercise industry, and fruit and vegetables are not. “If you look at obesity from a libertarian perspective, it is difficult to argue for an approach that involves laws, regulations and enforceable policies; people have a right to be unhealthy if they choose to be. A protectionist approach can be used for children, whom it can be argued have a right to be healthy. However, even in adults you can justify policies such as detailed food labelling on the grounds that they will support healthy choices — making healthy choices easy choices.” While he acknowledged vast differences between the tobacco industry and the food industry, Chris Reynolds (Senior Lecturer in Law, Flinders University) pointed out the similarities in the way the two industries have marketed their products. Restrictions on marketing have had a major role in tobacco control, but so far in Australia, public policy for obesity has centred on exercise, education, and consideration of the built environment. Recent calls for controls on a range of other fronts, including food marketing, have been controversial and not supported by the federal government. While supportive of the idea of personal responsibility, Reynolds did not see this as excluding a community or collective response to public health issues. Personal choice will be influenced by the environment in which people are making that choice. “People are more likely to exercise personal responsibility if they’re not expected to swim against a current of advertising and promotion.” Elizabeth Handsley (Associate Professor, School of Law, Flinders University) is currently involved in a multinational study of the regulation of food advertising to children in Australia, the United States, Canada, the United Kingdom, Sweden and Norway. These countries vary in their regulatory structures, rules (from minimal restrictions to a complete ban), and sanctions imposed for breaches. Interesting issues raised include: who should be the regulator (industry is more efficient but government is more independent)?; to what extent should surveillance rely on public complaint versus active monitoring?; what are the relative roles of parents and society?; how should the “rules” be defined?; and, what sanctions should be imposed? The US and the UK: According to James Hodge (Associate Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA), Americans are split between viewing obesity as a public health issue or as a personal issue, and are more likely to support interventions aimed at children. He gave a colourful account of a raft of US strategies, covering various areas of the law. These occur at every level of government, with state and even local government jurisdictions not waiting for the federal government to act. They include incentives to encourage healthier behaviour, disincentives to discourage unhealthy behaviour, litigation by injured (obese) people seeking recourse (this has generally not been successful and many states have introduced “personal responsibility” laws that prohibit it), and restriction of access to unhealthy foods (local governments achieve this via zoning laws). Robyn Martin (Professor, Public Health Law, University of Hertfordshire, UK, and Visiting Professor, Public Health Law, Chinese University of Hong Kong) pointed out that, although obesity affects many different nations, the context differs. In the UK, the context includes the political system, a culture of long working hours, class- and age-related food traditions, and even the climate! Over the past 5 years, obesity has been variously categorised in government documents as a medical problem, an economic problem, a societal problem, a public health problem and, most recently, by Prime Minister Tony Blair, as a personal problem. In a 2006 speech, he said: “Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle . . . the result of millions of individual decisions.” Even within this narrow framework, argued Martin, there is much that the government can do in the way of legal support and structures to make it easier for people to live healthily. A spurious dichotomy: Despite all the controversy, personal responsibility and the wider community response are not on opposite sides of the fence, says Chris Reynolds. “These two ideas are inextricably linked. One is necessarily supported and sustained by the other. The community must create the environment that maximises the potential for people to make healthy choices.” And Magnusson’s answer to that question from the floor about how the law can help reframe this debate? “We can turn it around and say that, if we really want to deliver on autonomy or individualism, we need to introduce legislation that allows people full freedom of choice.”

Ruth M Armstrong BMed

A national strategy for meeting the particular health needs of refugees would provide a more comprehensive approach The profile of refugees being resettled in Australia depends on global geopolitical conflicts, representations from the United Nations High Commissioner for Refugees to the Australian Government, and Australia’s response. Recent years have seen an enormous shift within Australia’s annual refugee intake, with 70% originating from countries in sub-Saharan Africa.1 The Australian Government requires those migrating under its Humanitarian Program to undertake certain health checks before being issued with a visa.2 Additionally, since mid 2005, the Department of Immigration and Multicultural Affairs (DIMA) has been rolling out an additional medical check known as a predeparture medical screen (PDMS) in the few days before departure (Kathy King, Director, Special Health Projects, DIMA, personal communication). This medical check was introduced in response to significant numbers of cases of communicable diseases being identified among new arrivals. Conducted mainly by medical staff of the International Organization for Migration (IOM), it is largely a fitness-to-fly check, although it does include screening for malaria, measles–mumps–rubella vaccination, and empirical treatment for intestinal parasites. Although DIMA is expanding the geographical coverage for the PDMS, not all current humanitarian entrants are subject to this screening. In this issue of the Journal, a collection of articles and a letter on refugee health indicate a high prevalence of various conditions among recent refugee arrivals (Chih et al, Outpatient treatment of malaria in recently arrived African migrants; Tiong et al, Health issues in newly arrived African refugees attending general practice clinics in Melbourne; Martin and Mak, Changing faces: a review of infectious disease screening of refugees by the Migrant Health Unit, Western Australia in 2003 and 2004; Cherian et al, Severe Plasmodium falciparum malaria in refugee children despite reported predeparture antimalarial treatment). Some of the data were collected before the introduction of the PDMS, which may have lowered the rate of malaria and intestinal parasite burdens. However, recent experience in New South Wales has been that cases of malaria continue to be detected despite antigen testing overseas. The detection rate for HIV among this previously screened population reported here by Martin and Mak (page 607) is low (0.12%), but is not zero. Further consideration of whether to repeat routine HIV screening after arrival is warranted. Hepatitis B tests are only conducted in a minority of entrants,2 yet this disease has important personal and public health implications. It is apparent that the screening conducted overseas, no doubt under difficult circumstances, remains suboptimal. Additionally, conditions such as anaemia, schistosomiasis and vitamin D deficiency flagged in the articles are, appropriately, not screened for overseas, yet warrant early detection and treatment. At the same time, the risk to the public from various conditions must not be exaggerated, as this is potentially detrimental to attitudes about already marginalised people, as shown by Leask et al (page 591). The fact that refugees have considerable health care needs is well documented, and these needs vary with region of origin and other factors.3,4 Health care professionals in Australia may be unfamiliar with some conditions, and diagnosis might be delayed if these conditions are not detected in their asymptomatic stages through adequate screening. The principles of prevention and early intervention, our existing knowledge about refugee health care needs, and the additional evidence from the articles in this issue of the Journal justify a call for nationally coordinated, comprehensive health assessments to be offered to all newly arrived refugees. This need for comprehensive health assessments was highlighted in a recent report on refugee children.5 However, entire families in this setting have the same requirements, and a family-centred approach is needed. Health assessments must not only focus on infectious diseases, but should take into account the refugee trauma experiences of families and individuals, and assess physical, psychological and psychosocial needs. Sufficient attention needs to be given to oral health, nutrition, undermanaged chronic conditions, and the impacts of violence. Currently, each state and territory has a different model and varying coverage for postarrival checks, as shown by some of the reports in this issue. Some jurisdictions have centralised clinics in public hospital venues, focusing mainly on infectious disease screening (eg, Tasmania, Western Australia). NSW, with an annual intake of 4000 refugees who are dispersed widely across the state, has a state-funded Refugee Health Service with some clinical role but which also supports mainstream health services to assist refugees. Victoria has a different model again, with a focus on general practitioners in community health centres and private practice, supported by refugee health nurses. Sheikh-Mohammed et al (page 594) and Tiong et al (page 602) highlight the important role that GPs play in providing health care services to refugees. However, there are limitations to GPs being able to perform comprehensive assessments, including time constraints, the challenges of using an interpreter over the phone, and the need for specialised knowledge. The release in May this year of a new Medicare item number for refugee health assessments goes some way towards supporting GPs who take on this role.6 Unfortunately, the opportunity to link the release of this item number to targeted GP education was missed at the national level. Indeed, a system of “accredited practices” could even be envisaged, with key GPs linked into, and supported by, clinicians and public health staff experienced in refugee health. As with health care provision to other special-needs groups, there are debates about the need for mainstream versus specialised services.7 In locations with significant ongoing refugee settlement, a mix of models is likely to be needed. Publicly funded clinics offer a number of advantages, including centralised knowledge and strong links with key refugee agencies. Specialised health care services targeting refugees also provide important education and support to GPs and other health care staff. Whatever the model for providing health assessments, newly arrived refugees need help to overcome the barriers they face in accessing health care.8 Increased availability of DIMA-funded case workers and of volunteers will help refugees negotiate our complex health care systems.9 Community education about available health care services is also important. Mainstream health care services must be capable of providing sensitive, culturally appropriate care to these vulnerable groups. At the national level, there are a number of initiatives underway in refugee health in addition to the new Medicare item number. In response to issues similar to those raised in the articles in this issue, the Department of Health and Ageing has, over the past year, convened a working group on refugee health, with representatives from all states and territories. This group has made recommendations to the Australian Health Ministers’ Advisory Council, some of which aim to address issues raised by Tiong et al (page 602). These include the cost of certain medications, such as praziquantel for schistosomiasis, and the limited availability of some vaccines for catch-up schedules. Refugee health is a varied field crossing multiple disciplines and presenting complex issues. The development of a national refugee health strategy would promote greater direction, coordination and standardisation nationally. One aspect should be data collation and monitoring of disease detection prevalence across jurisdictions. National guidelines relevant to refugee health, some of which are already being developed, are required. Finally, although clinicians and others working with refugees do network informally, more formalised networks between these health professionals will aid communication and collaboration across borders.

Mitchell M Smith MB BS, MPH, FAFPHM

Broader measures are needed to reduce road trauma related to mobile phone use The effect of mobile phone use on driving performance and safety has been a major focus of distraction research. Around 94% of Australians (19 million) own a mobile phone,1 and the capabilities of these devices are rapidly expanding. They can be used to talk, read and send text messages, download and play video clips from the Internet, navigate to chosen destinations, and perform other functions.2 When used while driving, they are capable of distracting drivers by taking drivers’ eyes off the road (eg, when reading a text message), taking their attention off the road (eg, when talking), and physically interfering with vehicle control (eg, when reaching to answer the phone while steering). There is converging evidence that the use of mobile phones while driving increases crash risk. A New Zealand study estimates that crashes involving mobile phones account for about 0.5% of all reported crashes there,3 and a fourfold increase in crash risk has been reported in some epidemiological studies, for both hand-held and hands-free use.4 This increase in risk is similar in magnitude to that associated with a blood alcohol concentration of 0.08%. Few epidemiological studies have reported data on the increased crash risk associated with driver exposure to other sources of distraction, although threefold increases in crash risk have been reported for young drivers who carry three or more passengers.5 However, it is not clear if this increase can be attributed solely to distraction. Controlled psychological studies, conducted mainly in simulators, have shown distraction-related decrements in driving performance with use of mobile phones that appear to underlie these increases in crash risk: impaired lane-keeping ability; poorer speed and following distance control; longer reaction times; missed traffic signals; a reduced useful visual field of view; and other related decrements.6 In determining the increased risk to the public of mobile phone use while driving, it is necessary to know the prevalence of this practice. Taylor and colleagues observed 17 000 drivers at 12 metropolitan road sites in Melbourne in October 2002.7 Overall, 1.85% of drivers (315) were observed using a hand-held phone. Older drivers had a significantly lower rate of use than middle-aged or young drivers. In this issue of the Journal, McEvoy and colleagues report a cross-sectional survey to explore the use and effects of mobile phones while driving for drivers in New South Wales and Western Australia.8 Participants were 1347 licensed drivers aged 18–65 years. While driving, around 57% of drivers had ever used a mobile phone (39% of these had used a hand-held phone) and 12% had written and sent text messages. The authors estimate that, for all drivers aged 18–65 years in these two Australian states, about 1% will have ever had a crash while using a mobile phone and, in the preceding year, around 3% will have taken evasive action to avoid a crash because of their phone use. Collectively, the authors of these articles conclude that, despite legislation that bans the use of hand-held phones in Australia, mobile phone use is prevalent among drivers, particularly younger drivers, and that it can result in adverse consequences, including crashes. There are certain driver and task characteristics that appear to moderate the effect of mobile phone use on driving performance and safety:9 the amount of time the driver engages in phone-related activity; the complexity of phone design and the phone task itself; current driving demands; driver experience and skill; and driver willingness to engage in phone-related activity. Countermeasures to mitigate the effects of distraction should take these into account. The Australian Mobile Telecommunications Association provides the following specific advice to mobile phone users to minimise the potentially adverse effects of distraction: use a hands-free phone; plan trips and make calls when stationary; avoid making calls in heavy traffic or poor weather conditions; avoid complex or emotional conversations; use message services to answer calls; pull over safely when stopping to make calls; use phone features to reduce the effort involved; never take notes, look up phone numbers, or read or send text messages while driving; tell callers you are driving when on the phone; and use the phone to call for help in emergencies.10 These recommendations appear to be sensible strategies if applied to hands-free phones, the use of which is presently legal. The use of hand-held mobile phones while driving is banned in Australia, although exemptions do exist for some drivers (eg, police). At a broader level, there is scope for further countermeasure development, and policymakers have many strategies at their disposal.2 These include: Data collection to better quantify mobile phone use as a contributing factor in crashes: enhanced police report forms to record mobile phone use as a potential source of distraction; regular mobile phone distraction exposure surveys; use of “black boxes” to record phone use in crashes; Education: publicity campaigns to raise awareness of risks, especially for hands-free phone use and text messaging; highlight factors that increase vulnerability to risks, especially driver inexperience; promote strategies for minimising distraction, especially the purchase of the most ergonomic hands-free phone types; and raise awareness of penalties for using hand-held phones; Training to address when, optimally, to expose learner drivers to hands-free mobile phone use; the least distracting methods of interacting with hands-free phones; self-awareness of the effects of phone distraction on driving; the training of passengers as co-pilots to manage phone use; Legislation and enforcement: prohibit learner and probationary drivers from using all mobile phones while driving; review exemptions and anomalies in existing legislation; improve effectiveness of police enforcement of current legislation; develop technologies to prevent phone use in vehicles moving at high speed; increase penalties; Phone design: improve ergonomic design of in-built and portable hands-free phones to reduce distraction — although it is possible that improved design and ease of use could promote increased phone use while driving, and as a consequence paradoxically undermine safety; Vehicle design: use intelligent on-board “workload manager” technologies to temporarily suppress calls and prevent access to phone functions and controls when distraction potential is estimated to be high; Fleet safety: as a duty of care, develop, implement and enforce company policies on mobile phone use while driving; Licensing: provide information on risks of mobile phone use while driving in licensing handbooks; test knowledge of these risks; design practical driving tests to identify, and prevent from being licensed, learner drivers who are incapable of compensating for the effects on driving of hands-free mobile phones; and Research: to further understand the theory, effects and mitigation of mobile phone distraction. Many of these have been adopted as recommendations in the recently released report of the Parliament of Victoria Road Safety Committee Inquiry into Driver Distraction.10 The use of mobile phones while driving will continue to contribute unnecessarily to road trauma in this country unless countermeasures such as these are developed, implemented and properly evaluated.

Michael Regan BSc(Hons), PhD

Objective: To explore the use and effects of using mobile phones while driving.Design: Cross-sectional survey.Setting: New South Wales and Western Australia, 20 October to 7 November 2003.Participants: 1347 licensed drivers aged 18 to 65 years. Data were weighted to reflect the corresponding driving population in each state.Main outcome measures: Mobile phone use while driving (hand-held, hands-free and text messaging); adverse effects of use.Results: While driving, an estimated 57.3% ± 1.5% of drivers have ever used a mobile phone and 12.4% ± 1.0% have written text messages. Men, younger drivers and metropolitan residents were more likely to use a phone while driving and to report a higher frequency of use. Enforcement of hand-held phone restrictions was perceived to be low (69.0% ± 1.5%) and an estimated 39.4% ± 2.1% of people who phone while driving use a hand-held phone. Half of all drivers (50.1% ± 1.6%) did not agree with extending the ban to include hands-free phones. Among drivers aged 18–65 years in NSW and WA, an estimated 45 800 ± 16 466 (0.9% ± 0.3%) have ever had a crash while using a mobile phone and, in the past year, 146 762 ± 26 856 (3.0% ± 0.6%) have had to take evasive action to avoid a crash because of their phone use.Conclusions: Phone use while driving is prevalent and can result in adverse consequences, including crashes. Despite legislation, a significant proportion of drivers continue to use hand-held mobile phones while driving. Enhanced enforcement is needed.

Suzanne P McEvoy MB BS(Hons), MAppEpid, FAFPHM · Mark R Stevenson PhD, MPH · Mark Woodward PhD, CStat

The most arresting brief I have so far received was that from the Chief Medical Officer, Professor John Horvath, about the potential threat of an influenza pandemic occurring. The brief warned of the far from hypothetical risk of a new disease that could infect up to 25% of the population in the first 3 months of a moderate outbreak in Australia. Since February 2004, the Commonwealth Government has taken this threat just as seriously as it would a threat to national security, and has implemented a series of precautionary measures that mean Australia is better prepared than almost any other country in the world to deal with a new influenza strain if it emerged. This supplement provides a snapshot of the latest research and preparations being undertaken in Australia to adequately respond to an influenza pandemic should it occur. A range of health professionals explore planning to counteract a possible pandemic; the biology and history of the influenza virus; the clinical manifestations of influenza; laboratory diagnosis; the role of antivirals, vaccine development, non-pharmaceutical interventions, and infection control in a pandemic; and the crucial role of general practice. I expect this supplement to generate debate among health professionals and the general community as we all grapple with our roles, responsibilities and possible responses to a potential pandemic influenza outbreak. Tony Abbott Australian Government Minister for Health and Ageing

Tony Abbott

Objective: To compare cervical screening policy, screening uptake, and changes in cervical cancer incidence and mortality between Australia and the United Kingdom.Design: Analysis of screening registry data and national cancer statistics.Setting: In Australia, organised cervical screening was initiated in 1991 for sexually active women aged 18–69 years, with a recommended 2-yearly interval. In the UK, organised screening began in 1988 for women aged 20–64 years, with a recommended 3-yearly interval in most regions.Results: Estimated lifetime screening participation rates in 2001 were similar in the two countries, at 88% in Australia and 90% in the UK. For women who were screened and had a negative result, the median time to the next screen was 27 months in Australia and 38 months in the UK. At 39 months, equivalent proportions (74%) had been re-screened in the two countries, and by 60 months the re-screened proportions were 81% in Australia and 94% in the UK. From 1991–1993 to 1998–2000, the incidence of cervical cancer in women aged 20–69 years fell by 33% in Australia and 33% in the UK, and mortality from cervical cancer fell by 36% in both countries.Conclusions: After the introduction of organised screening, similar reductions in cervical cancer incidence and mortality were achieved in Australia and the UK. Therefore, the 2-yearly screening policy in Australia and the predominantly 3-yearly screening policy in the UK appear to have been of broadly similar effectiveness.

Karen Canfell DPhil · Freddy Sitas MSc(Med), MSc(Epi), DPhil · Valerie Beral FRS

Re: “The repeating history of objections to the fortification of bread and alcohol: from iron filings to folic acid”, a letter by Hasantha Gunasekera in the 18 September issue of the journal (Med J Aust 2006; 185: 343). The Food Standards Australia New Zealand proposal for fortification was changed after the letter was accepted for publication, to propose fortification of bread, rather than bread-making flour. The first sentence of the letter should read: “The recent viewpoint by Kamien1 is timely, given Food Standards Australia New Zealand is currently advocating for the mandatory fortification of bread with folic acid (80–180 μg per 100 g of bread).” The html and pdf versions of this article were corrected on 6 Nov 2006.

Hasantha Gunasekera

Rotavirus vaccines are finally available, and introducing them into the routine vaccination schedule will have a significant impact on the health of children After a dramatic false start, oral rotavirus vaccines are now available to prevent severe, dehydrating diarrhoea in small children. Rotavirus infection in children can be as severe as cholera in adults, but affects a group who cannot complain. Since its discovery in Australia in 1973, rotavirus has become accepted as the single most common cause of severe diarrhoea in children worldwide. It still kills over 500 000 young children each year. In Australia, it is estimated that 10 000 children require hospitalisation annually1,2 (more than 4000 actually coded for proven rotavirus3), and as Schultz reports in this issue of the Journal, the impact on Indigenous children is especially severe.4 Oral rehydration has greatly reduced mortality, but the World Health Organization recognises the potential of rotavirus vaccines to further reduce under-5-year mortality rates, Goal 4 of the Millenium Development Goals.5 It is exciting to have two efficacious oral rotavirus vaccines, RotaRix (GlaxoSmithKline [GSK], Boronia, VIC) and RotaTeq (Merck/CSL, Parkville, VIC) licensed this year in Australia. Each has been extensively tested in placebo-controlled trials of more than 60 000 participants. Both vaccines prevented severe disease, and reduced the need for hospitalisation by 85%–94%. There was a reassuring lack of intussusception, a rare (one in 10 000–32 000) event associated with RotaShield, the first licensed rotavirus vaccine, which led to its withdrawal from the United States market in 1999, just 12 months after its introduction.6 Re-analysis of the data suggested that the intussusception risk emerged in infants receiving the first vaccine dose after 3 months of age.7 Thus both GSK and Merck/CSL state that the first dose should be administered before that time. Several issues remain to be resolved with these two new vaccines. Efficacy has not been established in developing countries. Availability will depend on distribution (including the need for a cold chain), the ability to piggyback rotavirus vaccines with other routine vaccinations, and manufacturing capacity. The greatest uncertainty is the cost of the vaccine. Current prices exceed $200 per course in the private market. While tier pricing and subsidisation by international agencies for poorer countries is being considered, it is not clear whether these mechanisms will sustain programs in most parts of the world. Hence, other candidate vaccines linked to developing country manufacture are under early development in China, India, Indonesia and elsewhere. Who should get rotavirus vaccine in Australia? Ideally all children under 3 months of age, as all will eventually be exposed to rotavirus, and one in 25 will be admitted to hospital for rotavirus gastroenteritis during the first 5 years of life. Morbidity across our country is high. Apart from the 10 000 annual hospital admissions, there are 22 000 visits to emergency departments and 115 000 visits to general practitioners.2 Nosocomial infection rates are as high as 14% in children’s hospital wards and may be higher in childcare centres.8,9 Schultz’s report indicates that Indigenous children have 2–4 times the disease burden of non-Indigenous children.4 Gastroenteritis in Indigenous children comes with comorbidities and a significantly increased average length of hospital stay. Add to that the large costs of air transport of patients for hospital admission in northern and western Australia and the disruption to remote families, and the case for rotavirus vaccination of Indigenous infants becomes compelling. The Northern Territory Health Department recognised the importance of rotavirus infection by making it a notifiable disease, and Queensland recently followed suit. Breaking news is that from October 2006, the NT Government will include rotavirus vaccine in the routine vaccination schedule for NT children.10 The only real issue is cost. A 1999 cost–benefit analysis suggested that break-even vaccine cost was $78 per course,11 somewhat less than current prices. However, the community should be prepared to pay something to prevent this wretched disease. For maximum benefit, the first dose should be given before 3 months of age. Infants under 6 months of age accounted for 24% and 9% of rotavirus gastroenteritis cases in studies in the NT and Melbourne, respectively.4,12 In Africa, many infants are infected in the first 2 weeks of life.13 There is enthusiasm for giving the first dose of vaccine within the first month of life, but neither licensed vaccine has been tested at this age. Roll-out of a universal program in Australia has a few caveats. The inevitable concern about intussusception, in spite of the reassuring clinical trial results, probably means that catch-up campaigns, where the first dose is given after 3 months of age, will not happen. Evidence of the spectrum of protection afforded by both vaccines against the full range of human rotavirus serotypes is still lacking. There is a need to continue national strain surveillance to ensure that the current vaccines are appropriately protective against the range of serotypes in Australia, and to monitor the effect of vaccine pressure on the evolution of strains. After three decades, there is real excitement at suddenly having such an effective tool to prevent a common, miserable disease affecting infants and children. Rotavirus vaccination is not only justified on the basis of disease burden, but will be welcomed by all who care for sick children. It will not be hard to measure real improvement for Indigenous children in the NT, given the baseline data presented elsewhere in this issue of the Journal.4 While other candidate vaccines are in development, there is no excuse for waiting any longer for a national program. The improvement in child health will be obvious.

Graeme L Barnes MD, FRACP · Ruth F Bishop AO, DSc, PhD

Objective: To present data on rotavirus notifications in the Northern Territory to provide knowledge about the local epidemiology of rotavirus gastroenteritis that can be used to inform the use and funding of rotavirus vaccines.Design: Retrospective analysis of data from the Northern Territory Notifiable Diseases Database.Participants and setting: Patients with cases of rotavirus infection notified to the NT Centre for Disease Control from 1 January 1995 to 31 December 2004.Main outcome measures: Patterns of rotavirus notifications over time; infection rates in Indigenous versus non-Indigenous children aged 0–5 years; age groups infected with rotavirus.Results: Numbers of rotavirus notifications over the period 1995–2004 show annual, monthly and regional variability. The rotavirus notification rate for Indigenous children aged 0–5 years was 2.75 per 100 per year, compared with 0.98 for non-Indigenous children, with a relative risk for Indigenous children of 2.17 (95% CI, 1.97–2.39) over the 10 years. Indigenous children infected with rotavirus were younger than non-Indigenous children, with median ages of 11 months and 16 months, respectively. Rotavirus gastroenteritis occurred in outbreaks, transmitted over months throughout the NT.Conclusion: Large numbers of cases of rotavirus gastroenteritis affecting Indigenous and non-Indigenous children in the NT are notified every year. The rate in Indigenous children may be decreasing relative to non-Indigenous children. An effective rotavirus vaccine could prevent significant morbidity.

Rosalie Schultz MB BS, MPH

Objective: To examine trends in suicide in the Northern Territory between 1981 and 2002, and demographic and other characteristics of people completing suicide in the Top End region in 2000–2002.Design: Retrospective descriptive analysis of Australian Bureau of Statistics death registration data and data from the NT Coroner’s Office.Setting and participants: All residents of the NT who completed suicide between 1981 and 2002.Main outcome measures: Changes in the age-adjusted and age- and sex-specific rates of suicide in Indigenous and non-Indigenous NT residents over time; prior diagnosis of mental illness and use of alcohol or other drugs by those completing suicide.Results: The age-adjusted suicide rate in the NT increased significantly between 1981 and 2002 (P < 0.001). Over this period, the rates among the Indigenous and non-Indigenous male populations increased by 800% (P < 0.05) and 30% (P > 0.05), respectively. Indigenous males aged under 45 years and non-Indigenous males aged 65 years and over were most at risk. In the Top End, a history of diagnosed mental illness was present in 49% of suicide cases, and misuse of alcohol or other drugs around the time of death was associated with 72% of suicide cases.Conclusion: Our study highlights the rising rate of suicide in the NT and suggests that suicide prevention initiatives need to specifically target Indigenous and non-Indigenous males in the age groups most at risk.

Mary-Anne L Measey MPH · Shu Qin Li MPH · Robert Parker FRANZCP · Zhiqiang Wang PhD

BCG vaccination is no longer routinely offered to all medical students in Victoria. Practices in Australia’s 15 medical schools vary widely with respect to BCG vaccination and surveillance for tuberculosis (TB) infection during the medical course. Health care workers can be exposed to TB in Australian hospitals, but the risk is much higher if they undertake work in countries with a high prevalence of TB, such as during student electives. BCG vaccination is safe, cheap and protects 50% or more of recipients from active TB, including multidrug-resistant TB. Protection is long-lasting, requires only a single dose, and there is new evidence that BCG may prevent primary infections, not just active disease. Although BCG vaccination interferes with the interpretation of the tuberculin skin test (TST), newer tests (QuantiFERON-TB Gold, T-SPOT.TB) are unaffected by BCG vaccination. We propose a standard approach for all Australian medical students that includes screening with TST and QuantiFERON-TB Gold/T-SPOT.TB at course entry, and recommending BCG vaccination for students who test negative, provided they have not previously received BCG vaccine.

Maryza Graham MB BS · Tanya M Howley MB BS · Robert J Pierce MD, FRACP, FCCP · Paul D Johnson PhD, FRACP

The recent viewpoint by Kamien1 is timely, given Food Standards Australia New Zealand is currently advocating for the mandatory fortification of all bread-making flour with folic acid (80–180 μg per 100 g of bread). The proposal is now before the Australia and New Zealand Food Regulation Ministerial Council, and a decision is imminent. In 1991, the Medical Research Council Vitamin Study Research Group reported a randomised double-blind trial conducted at 33 centres in seven countries. Periconceptual folic acid supplementation had a 72% protective effect against neural tube defects (relative risk, 0.28; 95% CI, 0.12–0.71).2 Because folic acid supplementation is ineffective when started after the pregnancy is confirmed, fortification of staple foods such as bread remains best practice. The United States started mandatory fortification of enriched cereal-grain products a decade ago. As expected, there has been an increase in the population geometric mean concentrations of serum folate and red blood cell folate,3 and a corresponding reduction in the number of babies born with debilitating neural tube defects.4 The benefits are clear and the risks are vague. Historical concerns that folic acid supplementation could mask pernicious anaemia and cause cancer have not been substantiated by international experience in more than 50 countries. Australian health professionals have a brief window of opportunity to join Maberly and Stanley5 and advocate for mandatory fortification in spite of commercial objections, which are based on market-share concerns for existing “designer” products. If we educate and inform our patients and the community at large, the decisionmakers should finally get the message and this cheap, safe and effective public health policy would be implemented — a decade overdue.

Hasantha Gunasekera

Many disparate groups in Australia now concur about the need for continuous food and nutrition monitoring Poor nutrition contributes to Australia’s current health problems in several ways. Heart disease and cancer, both strongly related to nutrition, remain the leading causes of death. At the same time, the prevalence of obesity and diabetes is alarmingly high, and deficiencies of vitamin D, iodine, and calcium are re-emerging. As a consequence, policymakers, food regulators and health professionals need up-to-date and specific information about what people are eating and how much they are eating. They need to know the health and nutritional status of the Australian population. They also need to know how supplies of food and food consumption patterns are changing over time, and what food products contain. In turn, consumer education policies and tools, such as population dietary guidelines and food selection guides, need to be built on a solid foundation of knowledge about the national nutrition profile to reduce the risk of serious nutrition-related diseases and conditions. Food safety regulators also need this information to estimate current exposure to bioactive compounds that may be of concern, such as food additives and contaminants, to inform food fortification policies, and to ensure that nutrition information on food labels is relevant to current consumption patterns. Yet, Australia is unusual among its peers for not having continuous nutrition intelligence. Health-related data about Australians are compiled biannually, but current information about food and nutrient consumption, and trends in these, is conspicuous by its absence.1 The United States, the United Kingdom, and many European nations have had ongoing, systematic programs for monitoring the diet and nutritional status of their populations for many years.2-4 These programs are not confined to large countries with big budgets. For example, in 2001, New Zealand embarked on a 10-year strategic plan for a coordinated national population survey program that includes nutrition surveys in adults and another in children every 10 years, with the next surveys of adults and of children due in 2007–08, and 2012, respectively.5 In contrast, Australia has conducted only three national surveys of diet in the past 50 years: a national dietary survey of adults in 1983, and of children in 1985, and the National Nutrition Survey in 1995, which included both adults and children.6-8 Each cross-sectional survey was conducted by a different agency, using different sampling and collection methods and food composition data. These differences limit our ability to describe trends in food and nutrient consumption.9 Several state and territory governments in Australia have established monitoring systems that survey health behaviours, including food habits.10 These systems provide important information for tracking change, but food production, retailing and consumption are not limited by state boundaries, and information about selected food habits is not a sufficient base on which to build nutrition and food regulatory policy. Those with commercial as well as health interests in nutrition surveillance now favour a new national effort — one that goes beyond the brief encounters of cross-sectional surveys — to provide continuous detailed information on trends in food and nutrient consumption, the food supply and the nutritional status of Australians. Continuous nutritional surveillance must form part of a comprehensive policy to combat nutritional disorders. Where such surveillance exists, such as in the US, the data have been used to evaluate dietary guidelines, revise food selection guides,11 develop and evaluate fortification programs, set “real-life” serving sizes for nutrition information panels on food labels, make decisions about specific food processing regulations, and model the impacts of bioterrorism threats from food contamination.2 The centrepiece of the US system is the continuing National Health and Nutrition Examination Survey (NHANES), which is supplemented by many other sources of data.12 International experience suggests that there are two important actions for Australia to take in developing a food and nutrition monitoring system: 1. Establish a small, affordable, but statistically robust ongoing nutrition survey program, with data collected from a sample each year and reported cumulatively over a number of years. This program should be based within a federal agency that has health information responsibilities, uses consistent methods, can document and maintain databases, and reports on a predictable and timely basis. 2. Create a small nutrition monitoring unit to compile, disseminate and promote the use of all appropriate information about the food and nutrition situation in Australia for various policy, program, and regulatory purposes. The Australian Government Department of Health and Ageing recently commissioned the preparation of a business case for a no-frills national nutrition surveillance system in Australia, and consulted widely with stakeholders on its importance and suitability.13 Many disparate groups in Australia — in food production, marketing, regulation, and consumer health — now concur about the need for continuous food and nutrition monitoring, as well as the imperative to find workable solutions to long-term funding needs. While a national cross-sectional nutrition survey of children is currently being planned, its value would be greater if it were the start of a continuing surveillance program. In this regard, the recent announcement by the Minister for Health and Ageing of $3 million initially for a survey of diet, physical activity, and the weight status of Australian children, and $1 million annually thereafter for the collection of similar data on all population groups in Australia, is welcome, especially if it evokes a matching response from other key data users, including the states and territories.14 This may be the politically propitious moment for a long-term commitment to a system of continuous monitoring of food and nutrition in Australia.

Karen L Webb PhD, MPH · Ingrid H Rutishauser MSc · Geoffrey C Marks PhD, MS, DipNutrDiet · Gregory Masters MSc · Stephen R Leeder PhD, FRACP

Vitamin D deficiency has re-emerged as a significant paediatric health issue, with complications including hypocalcaemic seizures, rickets, limb pain and fracture. A major risk factor for infants is maternal vitamin D deficiency. For older infants and children, risk factors include dark skin colour, cultural practices, prolonged breastfeeding, restricted sun exposure and certain medical conditions. To prevent vitamin D deficiency in infants, pregnant women, especially those who are dark-skinned or veiled, should be screened and treated for vitamin D deficiency, and breastfed infants of dark-skinned or veiled women should be supplemented with vitamin D for the first 12 months of life. Regular sunlight exposure can prevent vitamin D deficiency, but the safe exposure time for children is unknown. To prevent vitamin D deficiency, at-risk children should receive 400 IU vitamin D daily; if compliance is poor, an annual dose of 150 000 IU may be considered. Treatment of vitamin D deficiency involves giving ergocalciferol or cholecalciferol for 3 months (1000 IU/day if < 1 month of age; 3000 IU/day if 1–12 months of age; 5000 IU/day if > 12 months of age). High-dose bolus therapy (300 000–500 000 IU) should be considered for children over 12 months of age if compliance or absorption issues are suspected.

Craig Munns MB BS, PhD, FRACP · Margaret R Zacharin MB BS, FRACP · Christine P Rodda MB BS, PhD, FRACP · Jennifer A Batch MB BS, MD, FRACP · Ruth Morley BA, MB BChir, FRCPCH · Noel E Cranswick MB BS, BMedSc, FRACP · Maria E Craig PhD, FRACP, MMed · Wayne S Cutfield BHB, MB ChB, MD · Paul L Hofman MB ChB, FRACP · Barry J Taylor MB ChB, FRACP · Sonia R Grover MB BS, FRACOG · Julie A Pasco BSc(Hons), PhD · David Burgner MB ChB, PhD, FRACP · Christopher T Cowell MB BS, FRACP

Health professionals must create the climate to force politicians to act Australia is in the throes of an unprecedented epidemic of diabetes and obesity. The Australian Diabetes, Obesity and Lifestyle (AusDiab) study found that a million Australians are affected by diabetes, and it provided vital data on Australia’s obesity epidemic.1 Obesity is a driving force behind type 2 diabetes, which has cardiovascular and other complications, such as renal failure and blindness. The dominant effect of weight gain in precipitating glucose intolerance and its consequences suggests that reversal of the “diabesity” epidemic requires a public alert on the need to limit weight gain. The heightened risk of type 2 diabetes occurs at levels of abdominal or general obesity previously regarded as normal. For decades in affluent societies such as Australia, women have been obsessed with their shape and weight. They spend huge amounts of time and money desperately trying to slim, with little effect — men do no better. Meanwhile, the epidemic of both obesity and diabetes shows no sign of slowing. There is a biological component to persistence of the epidemic. The adaptation in hypothalamic control of appetite to reinforce higher food intakes and the endocrine and metabolic thermogenic adjustments with slow weight gain counteract attempts to lose weight.2 Coupled with the modern commercial drive to market unhealthy foods everywhere and seduce us into ever more sedentary leisure, this means we are facing a seemingly unstoppable juggernaut of obesity and diabetes. This epidemic is guaranteed to continue, unless we accept that the decades-long reliance on health promotion and intense media coverage of obesity have had virtually no effect. Dietary advice from doctors has induced only minimal reductions in blood pressure and cholesterol levels, and the results for weight control are probably worse.3 Meanwhile, politicians and health professionals confine themselves to promoting the value of health education. Evidence-based approaches now require us to discard our prejudices and preconceptions and consider converting policymakers and politicians. We must also recognise the influential commercial forces that contribute to an ever more obesogenic and diabetogenic environment. What, realistically, can our politicians do? Australia has a reputation for outstanding obesity research, ranging from public health and epidemiology to molecular biology. However, what is being done strategically about the problem? On the surface, Australia is making what are seen as major investments in promoting leisure time sports and other activities, especially for youth. Presumably, this is based on the recent advice that to cure the obesity problem we need only change input and output by a mere 100 kcal — which seems to be a minute change.4 This implies that all one has to do is get a pedometer to encourage walking, or eat one less slice of bread each day. Unfortunately, there is a dearth of evidence that this works. The current rates of weight gain, varying perhaps from 0.5 to 2 kg/year in the very susceptible, amount to about 10–40 kcal (ie, 0.3%–2% of energy turnover) in the average daily discrepancy between input and output. However, we need to walk briskly for 80–90 minutes daily (ie, about 350 kcal of daily effort) to maintain energy balance on current diets.5 This is a near impossible population goal for leisure time activity. Alternatively, given our current sedentary state, we would need to change to a diet of 20% fat intake with minimal sugary drinks.6 This implies that our hypothalamic regulatory system works to minimise energy imbalance, so the external environmental changes must be of a greater magnitude than the induced energy imbalance. It is ludicrous to expect the whole population — including the disadvantaged — to voluntarily become very active on an optimum diet. Thus, we need to change substantially our living conditions and environment. Our politicians need to accept that major legislative and other regulatory measures are required (see Box). We could arrest the development of obesity in children and adolescents within a year of introducing a coherent program. If the political will is there, then there is hope. The current pervasive marketing to children distorts their understanding, codifies their demands, and transforms their eating, drinking and exercise habits to generate obesity.7 Changing this requires legislative regulation of the marketing pressures (including television and other advertisements which now dominate children’s attention). Parliamentary enquiries in the United Kingdom have revealed that some food and advertising companies may be misleading consumers as blatantly as the tobacco industry did.7 Voluntary restrictions have never been shown to work. Health professionals and their peer organisations must demand that all junk foods and soft drinks be kept out of health institutions, schools and public institutions, as these products can induce as much illness as tobacco.8 They should also go public, demanding political change to transform the school environment and curriculum to improve physical and nutritional education, as well as the food and drink on the premises. In adults, the problem is greater. Nevertheless, a start could be made with statutory food labelling. Currently, labels cannot be understood by consumers nor converted into meaningful units for individuals with different energy needs. Furthermore, health claims are often misleading. Consumers’ views should dominate labelling design (eg, “traffic light” indicators of overall nutritional quality9). A universal display of nutritional health profiles of food products could dramatically change consumers’ choice. In Finland, the introduction of free vegetables and a salad bar with meals sold in canteens and restaurants was associated with a threefold increase in the population’s vegetable consumption. Standards are also needed for the nutritional content of all meals provided within the public sector. The food industry would respond rapidly to new requirements, to ensure continued sales and profits. It is natural that politicians focus on evident benefits within a short parliamentary cycle. But the result is that nothing will happen until health professionals, including the medical profession, engage politicians and media opinion leaders to create a climate that will force politicians to respond to public opinion. Targeting the protection of children’s health, presenting clear analyses of the financial cost of political inertia, and highlighting the need to resist short-term commercial interests is the way to engage high-level politicians. A great example was Tony Blair’s response within 24 hours when Jamie Oliver started soliciting potential votes unless British school dinners improved. The prevention of obesity and type 2 diabetes requires coordinated policy and legislative changes, with greater attention given to our urban environment, transportation infrastructure, and workplace opportunities for education and exercise. Governments — local, state and federal — should commit to optimising opportunities for exercise in a safe environment. A multidisciplinary, politically driven, coordinated approach in health, finance, education, sports, and agriculture can contribute to reversing the underlying causes of the diabesity epidemic. Our medical leaders must recognise their crucial role, and federal and state politicians must look beyond the next election. Is anyone in Canberra listening? Regulatory measures needed to prevent diabesity in Australia Ban all marketing of food to children, including television advertisements. Establish strict food and physical activity requirements for schools. Remove junk foods and drinks from all publicly funded premises. Require “traffic light” food labelling (based on nutritional profiling) on all foods, drinks and meals, wherever sold. Adjust fiscal policies to progressively change the relative prices of foods and drinks high in fat or sugar in favour of vegetables and fruit. Specify urban environmental requirements favouring pedestrians and cyclists.

Paul Z Zimmet AO, FRACP, FRCP(London), FTSE · W Philip T James MD, DSc

Australian doctors have a particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions Most people in the scientific community believe that global warming is occurring, and that it will cause dramatic changes in climate patterns, with potentially serious effects on human health in the form of widespread epidemics, trauma, malnutrition and, in vulnerable areas, famine.1,2 The special danger to children has been stressed.3 Recent observations on the shrinking Antarctic ice mass suggest that the pace of these changes far exceeds that previously predicted.4 There is now little contention that global warming is largely the result of carbon dioxide and other greenhouse gas emissions resulting from human energy consumption,2 and that these effects are just within reach of reversal only if worldwide emissions are rapidly stabilised. Medical debate about global warming has so far emphasised planning and response.2,5 It is therefore timely that we draw a parallel to medical involvement in the nuclear weapons disarmament movement in the 1980s. At that time, it rapidly became clear to physicians that civil defence planning for a medical response to nuclear weapons attack was not only futile, but dangerously counter-productive because it fostered a false community belief in a medical fix, thereby reducing the political incentive for preventive action. A remarkably unified international medical response helped turn political attention to prevention of accidental or intentional use of nuclear weapons through political initiatives. Economic factors may have ultimately secured the end of the Cold War, and nuclear weapons have not disappeared. However, the influence of the Nobel Peace Prize-winning organisation, International Physicians for Prevention of Nuclear War, was significant in the withdrawal from the brink of catastrophe, particularly because its protagonists had the ear of both United States and Soviet leaders.6 Doctors now have a similar particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions. Firstly, we can point to the futility of expending our energy, enterprise and long-term investment in advancing health care in the absence of action to preserve a liveable planet. Secondly, we can measure and communicate the effects of the threat of global environmental destruction on the current mental health of our children. At the height of the Cold War, when nuclear war appeared imminent, through accident or pre-emptive strike, school children reacted with despair and loss of motivation.7,8 Many children thought they would not survive to adulthood. We can actively contribute to the debate on global warming by providing good data on this specific issue, but the nuclear weapons experience suggests that our children and grandchildren will react to expanding knowledge of climate change with despair. Thirdly, we are in a strong position to draw attention to the psychology of denial, despondency and paralysing helplessness that characterises human response to the threat of overwhelming catastrophe.9 We can help professionally in the educated and rational process of action that can reverse this paralysis, pointing to the astounding historical successes that can result when an active community converts hopelessness into anger and political action. The abolition of slavery and the end of apartheid are just two examples. In each case, the central humanitarian principles that underpin medicine were guiding principles for those who went into the battle for change, in both cases against seemingly insurmountable economic odds. Australian doctors have a special responsibility because of the influence of Australia in Asian, American and European discussions on reducing green house gas emissions. We can inform the debate with reliable data on the mental and physical health consequences of global warming, and use our professional voice and leadership to instil it with urgency.

Richard F Kefford MB BS, FRACP, PhD

Objective: To examine the conditions leading to sideswipe injury of the upper limb in motor vehicle accidents and to highlight the severity of these injuries.Design and setting: Prospective study of upper-limb sideswipe injuries in patients admitted to Royal Perth Hospital, Western Australia, between August 2003 and January 2005.Participants: Eleven patients sustaining sideswipe injuries to the upper limb.Main outcome measures: Accident pattern, type of injury, surgical management, complications, and functional and employment implications.Results: Ten patients required open reduction and internal fixation for open fractures of the humerus, ulna and radius, and nine underwent additional surgical procedures including nerve, artery and tendon repair, and free flaps and split-skin grafting. The injury severity scores ranged from 9 to 25. The severity of injuries led to extensive functional deficits in eight patients, affecting employment prospects in seven.Conclusion: Appropriate educational programs, legislation and improvements in traffic conditions, especially in rural areas, as well as changes in current car design, could contribute to preventing these devastating and complex injuries.

Vera Kinzel PhD, MD, AFRCS · Allan P Skirving MB BS, FRCS · Michael N Wren MB BS, FRACS · Rene Zellweger MD, PhD

To the Editor: Leprosy rates in Australia are low (less than one case per million population)1 and predominantly occur in Indigenous Australians and immigrants from leprosy-endemic areas.2 A 21-year-old pregnant Burundian woman had migrated to Australia in 2005 from a refugee camp in Tanzania. In the year before her arrival, she had received intermittent courses of steroids for an undefined illness characterised by fever, nightsweats and painful symmetrical peripheral polyarthritis. Three months after arriving in Australia, the patient presented to a rural hospital with a recurrence of the previous symptoms. The symptoms improved on recommencement of prednisolone treatment. The patient was transferred to the Royal North Shore Hospital, where examination revealed bilateral peripheral sensory neuropathy (confirmed by nerve conduction studies); bilateral, enlarged, tender ulnar nerves; and tender hyperpigmented 2–3 cm nodules on the upper arms, but no other skin lesions or infiltrations. Skin biopsy revealed features consistent with erythema nodosum leprosum (ENL), but no acid-fast bacilli (AFB) were detected. Slit-skin smears were also negative for AFB. Leprosy was confirmed by histopathological examination of a sural nerve biopsy, which showed AFB and granulomatous changes of leprosy. The patient commenced multidrug therapy for multibacillary leprosy, with prednisolone for ENL. Leprosy is a chronic granulomatous infection of skin and peripheral nerves with Mycobacterium leprae. Host immune responses determine the spectrum of clinical presentations. Leprosy is classified into either multibacillary disease (≥ 6 skin lesions and/or skin smears positive for AFB) or paucibacillary disease (< 6 skin lesions, with no bacilli on skin smears).3 Type 1 (reversal) reactions are delayed-type hypersensitivity reactions and manifest as neuritis and increased inflammation of pre-existing skin lesions. Type 2 reactions (ENL) are a systemic response to immune complex deposition and manifest with multiple tender nodules, fevers, neuritis, arthritis and iritis.4,5 ENL occurs exclusively in multibacillary disease in 10%–20% of patients, and negative slit-skin smears (as in our patient) are unusual. Possible explanations include undisclosed diagnosis and treatment of leprosy in Tanzania or the combination of steroid therapy and immune changes that occur during pregnancy.6 Multidrug therapy is well established and regarded as safe for pregnant women. Diagnosis of infections that are uncommon in Western countries, especially leprosy, is often delayed.7 For refugees living in remote areas, access to expertise and support may be limited. Therefore, doctors, especially those involved in refugee health, should be aware of “exotic” infections and their varied presentations. Furthermore, effective referral networks should be encouraged, as this resulted in a swift positive outcome in our case.

Sebastiaan J van Hal MB ChB · Bernard J Hudson FRACP, FRCPA

To the Editor: We were pleased to read Turnbull and Parisi’s short piece on the effectiveness of shade structures, highlighting the challenges of ensuring adequate and effective shade protection, particularly in children’s settings.1 Cancer councils in various states have long recognised these challenges and provided assistance to those who design or manage facilities for children, in the form of training workshops, resources and guidelines. Epidemiological evidence indicates that childhood exposure to ultraviolet (UV) radiation is a strong determinant of risk of melanoma but there is also evidence of its contribution to the development of non-melanocytic skin cancer.2,3 It is estimated that living in Australia for the first 15 years of life contributes about two-thirds of the lifetime risk of melanoma of a lifelong resident.4 Sun exposure in childhood, especially that leading to sunburn, is the main environmental determinant of the number of melanocytic naevi. An individual’s number of naevi is the strongest measurable predictor (after age and ethnicity) of risk of melanoma.5 Our publication, Under Cover, referred to by Turnbull and Parisi, is one such resource, developed as a comprehensive reference tool for anyone involved in shade planning and design in New South Wales and has been adapted for use in other states by state cancer councils.6 Turnbull and Parisi comment that Under Cover provides inappropriate advice regarding the use of deciduous trees, as solar UV radiation levels can be hazardous during winter in subtropical Queensland. As might be expected, the NSW edition of Under Cover does not address winter solar protection issues in northern Queensland. We note that the “requirements for effective shade” cited by Turnbull and Parisi are identical to those prescribed in Under Cover. For those interested in determining when UV protection is required throughout the year in different locations, an interactive shade planning software program will be available shortly at <www.webshade.com.au>. In it, ShadeCalendar recommends what type of shade would be most appropriate for comfort and solar protection in different months of the year. The Bureau of Meteorology now issues the SunSmart UV Alert when the UV Index is forecast to reach 3 or above, highlighting when sun protection is required (www.bom.gov.au/products/uvindex_national.shtml). The SunSmart UV Alert is reported in most newspaper, television and radio weather forecasts across Australia. Shade is only one of a range of sun protection strategies recommended by the Cancer Council. With Australia having the highest skin cancer rates in the world, general practitioners play a pivotal role in providing sun protection counselling advice to parents of children aged 1–13 years.7 The Cancer Council NSW recommends a range of sun protection measures including UV avoidance during the peak UV times (10:00–14:00 or 11:00–15:00 during daylight saving time), shade, clothing, hats, sunglasses and use of sun protection factor 30+ broad spectrum, water resistant sunscreen.

Kay R Coppa MPH · John S Greenwood

Objective: To assess maternal concern about overweight in Australian preschool-aged children and factors predicting maternal concern about children’s current and future weight status.Design: Cross-sectional survey of child’s body mass index and parent questionnaire. Setting: Participants: A community-based cohort of 324 4-year-old children and their parents.Main outcome measures: Mothers’ reports of concern about the child’s current and future weight status, and perceptions of the child’s weight, diet and activity relative to their peers were compared with the child’s measured weight status, and parent and child characteristics.Results: The prevalence of overweight or obesity was 19%, but only 5% of mothers indicated concern about their child being currently overweight, while 16% worried their child would become overweight. Over 70% of mothers of overweight children saw them as being of similar weight to their peers. Most mothers saw their children as being equally or more active than other children and having a diet at least as healthy as their peers. Overweight daughters were more likely to elicit maternal concern about current weight than overweight sons (relative risk, 4.6; 95% CI, 1.1–19.8). Mothers were more likely to worry about their child’s potential for future overweight if they or the child’s father were overweight.Conclusions: Despite mounting public concern about childhood obesity in Australia, most mothers surveyed were not concerned about their child’s weight, and many mothers did not perceive their overweight children as different from their peers. This may have implications for interventions that rely on acknowledgement of child overweight as a first step to change.

Michele W-C Campbell FRACP · Joanne Williams PhD · Anne Hampton BSc, PGradDipPsych · Melissa Wake FRACP, MD