Environmental health

A program for routine health surveillance on international cruise ships visiting the Port of Sydney has been developed since 1998. Before introduction of this program, ships only reported quarantinable diseases and were not aware of the Australian requirement to report other infectious diseases. Voluntary routine reporting, developed in partnership with the cruise ship industry, provides timely information on all infectious diseases of public health interest during every cruise. During 1999–2003, the program resulted in detection of and response to 14 outbreaks of gastroenteritis or acute respiratory infection, affecting more than 1400 passengers and crew. The program has improved preventive action, and risk communication and management by cruise ship operators, and led to more timely investigation and support by public health authorities.

Mark J Ferson MD, FRACP, FAFPHM · Kelly-Anne Ressler BSc(Nutr), MPH

Environmental strategies must be complemented by behavioural approaches to help children learn to use roads safely In Australia, pedestrian injury is the leading cause of death among 1–14-year-olds.1 In 2000, 38 child pedestrians in this age group died2 and about 1140 (29 per 100 000) were hospitalised, often with lengthy stays, because of injuries sustained when hit by a vehicle.1 These rates decrease with age and are lowest for 10–14-year-olds.1 The most recent comparison with other OECD countries shows that Australia has the 13th lowest pedestrian fatality rate for 0–14-year-olds,3 with slightly more pedestrian deaths among 0–5-year-olds than the median rate for all OECD nations (1.03 per 100 000 versus 0.89 per 100 000).4 The primary predictors of this child pedestrian trauma relate to the interaction between the characteristics of the child and the design and nature of the road environment to which the child is exposed. A Western Australian case–control study of child pedestrians aged 1–14 years identified four key environmental and behavioural factors that independently predicted the likelihood of child pedestrian injury.5 These comprised the volume of traffic encountered by the child, presence of visual obstructions, availability of footpaths on the child’s street of residence, and the child’s behaviour. Predictors also vary according to the age of the child. Whereas 1–2-year-olds are more likely to be hit by a reversing vehicle, the most common cause of pedestrian trauma in 3–9-year-olds is mid-block “dart-out” (entering the road between intersections and not seeing, or misjudging, a gap in traffic).6,7 Pedestrians aged under 10 years are particularly vulnerable because of their small physical size and underdeveloped abilities for dealing with traffic situations, both cognitive (attention focus, interpreting traffic signs) and perceptual (locating sounds, judging speed, peripheral vision).6 Given these limitations, children under the age of 10 do not have the ability to cross roads without adult help. Ten to 14-year-olds are also vulnerable, but more because of their failure to apply safe pedestrian skills than because of their lack of skills. Further, road trauma in this age group may also be associated with general delinquency and problem behaviour.8 Many of these predictors of pedestrian trauma can be prevented or modified and are therefore amenable to intervention.7 While debate continues about the merits of environmental (passive) versus behavioural (active) intervention strategies to reduce this road trauma, evidence suggests that all are necessary, and no single strategy is sufficient.6 A multifaceted approach that combines strategies targeting the behaviour of all road users (including education, training and publicity), the road environment and vehicle design have been found to be the most effective.3 Strategic approaches involving public health, education, health promotion, urban planning, engineering and motor vehicle design are required. Consequently, while efforts are needed to make the road environment safer for pedestrians by reducing the speed and volume of traffic to which they are exposed, it is also necessary for pedestrians (particularly children) to learn how to use these road environments safely. Yet research into behavioural approaches to pedestrian safety has lagged behind environmental research.9 Behavioural programs for children need to be developmentally appropriate and include modelling and training by an adult in a social context and road environments relevant to the child. Programs also need to be interactive and involve problem-solving with consistent and prompt feedback from a caring adult, rather than merely following rules.10 The use of didactic knowledge-only strategies (such as rote learning of rules) is inappropriate, as younger children are not able to generalise this learning to real roads.11 Roadside training and, to a lesser extent, realistic simulations appear to improve visual timing and gap selection, to increase the ability to identify safe and dangerous crossing locations, and to enhance learning of appropriate strategies for crossing at parked cars. Such training has produced positive results with children as young as 5 years.12,13 Several new approaches to children’s pedestrian safety education are being tested. These include programs targeting younger children and adults who care for children, and use of new technologies. Two Australian reviews recommend targeting 0–5-year-olds, arguing that, with good quality pedestrian safety training, young children could demonstrate a rudimentary conception of danger, which improves with age.14,15 Some Australian jurisdictions have developed curricula and materials based on these approaches, such as the Victorian “Starting Out Safely” program. Engaging parents and helping them recognise their important role in their children’s pedestrian safety has the potential to significantly enhance children’s safety on and near roads.14 Parents provide the best role models and one of the only means for children to receive the necessary personalised one-on-one training and to practise crossing real roads. Technologies that use interactive simulations (eg, visual reality computer) coupled with real road experience and “pretend” road practice (the “pretend” road is set up parallel to a real one) can enable children to practise their skills, receive consistent and instant feedback and repetition, and be introduced with careful control to the complexity of traffic.16 While reviews of the impact of behavioural and environmental programs on preventing road trauma in children have demonstrated mixed success, it is apparent that programs need to take a comprehensive preventive approach with modifications to the road environment, enforcement, engineering and education. While much still needs to be done to determine the optimal mix and “dose” of these approaches to reduce child pedestrian trauma, every effort must be made to keep children safe near traffic and roadways that are becoming increasingly busy and complex.

Donna S Cross EdD · Margaret R Hall PhD

To the Editor: When discussing causes of childhood leukaemia, Ziegler et al stated, “Exposure to electromagnetic fields has been ruled out as playing any significant role”. 1 They cited one large study2 in support of this statement, but overlooked two independent pooled analyses that showed the opposite. Greenland et al analysed 12 studies involving 2656 patients and 7084 controls, 3 and Ahlbom et al analysed nine studies involving 3247 patients and 10 400 controls.4 Each analysis found an association with a doubling of risk of childhood leukaemia at levels of household exposure at and over 0.4 microtesla (4 milligauss). Confounders and sources of bias to explain these findings have been sought without success. Consequently, in 2002, the International Agency for Research on Cancer classified 50 and 60 Hz magnetic fields as a “possible carcinogen” (Group 2b)5 even though the mechanism of an effect is not clear. The role of magnetic fields in childhood leukaemia cannot be “ruled out”, given the substantial epidemiological evidence, the international classification of magnetic fields as a possible carcinogen, and the subtlety of gene–environment interactions. Moreover, although exposures to magnetic fields are low within most households, there is opportunity to easily prevent or treat the uncommon situations where household exposures exceed 0.4 microtesla by means of electrical engineering, household wiring and town planning.

Bruce Hocking

In reply: Hocking states that electromagnetic fields cannot be ruled out as a cause of childhood leukaemia. However, several large studies have all failed to find any association between childhood exposure to electromagnetic radiation and leukaemia.1-4 The two pooled meta-analyses Hocking refers to both found no increased incidence of leukaemia with exposure to electromagnetic fields of < 0.4 microtesla.5,6 Although there was an increased risk of leukaemia with exposure to ≥ 0.4 microtesla, 99.2% of children with leukaemia had not received such a high level of exposure. 5 In addition, both studies acknowledged the potential for selection bias. As such, for the overwhelming majority of children with leukaemia, exposure to electromagnetic fields does not play any significant causative role. Although we agree its effect cannot be ruled out for the remaining < 1% of patients, it should not be given undue epidemiological weight.

David S Ziegler · Luciano Dalla Pozza · Keith D Waters · Glenn M Marshall

The annual death toll from tuberculosis in the Indian Ocean region is 2–3 times higher than the toll from the recent tsunami A major earthquake measuring 8.9 on the Richter scale occurred off the west coast of Sumatra on 26 December 2004. 1 The quake even caused the earth to wobble in orbit. 2 The ensuing tsunami hit countries bordering the Indian Ocean. The estimated death toll exceeds 220 000. 1 The human and economic tragedy was evident to all, and national governments and international organisations have mounted an enormous relief effort. Coincidentally, seven of the tsunami-affected countries (India, Indonesia, Thailand, Bangladesh, Burma–Myanmar, Tanzania and Kenya) are among the 22 nations with the highest burdens of tuberculosis (TB). 3 Over three million new TB cases and 772 000 TB deaths occurred in these seven countries in the year 2000. 3 Similar annual statistics have been reported from these and other high-burden countries for more than 10 years. But the earth does not move! The human and economic toll is not appreciated, and an enormous global response is not mounted. The global TB situation is full of such paradoxes. It also highlights the global inequities in the distribution of healthcare services and other resources. 4 An estimated 8.3 million new TB cases and nearly 2 million TB deaths occurred worldwide in 2000. 3 Ninety-five percent of the TB cases and 98% of the deaths were in low-income countries. 4 Importantly, from Australia’s perspective, 60% of this global TB burden occurred in our neighbouring countries in South East Asia and the Western Pacific. 3 What is happening in low-income countries? In Africa, 38% of new adult TB cases in 2000 were in people who were HIV-positive. 4 HIV infection increases an individual’s susceptibility to infection and disease progression, and the increased burden of HIV-associated cases may increase TB transmission to those who are HIV-negative. HIV-related TB has swamped TB-control efforts in Africa, where case numbers increased 6.4% between 1997 and 2000. 3 Multidrug-resistant tuberculosis (MDR-TB), defined as Mycobacterium tuberculosis strains with resistance to at least isoniazid and rifampicin, is also perceived as a great threat to TB control. However, only an estimated 273 000 (3.2%) of new TB cases worldwide were multidrug resistant in 2000. 5 Mathematical modelling and other observations based on imperfect data suggest that MDR-TB strains are generally of lower reproductive fitness, and that MDR-TB will remain localised in foci such as the former Soviet Union. 5 Effective TB control in these MDR-TB-endemic foci may require additional measures, such as wider availability of drug-susceptibility testing and the use of second-line drugs under close expert supervision. 5 More mundane factors than MDR-TB are the real confounders of TB control in low-income countries. These factors include inadequate infrastructure (eg, roads, transport, electricity), weak primary healthcare systems, poor laboratory services, and insufficient engagement of private practitioners and other health providers in TB control. 6 A major impediment to TB control that must be highlighted is the lack of trained staff, particularly in HIV-endemic countries, where the epidemic has decimated the healthcare workforce. 6 What can be done in low-income countries? Effective TB control relies on halting transmission through the rapid detection and cure of infectious cases. International targets have been set to detect at least 70% of all new infectious cases and to cure at least 85% of those detected by 2005. 6 Attainment of these goals would result in a decline in TB incidence of 6%–7% per year. The World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease have recommended and validated a policy package entitled DOTS to achieve these case detection and cure rates. The DOTS strategy contains five elements: government commitment, accurate diagnosis principally by sputum-smear microscopy, standardised short-course chemotherapy with direct observation of treatment, provision of reliable drug supplies, and systematic program monitoring. 6 Unfortunately, the WHO annual TB reports to 2003 suggest that the global targets for case detection and cure rates may not be met by 2005. Additional initiatives have been recommended, including increasing government stewardship of TB-control programs, engagement of private health practitioners in DOTS programs, and involvement of local community groups. 6 Tuberculosis and HIV-control programs in Africa and other HIV-prevalent areas must also be coordinated and integrated to achieve enhanced TB and HIV case-finding, to institute TB preventive treatment, and to establish interventions against HIV, such as antiretroviral treatment (which will also indirectly control TB). 6 High-income countries with a low incidence of TB, such as Australia, confront different challenges.7 The incidence of TB in Australia was 4.9 cases per 100 000 population in 2003, which is one of the lowest rates globally, and this incidence has remained stable since the mid-1980s.8 However, people born overseas and Indigenous Australians remain at increased risk of TB (with 9.9 and 8.5 cases per 100 000 population, respectively).8 Maintaining awareness about TB among the medical profession and governments is difficult when the overall TB incidence is so low.7 Undergraduate and postgraduate education programs must ensure that clinicians consider TB, particularly in patients from at-risk subgroups.7 Governments must continue funding specialist TB treatment services (including specially trained staff and reliable drug supplies).7 The TB services themselves must realign policies and procedures towards TB elimination, and consider innovative measures for controlling TB in the subgroups who remain at increased risk of TB.7 The National Tuberculosis Advisory Committee has addressed these issues and published a strategic plan that includes performance indicators for evaluating our national TB-control efforts.9 World TB Day on 24 March is a reminder to Australian doctors that TB is not a vanishing disease. Rather, a “tsunami of TB” occurs every year overseas. What can we do? At the clinical level, Australian doctors must “think TB” when seeing patients, particularly those from subgroups at risk of TB. Australia has laboratory and clinical expertise in TB which is being shared increasingly with our neighbouring countries. Finally, we must advocate for the Australian and other governments to provide funds for TB-control programs in our neighbouring countries, as has happened for the tsunami relief effort. Australia must do so for humanitarian reasons and for self-interest.

Ivan Bastian PhD, FRCPA

Objective: To investigate whether Indigenous Australians with cancer have more advanced disease at diagnosis than other Australians, and whether late diagnosis explains lower Indigenous cancer survival rates.Design: Retrospective cohort study.Setting and participants: Indigenous and non-Indigenous people diagnosed with cancers of the colon and rectum, lung, breast or cervix and non-Hodgkin lymphoma in the Northern Territory of Australia in 1991–2000.Main outcome measures: SEER summary stage of cancer at diagnosis (local, regional or distant spread), cause-specific cancer survival rates and relative risk of cancer death.Results: Diagnosis with advanced disease (regional or distant spread) was more common for Indigenous people (70%; 95% CI, 62%–78%) than for non-Indigenous people (51%; 95% CI, 53%–59%) with cancers of the colon and rectum, breast, cervix and non-Hodgkin lymphoma, but for lung cancer the opposite was found (Indigenous, 56% [95% CI, 46%–65%] v non-Indigenous, 69% [95% CI, 64%–75%]). Stage-adjusted survival rates were lower for Indigenous people for each cancer site. With few exceptions, the relative risk of cancer death was higher for Indigenous people for each category of stage at diagnosis for each cancer site.Conclusions: Health services apparently could, and should, be performing better for Indigenous people with cancer in the Northern Territory, and probably elsewhere in Australia. This study has demonstrated that data from cancer registers, enhanced with data on stage at diagnosis, can be used to monitor health service performance for Indigenous Australians in the Northern Territory; similar data is available in other States, and could be used to monitor health service performance for Indigenous people throughout Australia.

John R Condon MPH, FAFPHM · Tony Barnes MSc · Bruce K Armstrong DPhil · Sid Selva-Nayagam FRACP · J Mark Elwood MD

Objective: To assess changes in and factors associated with recent malaria notifications in Western Australia (WA).Design: Retrospective analysis of the WA Notifiable Infectious Diseases Database and enhanced surveillance questionnaires completed by attending medical practitioners.Patients: Cases of malaria notified between January 1990 and December 2001.Main outcome measures: Annual notifications by demographic variables (including age, sex, occupation and place of residence), region/country of acquisition, chemoprophylaxis used, Plasmodium species and outcome.Results: 482 patients were notified (mean age, 31 years; 80% male); 57% lived in Perth, 31% in country areas and 12% in an immigration detention centre. Comparison between the 6-year periods 1990–1995 and 1996–2001 showed that Plasmodium falciparum cases increased from 29 (14%) to 108 (44%; P < 0.001), while Plasmodium vivax cases decreased from 157 (77%) to 122 (50%; P < 0.001); immigrants in detention, defence force personnel and cases from Africa were increasingly represented (P < 0.05 in each case). Only 31% of patients took regular chemoprophylaxis and, among these, the regimen was appropriate in only a quarter. There was a median period of 3 days between symptom onset and diagnosis. One patient died.Conclusions: There has been an increase in P. falciparum cases in WA since 1990. This reflects the influx of immigrants in detention, deployment of military personnel to East Timor and increasing numbers of cases from Africa. A significant number of Australian travellers who developed malaria had not taken chemoprophylaxis either regularly or at all, and, of those who had, the regimen was inadequate in most.

Donnetta M Charles MB BS · Julie Hart MB BS · Wendy A Davis MPH, PhD · Timothy M E Davis DPhil, FRACP · Eleanor Sullivan MPH · Gary K Dowse FAFPHM, MSc

We need restrictions on night driving and peer passenger numbers for novice drivers Road trauma remains one of the leading causes of death for young Australians.1 Of particular concern is the fact that more than a quarter of all fatal road injuries (27%) and hospitalisations (26%) are in the age group 17 to 25 years,2 and yet this age group comprises only 15% of licensed drivers.3 As well, despite continued funding and the implementation of effective road safety strategies, road fatalities in this age group have remained relatively constant since 1998. To achieve the national road safety strategy target of reducing the population-based road fatality rate by 40% (from 9.3 to 5.6 per 100 000) by 2010,4 various road safety strategies must receive priority. These include greater investment in the road infrastructure and adoption of further standards for motor vehicle safety, as well as enhancements to existing programs such as speed management and random breath testing. Importantly, implementation of promising new road safety initiatives that target the over-representation of newly licensed young drivers in the road crash statistics is necessary. Newly licensed or novice drivers are at increased risk of crashing, especially in the first months of licensing, with a recent study finding 14% of young drivers crash within the first 12 months of driving.5 The risk remains whether the drivers are licensed at 16 years of age (as in many states of the United States6) or at age 17 or 18 years (as in Australia7). The disproportionately high number of newly licensed drivers in the crash statistics has been attributed to factors such as inexperience, an inability to identify hazards, night-time driving, carrying same-age or peer passengers, and risky driving behaviour such as speeding.8,9 A response that has achieved some success in reducing the disproportionate number of crashes of young drivers has been the introduction of graduated licensing systems throughout Australia. The aim of graduated licensing systems is to moderate the effect of risk taking and inexperience, and thereby reduce a young driver’s risk of crashing and the concomitant risk of trauma to the passengers of young drivers and associated third parties. Graduated licensing can be described as a process whereby novice drivers begin their driving careers with significant restrictions, which are removed in stages depending on driving experience or successful test results. An elementary graduated licensing system exists in all Australian states and territories — Learner drivers are required to drive only under the supervision of an experienced driver, and Probationary/Provisional drivers have significant restrictions placed on blood alcohol content and, in some states, maximum speed. Integral to the effectiveness of the graduated licensing system is late night driving and peer passenger restrictions during the early probationary period of licensing. To date, no Australian jurisdiction has incorporated these restrictions into the system, although, in the first half of 2005, NSW will introduce passenger restrictions for provisional drivers who have previously lost their licence.10 Graduated licensing systems that include the three stages and the late night and peer passenger restrictions have shown significant reductions in fatal and injurious crashes involving young drivers. In New Zealand, where the licensing system has included these restrictions, reductions of between 7% and 23% in serious injury have been observed.11 Importantly, evaluations of graduated licensing systems that include late night driving restrictions have shown crash reductions of up to 60% during the late night hours.6 Discussions surrounding whether late night and peer passenger restrictions should be introduced in Australia have met with a number of objections: law enforcement officials perceive the restrictions would be difficult to enforce; politicians perceive a potential backlash from constituents; and young drivers (particularly rural drivers) believe the restrictions would place an undue burden on them given the absence of alternative transport. Despite these concerns, studies in countries that have implemented the restrictions have reported overwhelming support. For example, enforcement appears not to be onerous, as many parents play a significant role in policing the restrictions.12 With reductions in road trauma due, in part, to the comprehensive graduated licensing system, politicians in these countries have seen support rather than retribution. Finally, and most significantly, feedback from young rural drivers in the United States following the introduction of restrictions shows overwhelming support — young rural drivers either strongly agreed (10%) or agreed (53%) with the restrictions.13 A road safety policy that attempts to identify at-risk young drivers and to impose restrictions only on those drivers is unlikely to succeed, because there is no reliable screening test for at-risk drivers. Identifying at-risk young drivers on the basis of prior traffic violations (as proposed by the NSW government10) would not be useful, as most fatally injured young drivers have no prior traffic violations.6 Instead, a whole-population approach such as graduated licensing, which targets all newly licensed drivers, is likely to achieve reductions in young driver fatalities and serious injury. Of importance, however, is the unequivocal evidence that graduated licensing systems that incorporate late night and peer passenger restrictions reduce road fatalities and serious injury and convey a benefit to cost ratio of 74 to 1.6 It is evident that our current graduated licensing systems have been steering young drivers in the right direction. However, until night driving and peer passenger restrictions are incorporated into the graduated licensing system throughout Australia, it is unlikely that the national road safety strategy target for 2010 — to reduce the road fatality rate by 40% — will be achieved.

Mark R Stevenson PhD, MPH

Obesity in children and adolescents has reached alarming levels — 20%–25% of children and adolescents are overweight or obese, and 4.9% of boys and 5.4% of girls are obese. Rates of obesity have increased significantly in Australia from 1985 to 1995, with the prevalence of overweight doubling and obesity trebling. Body mass index (related to reference standards for age and sex) is recommended as a practical measure of overweight and obesity in children, and is used in monitoring individual progress in clinical practice. Obesity in childhood and adolescence may be associated with a range of medical and psychological complications, and can predispose individuals to serious health problems in adult life, including type 2 diabetes, hypertension, dyslipidaemia and non-alcoholic steatohepatitis. Obesity interventions for which there is some evidence include family support, a developmentally appropriate approach, long-term behaviour modification, dietary change, and increased physical activity and decreased sedentary behaviour. Prevention of obesity in children and adolescents requires a range of strategies involving changes in both the microenvironment (eg, housing, neighbourhoods, recreational opportunities) and the macroenvironment (eg, food marketing, transport systems, urban planning).

Jennifer A Batch MB BS, MD, FRACP · Louise A Baur MB BS, PhD, FRACP

Megan L Counahan,* Ross M Andrews,† Rick Speare‡ * Surveillance Manager, Communicable Diseases Section, Department of Human Services, Level 17/120 Spencer Street, Melbourne, VIC 3000; † Senior Research Fellow, Centre for International Child Health and Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, VIC; ‡ Professor, School of Public Health and Tropical Medicine, James Cook University, Townsville, QLD. megan.counahanATdhs.vic.gov.au To the Editor: For parents to treat head lice (pediculosis) effectively in their children, it is necessary for them first to recognise it is present. We conducted a school-based screening program involving 1838 children from 16 randomly selected primary schools in Victoria between May and October 2001 (participation rate, 55.2%).1 As part of this program, we compared a written report from parents on their child’s pediculosis status against results of our examination (7–10 days later). We examined the scalp and hair of each child for lice (“crawlers”) or viable louse eggs (“active infestation”) and dead or hatched louse eggs (“inactive infestation”) using white hair conditioner, which makes lice and eggs easier to see with the naked eye, and a fine-toothed head lice comb. This is a validated, accurate and sensitive diagnostic technique.2 Parents were unaware of the proposed screening date, and the study team was unaware of the parents’ reports. We compared parental report about pediculosis against results of our screening for 1179 children who could be matched with completed questionnaires. Overall, 149 children (12.6%) had active pediculosis, but parents reported head lice in only 36 children (3.0%) (Box 1 and Box 2). These comprised 24 of the 149 children with confirmed pediculosis (16%), and another 12 children who did not have pediculosis when examined. The positive predictive value (PPV) of parental report was 66.6%, indicating that parental reporting was not a reliable indicator of pediculosis. An implication of the low PPV is that some children may have been unnecessarily treated with insecticide for an infestation they did not have. On the other hand, a substantial proportion of children with head lice had not been identified by their parents and could contribute to ongoing transmission within schools. While it was possible they were infected subsequent to completion of the questionnaire, this seemed unlikely, as 72% were found to have multiple louse eggs, indicating a longer duration of infestation than the 7–10 days since the questionnaire was completed. Our study clearly demonstrates that parental reporting of head lice in their children is unreliable. We suggest several possible reasons: parents did not see the head lice, did not recognise them, or used a diagnostic technique with a lower sensitivity than the method we chose, such as examining dry hair. It is also possible that parents were inhibited from reporting pediculosis by the possible repercussions, such as exclusion of the child from school. Indeed, children whose parents failed to answer the question about pediculosis had a higher prevalence of head lice than those whose parents answered. Nevertheless, parents’ management of pediculosis is likely to improve if a sensitive detection method is used. To improve the sensitivity of parental diagnosis and control of head lice we recommend that parents be instructed to screen their children weekly using hair conditioner and combing. 1 Screening results compared with parental report Pediculosis by parent report Pediculosis on examination Yes No Total Yes 24 12 36 No 99 969 1068 Unsure 26 49 75 Total 149 1030 1179 2 Sensitivity and specificity of parental report versus screening Pediculosis prevalence By parental report 3.0% (36/1179) By screening 12.6% (149/1179) Sensitivity 16.1% (24/149) Specificity* 98.8% (1018/1030) Positive predictive value 66.6% (24/36) Negative predictive value* 89.0% (1018/1143) * Specificity and negative predictive value were calculated after grouping “unsure” and “no” responses.

Megan L Counahan · Ross M Andrews · Rick Speare

The medical community has important roles in reducing harm from alcohol and other drugs A contemporary vision of how to prevent harmful alcohol and drug use is emerging, at a time when a new approach is vitally needed. In 1998 (the most recent year for which mortality data on all recreational substances are available), substance use killed some 23 000 Australians.1 Licit drug use accounted for 96% of these deaths, with tobacco the leading cause. In the same year, drug use cost the Australian community $34.7 billion, representing almost 2% of GDP for alcohol, 1.71% for tobacco and 1.76% for illicit drugs.2 Rates of tobacco and alcohol use have increased over the past decade among adolescents and young adults. Although the problem is of large scale,3 there have been major recent advances in the understanding of how to prevent much harmful drug use. One such advance is the “developmental pathways” approach, emphasised in Australian mental health4 and crime prevention5 strategies. This approach draws on life-course development research, community epidemiology and preventive intervention trials.6,7 Studies have demonstrated that from early in life similar developmental, social-risk and protective factors lead to a range of problem and risk behaviours in adolescence and young adulthood, including problematic substance use.8 Attention to these underlying factors is an essential element in preventing problematic substance use. Hence, we need to consider how these forms of prevention can be integrated into Australia’s existing harm-minimisation framework. Recent evidence also warrants an increased acknowledgement of the significant and influential role regulation and legislation play in prevention,9 including the symbolic role of law in reinforcing social norms against harmful drug use.10 The challenge is to integrate this new knowledge while accepting that there have also been clear advances through the use of harm-reduction strategies for people who are unable or unwilling to abstain from risky drug use .11 In recognition of the need for these different approaches to prevention to be integrated into national drug policy, the Australian Department of Health and Ageing commissioned a major review of Australian and international literature. The review was recently published as a monograph, The prevention of substance use, risk and harm in Australia.12,13 As part of the focus of integrating different prevention approaches, 159 preventive interventions were reviewed. The highest level of evidence for effectiveness was found for eight interventions (Box). What can the medical profession do to assist?Interventions for families and adolescentsA number of effective interventions for families and adolescents are implemented predominantly by healthcare professionals: Antenatal and postnatal home visiting by nurses to support high-risk parents in effectively meeting the child’s basic needs and to encourage healthy bonding; Early identification of fetuses or infants at risk of manifesting the effects of drug exposure, including early intervention to encourage reduction of harmful maternal drug use, particularly smoking; Child development support for families with problems associated with alcohol and drug use; Assistance for parents and families in developing skills and gaining support to enhance healthy child development and prevent substance use beginning at an early age or occurring regularly during adolescence; Identification of training and evaluation strategies to improve the preventive screening and health promotion offered to adolescents by primary healthcare professionals. Interventions within the general communityAs well as specific medical interventions, the medical profession plays an important role in supporting the development of evidence-based alcohol and other drug policy.14,15 Evidence attests to the value of interventions in the general community which prevent the sale of tobacco to minors,16 encourage responsible alcohol marketing and distribution,17 integrate treatment and harm reduction services18 and reduce the availability of illicit drugs.19 Behavioural risk factors for a variety of health issues can be managed in general practice using initiatives such the Smoking, Nutrition, Alcohol and Physical activity (SNAP) Framework to address cardiovascular health.20 Brief interventions by general practitioners appear effective for reducing both smoking and early-stage alcohol problems.21 Despite this, GP uptake of brief interventions has been poor, and many GPs fail to detect individuals at risk of developing alcohol and other drug problems.22 Professional support for GPs can improve rates of screening and brief interventions. Practice nurses should also be considered as alternative service delivery agents.22 There is a solid research base to show that treatment for a range of drug and alcohol problems is effective and can improve mental and physical health and social functioning. Treatment is an essential aspect of prevention, having population-level effects on levels of crime and disorder. Treatment of families minimises the intergenerational transmission of substance-use problems. However, most treatment programs engage only a small proportion of the people with drug and alcohol dependence. Including advice from a GP, only one in three people with an alcohol problem will receive any kind of treatment from a healthcare professional in a 12-month period.23 ConclusionAn integrated vision of prevention brings together action from many areas, including health, with a common goal of creating healthy social environments. Healthcare providers play a critical role and are encouraged to see the provision of services to drug- and alcohol-dependent individuals as a core responsibility.24,25 The evidence supports an increase in the capacity of mainstream healthcare providers to provide brief and early interventions and treatment. Further funding for drug-dependency services, training for healthcare practitioners in managing drug-dependent patients, improved access for GPs to specialist support, and the recognition of medical practice in the drug-dependency field as a legitimate medical specialty have all been recommended.24 GPs are ideally placed to identify children at risk of developing psychosocial problems because of their family backgrounds, particularly where adults and children present with problems associated with substance use by parents. Early identification of these children and appropriate treatment or referral of both the child and the parent may help to prevent the intergenerational transfer of alcohol and drug problems within families. Finally, advocacy by the medical and healthcare professions for effective non-medical interventions such as taxation, law enforcement and harm reduction is vital to ensure their wider and more effective application. Eight interventions with the highest level of evidence to prevent harms associated with substance use Tobacco taxation to create and maintain price disincentives Enforcement of environmental tobacco smoke regulations Alcohol taxation based on alcohol content of drinks Random breath testing of drivers Brief interventions by primary healthcare providers in relation to alcohol and tobacco use* Treatment for dependent alcohol and other drug use* Needle and syringe distribution programs Hepatitis B vaccination* * There is a role for the medical profession in these three interventions.

Wendy M Loxley BA(Hons), M.Psych, PhD · John W Toumbourou BA(Hons), MA, PhD · Timothy R Stockwell MA(Oxon), MSc, PhD

It is truly a bold concept — to recruit 1% of the UK population into a massive cohort study — but, 1000 days into the project, not a single participant had been enrolled Over 5 years ago leading minds within the Wellcome Trust and the Medical Research Council (MRC) realised that charting the entire genome of one human would do nothing to improve health. They argued that the real meaning and significance of genes could only be unravelled by also studying their owners’ behaviours and environments to determine which combinations conferred resilience and which resulted in disease. And so the idea of the UK Biobank was born. UK Biobank . . . seems baffled by its own complexity, stranded in a bunkum of companies, contracts and consortia that makes decoding the double helix look like child’s play It is truly a bold concept — to enrol 1% of the United Kingdom’s population, or around 3% of people in the target age-group 45–69 years, into a massive cohort study in which genetic material is held for all participants. With 500 000 participants, the UK Biobank cohort stands to be 50% larger than the set of men originally screened for the Multiple Risk Factor Intervention Trial in the United States, twice the size of the cohort for the combined US Nurses Health Studies, 12 times bigger than that of the study of smoking in British doctors, and 100 times larger than that of the famous Framingham Heart Study. Indeed, the driving force behind UK Biobank is a desire to have adequate statistical power to study gene–environment interactions for individual types of cancer, bearing in mind that, in the UK, all types of breast cancer combined account for about 4% of all deaths in women, and all types of lung cancer collectively cause about 7% of deaths in men. Despite this, there is not yet any commitment to go beyond “risk factorology” to answer questions of public health importance. For example, Biobank would be an invaluable opportunity to explore the relationship between individual characteristics and either the contextual influences on health, such as the physical and social nature of one’s neighbourhood, or the impact of health and social policy programs. Between them, Wellcome, the MRC and the UK Department of Health have made £61 million available to UK Biobank. But, 1000 days into the project, not a single participant had been enrolled, even into a pilot study. Instead, time and energy has been consumed in: creating UK Biobank Limited as a private company, limited by guarantee, and as a registered charity; having consortia of universities (mainly their medical schools) bid to be regional collaborating centres, and then drafting and redrafting contracts for them to provide “research services” to the private company; recruiting a Chief Executive Officer, a Chief Scientific Officer, a Chief Operating Officer, a Director of Operations (Laboratory), a Director of Clinical Operations, a Head of Communications, and a Chief Information Officer; commissioning a market research company to report on attitudes of people in later middle age to inform a Communications and Consultation Strategy; developing an Ethics and Governance Framework, compliance with which is to be overseen by an Ethics and Governance Council, whose members will be recommended to the funders by an appointments committee; writing an Intellectual Property and Access Policy; and asking a marketing agency to develop a logo and brand. There have also been protracted debates about which behavioural, lifestyle and environmental factors to document, and whether the collaborating centres that enrol participants should have any preferential access to the data and samples held by UK Biobank, let alone a share in their formal ownership. As yet, there has been very little consideration as to how endpoints of interest will be identified and validated. Sir Humphrey Appleby would be proud! On the subject of public image, perhaps it is the picture of a happy granny riding a moped without a helmet, shown in the original documents with general information about the project, that crystallises a suspicion that people with world-class expertise in the “molecules of life” do not necessarily have a strong grasp of public health and the skills required to enrol and follow up very large numbers of intact, free-living humans. Also interesting is the stark contrast between UK Biobank and Australia’s Risk Factor Prevalence Study. The latter was initiated by a non-government organisation, the National Heart Foundation (NHF), which succeeded in completing three large, population-based surveys of risk factors for cardiovascular disease, mainly in Australia’s capital cities, during the 1980s.1 Enrolment involved completion of a questionnaire, a brief physical examination, collection of a blood sample and sometimes a dietary survey, directly equivalent to what participation in UK Biobank is likely to involve. The survey centres had their costs covered, as is proposed for the UK project, but, unlike UK Biobank, their leaders made up the main committee overseeing the study and directed the principal analyses and their publication, initially under the aegis of the NHF alone, and in the last survey in collaboration with the Australian Institute of Health and Welfare. Each survey took about a year to plan, a year to complete and two further years to publish. Covering slightly under 0.1% of Australia’s population, the Risk Factor Prevalence Study was an order of magnitude less ambitious than UK Biobank, but it constitutes a model of energy, trust, efficiency and goodwill that the Brits are struggling to emulate. It was not always thus, for Richard Doll and Richard Peto (and colleagues) recently published the 50-year results from their study of British doctors, a project whose outstanding achievements include a follow-up that is 99% complete.2 UK Biobank, by contrast, seems baffled by its own complexity, stranded in a bunkum of companies, contracts and consortia that makes decoding the double helix look like child’s play.

Konrad Jamrozik DPhil, FAFPHM, MFPH · David P Weller MPH, PhD, FRACGP, FAFPHM · Richard F Heller MD, FRCP, FRACP, FAFPHM

A stocktake of vaccination strategies and challenges The 9th National Immunisation Conference of the Public Health Association of Australia was held in August 2004 in Cairns, Queensland, in conjunction with the 1st Asia–Pacific Vaccine Preventable Diseases Conference. The conference was attended by more than 400 delegates, predominantly from the Asia–Pacific region. A theme of the conference was the potential of vaccines to achieve greater equity in health outcomes. A session on the Australian recommended immunisation schedule generated vigorous discussion, highlighting the difficulty of dealing with a schedule that includes vaccines not funded for universal use. Meningococcal diseaseThe epidemiology of meningococcal disease differs substantially around the world, with variation in both incidence and predominant serogroups. In parts of Africa, serogroup A causes regular epidemics. New Zealand has experienced a serogroup B epidemic for more than a decade, focused on the Maori–Pacific Islander community. In Australia, serogroup C has caused about 50%–70% of cases in Victoria and Tasmania since 2000, while serogroup B has been more common elsewhere.1,2 Serogroup C has also emerged as a significant problem in the United Kingdom and parts of Europe, especially in older children and adolescents. Mary Ramsay (Communicable Diseases Surveillance Centre, UK) provided an overview of the European experience of meningococcal disease, comparing vaccine schedules and outcomes. Use of meningococcal C conjugate vaccines, which provide more predictable and long-lasting immunity than polysaccharide vaccines, was pioneered in the UK with a national campaign beginning in 1999. Following the UK success, other European Union countries have begun programs, but schedules differ. In the UK, the vaccine is given at 2, 3 and 4 months; in Spain, at 2, 4 and 6 months; while, in The Netherlands, a single dose is given at 12 months. The last schedule, identical to that in Australia, was chosen because serogroup C is uncommon under the age of 12 months, and a single dose is sufficient for protection over this age. Preliminary data suggest that immunity persists longer when the last dose is given after 5 months of age.3 As outlined by Rosemary Lester (Department of Human Services, Victoria), meningococcal C conjugate vaccine was funded in Australia for children at age 12 months from 1 January 2003, and was accompanied by a catch-up program for children and adolescents aged 1–19 years. The school-based component of the catch-up program achieved good coverage across Australia in 2003–2004. Data on disease impact will be available in subsequent years. While a polysaccharide vaccine protects against meningococcal serogroups A, C, W135 and Y, and a conjugate vaccine protects against serogroup C, there is no commercially available vaccine against serogroup B. Since 1990, New Zealand has experienced a prolonged meningococcal epidemic thought to be attributable to a specific strain of serogroup B, combined with crowding and exposure to tobacco smoke. In response to this epidemic, and in partnership with the Norwegian Institute for Public Health and Chiron Vaccines, the New Zealand government has sponsored development of a vaccine for the New Zealand strain (MeNZB). After demonstration of adequate immune responses, a national rollout of this vaccine began in July 2004. Because of the unique nature of this program, assuring vaccine safety is critical. Stewart Reid (Chair of the New Zealand vaccine advisory committee) described a national safety monitoring program which, in scope and comprehensiveness, is at the level of world’s best practice. Pneumococcal diseaseKim Mulholland (Centre for International Child Health, University of Melbourne) gave an overview of the rapid and varied developments in conjugate pneumococcal vaccine trials around the world. Use of the polysaccharide pneumococcal vaccine was shown over 20 years ago in Papua New Guinea to reduce deaths, but neither this vaccine nor the newly available conjugate vaccine is used in any country with high death rates from childhood pneumonia. Although the current conjugate pneumococcal vaccine covers only seven serotypes, this vaccine, with two additional serotypes, has been shown to prevent invasive pneumococcal disease (IPD) and non-bacteraemic pneumonia in children from Soweto, South Africa.4 Peter McIntyre (National Centre for Immunisation Research and Surveillance, Sydney) and Vicki Krause (Centre for Disease Control, Northern Territory) outlined vaccine programs to control pneumococcal disease in Australian adults and children. Since the late 1990s, the 23-valent polysaccharide pneumococcal vaccine has been funded nationally for Indigenous adults aged 50 years and over and, in Victoria, for all adults aged 65 years and over. There is now convincing evidence from north Queensland of a decrease in IPD among Indigenous adults. Among the elderly, recent data have also shown a greater reduction in IPD in Victoria than in New South Wales, where there is no funded program for this age group.5 The polysaccharide vaccine will be funded for all adults aged 65 years and over from January 2005. Since 2001, the seven-valent pneumococcal conjugate vaccine has been funded only for Indigenous children and for others with specified medical conditions. From January 2005, it will be funded for all children under 2 years of age. Data from national surveillance of IPD for 2003, presented for the first time at the conference, show a measurable decrease in IPD in Indigenous children, so that the incidence in these children is now below that in non-Indigenous children. It is clear that universal funding is timely, and that vaccination has contributed to greater equity in health outcomes between Indigenous and non-Indigenous children in Australia, as previously shown for black children and white children in the United States.6 Immunisation in the PacificViliame Sotutu (Fiji School of Medicine) and Rob Condon (Public Health Physician, Fiji) highlighted the problems in providing vaccines to children in the 22 countries and territories in the Pacific, most of which are small and separated by vast distances. Many of the countries have young, growing populations with low living standards and high unemployment rates. Health status is variable, and political instability is not uncommon. The Expanded Programme on Immunization was introduced in 1977, jointly funded by the World Health Organization and individual countries. However, immunisation schedules vary between countries, and procurement and logistic strategies are often inefficient. Recent outbreaks of measles in Papua New Guinea and the Solomon Islands, with high death rates, and outbreaks of rubella in Samoa, with cases of encephalitis, highlight the fragility of control of vaccine-preventable diseases in the Pacific. More emphasis should be placed on vaccine delivery to island communities, and Australia can make an important contribution to this effort. Haemophilus influenzae type b diseaseAgustinus Sutanto (Catholic Hospital in Ampenan, Lombok, Indonesia) presented the results of a recently completed randomised controlled trial of the Haemophilus influenzae type b (Hib) vaccine PRP-T on the Indonesian island of Lombok. The trial, which enrolled 55 000 children aged under 2 years and was randomised by hamlet, produced evidence of a substantial, unrecognised burden of Hib disease. This type of “vaccine probe” study, pioneered in Gambia, is able to measure disease burden through differential vaccine impact, where routine data on disease notification and hospitalisation are not available.7 Mary Ramsay (Communicable Diseases Surveillance Centre, UK) presented the results of a series of studies, including seroepidemiology, nasopharyngeal Hib colonisation and routine measurement of disease frequency, to explore reasons for a resurgence of Hib disease in the UK. First, herd immunity, resulting from the 1992–1993 national catch-up program for children up to 5 years of age, had waned because no booster dose had been given in the second year. Second, this effect was exacerbated by the introduction of a less immunogenic vaccine combination. This resulted in an increase in cases among children aged 1–4 years, who were consequently targeted by a national booster campaign. The UK experience emphasised the importance of maintaining high-quality surveillance in order to rapidly assess unexpected problems, which may emerge even in apparently very successful vaccination programs.8 New vaccinesGraham Barnes (Gastroenterology Department, Royal Children’s Hospital, Melbourne) is involved in developing an Australian candidate rotavirus vaccine. The first licensed vaccine was withdrawn from the US market in 1999, after identification of a small but definite increased risk of intussusception. Following this experience, trials of new vaccine candidates have needed to be large enough to exclude any significant increased risk of intussusception. Two new candidate vaccines appear to have achieved this goal, one of which was recently licensed in Mexico. Terry Nolan (School of Population Health, University of Melbourne) described progress with vaccines against human papillomavirus (HPV), the major cause of cervical cancer worldwide. It is now established that these vaccines prevent HPV infection, and long-term studies will determine their impact on cancer. The potential availability of HPV vaccines has raised new issues of timing of vaccination and communication of the rationale to parents, who may not appreciate the risk of sexually acquired infections during adolescence. Both rotavirus and HPV vaccines are likely to be available in Australia within the next 3–5 years. Conference themes and resolutionsTraditionally, the final session of the conference is devoted to developing resolutions, many of which have been implemented. On the basis of public health benefit, the Australian Technical Advisory Group on Immunisation and the National Health and Medical Research Council recommend vaccines for inclusion in the Australian Standard Vaccination Schedule. Conference resolutions were dominated by the strong feeling that the Australian government should fund all vaccines that have been recommended by these two bodies.

Peter B McIntyre PhD, FRACP, FAFPHM · Heath A Kelly MPH, FAFPHM · E Kim Mulholland MD, FRACP

Gwendolyn L Gilbert,* Heather F Gidding,† Josephine Backhouse,‡ Peter B McIntyre§ * Director, ‡ Serology Project Officer, Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, PO Box 533, Wentworthville, NSW 2145. † Epidemiologist, § Director, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, University of Sydney, Westmead, NSW. LyngATicpmr.wsahs.nsw.gov.au To the Editor: Varicella vaccine was licensed in Australia in 2000. It is safe and efficacious and can prevent significant acute morbidity, significant out-of-pocket expenses for parents of affected children and, in Australia, prevents an estimated 450 admissions to hospital and one death per year.1 In September 2003, the National Health and Medical Research Council (NHMRC) recommended giving varicella vaccine to all children at 18 months of age.2 The net effect of childhood immunisation on varicella morbidity will depend on vaccination coverage. Modelling of Australian (unpublished National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases data) and UK3 seroprevalence data suggests that, for a range of vaccine efficacy estimates, 80% coverage is required before morbidity is reduced in adults. Accurate Australian coverage data are unavailable, as varicella vaccine is not funded under the National Immunisation Program.2 National serosurveillance can provide a practical alternative estimate of vaccine uptake. The first Australian national serosurvey of vaccine-preventable diseases, for which sera were collected between July 1996 and February 1999, established baseline seroprevalence for future assessment of the effects of changes in the vaccination schedule. It showed that the incidence of varicella was highest in 5–9-year-old children,4 indicating that infant vaccination would provide optimal protection. The second national serosurvey (with sera collected in 2002) is under way, with methods identical to those of the first.4 We compared varicella IgG levels in children aged 1–5 years, testing 459 sera in the first serosurvey and 380 in the second (see Box). The proportion with protective or equivocal antibody levels increased between the two serosurveys. The difference was statistically significant only in 3–4-year-olds, which is consistent with the greatest uptake when children enter childcare. Although there is some variation in varicella incidence over time, the changes are consistent with only modest vaccine uptake in the time that varicella vaccine has been available in Australia. The only other available estimates of varicella vaccine uptake are from GP consultations5 and reports to the Australian Childhood Immunisation Register (ACIR), which also indicate it is modest. For example, only 6.2% of children aged 4 years were reported to the ACIR to have received varicella vaccine (Brynley Hull, Epidemiologist, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, personal communication). This is probably an underestimate, as there is no incentive for notifying varicella vaccination. However, a low vaccination uptake is consistent with use only in the private sector, and could lead to an increase in adult morbidity (despite an overall reduction in infection rates) because of a higher average age of infection (unpublished National Centre for Immunisation Research data). Unless vaccine is provided in the routine immunisation program at no cost to parents, uptake is unlikely to meet the 80% target required to reduce disease burden in all ages.3 Varicella IgG seroprevalence in preschool children in the 1st and 2nd national serosurveys 1st serosurvey, July 1996 to February 1999 2nd serosurvey, 2002 Age group No. Positive Negative Equivocal* No. Positive Negative Equivocal* Increase in positive and equivocal (95% CI) P 1 to < 3 years 138 27 (19.6%) 111 (80.4%) 0 152 34 (22.4%) 118 (77.6%) 0 2.8% (−6.6 to 12.2) 0.6 3 to < 5 years 214 72 (33.6%) 140 (65.4%) 2 (0.9%) 152 73 (48.0%) 79 (52.0%) 0 13.4% (3.3 to 23.6) 0.01 5 years 107 61 (57.0%) 46 (43.0%) 0 76 43 (56.6%) 33 (43.4%) 0 −0.4% (−15.0 to 14.1) 1.0 Total 459 160 (34.9%) 297 (64.7%) 2 (0.4%) 380 150 (39.5%) 230 (60.5%) 0 4.2% (-2.4 to 10.8) 0.2 *Sera giving equivocal results by enzyme immunoassay were retested and most were resolved by immunofluorescence (IF). These results represent the few that were still equivocal by IF and are probably low-titre positive results.

Gwendolyn L Gilbert · Heather F Gidding · Josephine Backhouse · Peter B McIntyre

Barbara A Hawkshaw,* Yeqin Zuo† * Planning and Evaluation Officer, Health Promotion Unit, Central Sydney Area Health Service, Level 9 North, King George V Building, RPAH, Missenden Rd, Camperdown, NSW 2050; † Currently Tobacco Control Program Coordinator, Cancer Institute NSW, Sydney, NSW barbara.hawkshawATemail.cs.nsw.gov.au To the Editor: The World Health Organization recommends that hospital staff ask about the smoking status of every patient, and offer brief quit advice and pharmacotherapy.1 These effective strategies2 underlie the Central Sydney Area Health Service (CSAHS) Smoke Free Environment Policy,3 which specifies the use of nicotine replacement therapy (NRT) in managing nicotine dependence of inpatients. Recording quit advice is yet to become a regular feature of medical records, but documentation of smoking status and NRT prescribing is evidence of compliance with the policy. To monitor the implementation of this policy in CSAHS, we examined the medical records of smokers for evidence of NRT prescribing in hospital or at discharge. A small sample was chosen to provide a “snapshot” of NRT use. First, we identified 2718 patients admitted to Royal Prince Alfred Hospital and Canterbury Hospital between 1 July 2001 and 30 June 2002 who were single admissions, stayed 48 hours or longer, and were current smokers (ICD-10 code Z720).4 Current smokers were defined as those who had smoked any tobacco in the past month.4 Sixty medical and 60 surgical patients from each hospital were selected randomly by random number generation (medical/surgical status was based on the specialty of the admitting doctor). After excluding 33 patients who were either ex-smokers or smokers who died during admission, the sample included 207 patients. Records were examined for smoking history, NRT prescribing during hospitalisation, and documentation of smoking status or NRT prescribing on discharge summary. NRT was prescribed to 13 patients (6.3%) during their hospitalisation (Box). All 13 received patches. A larger proportion of medical patients than surgical patients had NRT prescribed in hospital (8.1% v 4.6%) and at discharge (7.1% v 2.8%). In 8% of records, smoking was identified on the discharge summary. Most records (80%) provided numerical information about daily cigarette consumption. Seventy per cent of our sample smoked more than 10 cigarettes per day. Other records described consumption in subjective terms only, such as “heavy”. We believe that this is the first study in Australia to estimate the NRT prescribing rate for inpatients using medical record audit. Very few patients who were smokers were prescribed NRT. It is encouraging that most patients who were prescribed NRT were given a supply of patches at discharge. The NSW Health Department’s Guide for the management of nicotine dependent inpatients is a commitment to assisting people to quit.5 Implementation of the CSAHS Smoke Free Environment Policy3 by hospital staff requires a greater knowledge of the barriers to prescribing NRT and documenting quit activities at all levels of the hospital system. Nicotine replacement therapy (NRT) prescribing and smoking history Medical* Surgical* Total NRT prescribing (n = 99) (n = 108) (n = 207) During hospital stay 8 5 13 (6%) At discharge 7 3 10 (5%) Smoking history (n = 99) (n = 108) (n = 207) Number of cigarettes recorded 76 90 166 (80%) Years of smoking recorded 26 41 67 (32%) Cigarettes per day (n = 76) (n = 90) (n = 166)† 1–10 25 24 49 (30%) > 10 51 66 117 (70%) * Admission categorised according to specialty of admitting doctor. † Only 80% of total sample indicated number of cigarettes per day.

Barbara A Hawkshaw · Yeqin Zuo

Ailsa Goulding,* Andrea M Grant,† Peter L Davidson‡ * Professorial Research Fellow, † Assistant Research Fellow, Department of Medical and Surgical Sciences, ‡ Research Fellow, Injury Prevention Research Unit, University of Otago, Dunedin, New Zealand. Ailsa. GouldingATstonebow.otago.ac.nz To the Editor: The interesting article on playground safety and arm fractures by Sherker and Ozanne-Smith1 documents a steady increase in hospitalisation rates for arm fractures among Victorian children between 1987 and 2002. It would appear that the increase over this 15-year period was about 45%. These figures may represent the tip of the iceberg, as few children with arm fractures are admitted to hospital and most are treated on an outpatient basis. Increases of similar magnitude in forearm fractures in adolescence have also been reported recently in the United States.2 It would seem that children are becoming more vulnerable to such fractures. This is a concern, as fractures of the distal forearm are extremely common during growth. Indeed, about a quarter of all fractures during childhood and adolescence occur at this site. One factor that might be contributing to this rising incidence of arm fractures during growth is increasing childhood adiposity. Childhood obesity has increased sharply in Australian children over recent years.3 Obese children fall with more force, and, although they may have more bone for chronological age than children of healthy bodyweight, adaptive increases in bone mass are not enough to accommodate their high bodyweight gain, placing them at a biomechanical disadvantage during falls on the outstretched arm.4 Our studies of consecutive series of girls and boys with distal forearm fractures indicate that a high proportion of these children are overweight. Moreover, in a 4-year prospective study of 170 girls, we found that high bodyweight at baseline increased the risk of new fractures.5 In their study, Sherker and Ozanne-Smith measured the heights and weights of 402 children under 13 years of age who had broken their arm falling from playground equipment between 2000 and 2002. We wonder how many of these children were overweight or obese for their age. Examination of the body mass index values would provide this information, and we ask that the authors report these data for both girls and boys using international cut-off points. We would like to know whether or not overweight is contributing to rising rates of arm fracture in Australian playgrounds.

Ailsa Goulding · Andrea M Grant · Peter L Davidson

Shauna Sherker,* Joan Ozanne-Smith† * Postdoctoral Research Fellow, NSW Injury Risk Management Research Centre, University of New South Wales, Sydney, NSW; † Chair of Injury Prevention, Accident Research Centre, Monash University, Melbourne, VIC. Shauna. SherkerATunsw.edu.au In reply: The prevalence of obesity has increased dramatically among Australian children, particularly over the past 2 decades.1 However, the role of obesity as a risk factor for fall-related arm fracture remains unclear. Using standard definitions for child overweight and obesity,2 our study population3 (Box) did not demonstrate quite as high a prevalence of obesity as had been previously reported for Victorian schoolchildren.1 This case series was part of a larger, yet to be published case–control study, the results of which indicate no significant difference in body mass index between children who fell from playground equipment and fractured their arm (cases) and those who fell and landed on their arm with no significant injury (controls). The negative public health effects of increasing prevalence of obesity among Australian children highlight the need to promote safe and enjoyable physical activity. Playground equipment provides a very popular means of physical activity for children. Improving playground safety standards to minimise the risk of arm fracture — a traumatic, costly and preventable childhood injury — has never been more urgent. Children with arm fracture caused by falls from playground equipment, showing proportion of children who were normal weight, overweight or obese.* * Based on unpublished data from Sherker and Ozanne-Smith.3

Shauna Sherker · Joan Ozanne-Smith

Child health will only improve when local structures are further strengthened, enabled and supported Most countries in the western Asia-Pacific region have made consistent gains in child survival over the past 25 years (Box 1).1,2 Notable exceptions to this positive trend are Papua New Guinea (PNG) and East Timor. Sadly, a static child mortality rate such as has occurred in PNG, where the population has doubled over the past 25 years, means that, in this new century, about twice as many children are dying per year as in the mid-1970s. The health inequities between Australia and its nearest neighbours are many, and breathtaking in magnitude. In this issue of the Journal, McGain et al (page 687) document 87 deaths from snakebite at Port Moresby General Hospital (PMGH) (the largest hospital in PNG) over a 10-year period.4 This hospital serves a population of about 500 000 people. By comparison, throughout the whole of Australia since 1981 there have been an average of 2.6 snakebite deaths per year.5 McGain et al point out that lack of antivenom is a major reason for the high mortality, and that the cost of antivenom in real terms is 40 times greater in PNG than in Australia. The reasons for this include a per-capita gross national income that is 2.9% of that in Australia,2 price mark-up with privatisation of overseas distribution from Australian suppliers, and an Australian government subsidy for antivenoms sold in Australian hospitals that does not apply elsewhere. It is not difficult to suggest some feasible solutions to this problem: an Australian government subsidy for overseas developing-country purchasers, and/or direct supply from the manufacturer to the PNG Department of Health. However, snakebite is just one small piece of a very large puzzle of poor child health outcomes in PNG and the Asia-Pacific, and lack of antivenom is only one factor in high death rates from snakebite. Other factors are more systemic: limited access to health services, limitations in the quality of health systems, inadequate manpower, and poor management and financing. These problems are greater in rural areas, where 85% of the population lives; they have a major impact on all causes of avoidable child mortality, and are more difficult to solve than the lack of snake antivenom. PerspectiveAt PMGH, for every child who dies from snakebite, more than 50 die from other conditions that have been eradicated or controlled in Australia. In a 12-month period in 2001–2002 there were 238 child deaths at PMGH, of which four were from snakebite. Of 195 deaths in which the cause could be certified, 29 were from measles, 35 from meningitis (about a third of which were caused by Haemophilus influenzae type b [Hib]), 14 from HIV, 7 from tuberculosis, 66 from pneumonia and 11 from acute gastroenteritis.6 Throughout PNG, about a third of Hib isolates are resistant to available antibiotics (principally chloramphenicol),7,8 and rates of HIV are rising rapidly. The persistence of these infections in PNG despite the existence of effective methods of prevention or control should be a cause for concern and action in Australia as well as in PNG. Two-thirds of all child deaths are associated with moderate to severe malnutrition. On the role of aid and economic developmentAustralia currently allocates $435 million in aid to PNG (representing 20% of Australia’s official development assistance and 0.26% of its gross national income9 — far short of the benchmark of 0.7% agreed to by rich nations at the Earth Summit in 1992, and only achieved by Scandinavian countries and The Netherlands10). Much of Australia’s aid is now tied to strengthening law-making and law-enforcement facilities and financial management, but a proportion is allocated to social services (principally health and education). Aid programs in PNG often find themselves “between a rock and a hard place”. Sustainable development cannot occur in an environment of poor governance. When existing systems are not functioning well, one outcome, sometimes occurring by default and sometimes by design, has been the development or evolution of “parallel projects”, which circumvent existing government structures to achieve a flow of services or information to the periphery. There is a tension between this project approach and the building of genuine long-term capacity (ie, the resources and structures that enable self-sustainability) within government programs. However, if inequity within PNG and between PNG and Australia is to be reduced, aid allocated to social services must be spent in ways that will strengthen local systems so that services reach the most marginalised communities. One example of this dilemma is the Women’s and Children’s Health Project, funded by the Australian government and launched in PNG in 1997 (funding will cease at the end of 2004). The project has allocated $10 million a year to improve child and family health services. Credit must be given for its achievements, such as improvements to the vaccine “cold chain” (previously a major limitation on the quality of vaccines distributed in remote areas) and training and capacity support in some rural areas. However, results have generally been disappointing. Only a small proportion of the aid money has filtered down to the villages and settlements where child mortality is highest. Much has been consumed by large infrastructure costs in Port Moresby. In an attempt to tick off activities as completed achievements, weak and sometimes frustratingly inefficient government systems have often been circumvented using a “parallel project” mentality, rather than taking the much slower approach of working with and strengthening existing local structures. In a thought-provoking but pessimistic review, Professor Helen Hughes, Senior Fellow at the Centre for Independent Studies, has argued that aid has failed the Pacific nations.11 She believes that aid has created an ambiguity of independence, an environment in which government funds are spent on consumption rather than economic development, elevated exchange rates, and provided fodder for political corruption. These factors, plus high tariffs, have hindered manufacturing for domestic markets and export of agricultural products; reduced employment opportunities, skill development and entrepreneurship outside the government sector; and encouraged dependent welfare states. A partial solution suggested by Hughes11 is to make receipt of aid conditional on achieving certain goals, under an agreement of mutual obligation. This would require removing aid from government budgets, with mutual agreement between recipient and donor countries on its use, mutual monitoring, and disbursement subject to regular account auditing. Successful examplesPapua New Guinea (PNG) needs human capacity to provide a quality health service. In some areas of endeavour, this has been achieved. The Paediatric Society of PNG is one example of the slow and successful development of indigenous technical and professional capacity. This is a story of committed engagement by many paediatricians over four decades, building on the foundation laid by the late Professor John Biddulph. Progress has been based on the principles of quiet example and mentorship, working together at the front line of healthcare and grappling with everyday problems. In the past decade there has been increasing development of a few subspecialty areas and extraclinical skills, such as public health, research, evidence-based understanding, policy development, advocacy and child health nursing capacity. Australian public hospitals and individual paediatricians have played key enabling roles in this development, and, in turn, their support has been greatly assisted by AusAID through the PNG Medical Officer, Nursing and Allied Health Professional program and its predecessors. The outcomes are impressive. Locally trained PNG paediatricians now provide services in most of the 20 provinces, and contribute substantially to all areas of public child health, policy and service delivery.12 The PNG standard treatment manual,13 along with the National Government Health Plan, is a blueprint for a quality child health service in a resource-poor setting, and has been reproduced in many other developing countries and in internationally adopted strategies. These advances have only been achieved through the work of vital national child health institutions, the PNG Paediatric Society and the Department of Child Health at the University of PNG, with aid projects providing background support at various stages. Limiting factors to progressDespite some successful programs, many activities in PNG have not resulted in health gains where they are needed. Support areas of the health service remain weak: health and human resources management at all levels, drug and vaccine procurement, distribution and stock management, and health financing. Primary care, the most essential form of healthcare in rural areas but the least robust and most vulnerable level of the health service, has suffered the most because of these deficiencies.14 There needs to be a similar concentration on building capacity and commitment in these areas, improving efficiency, and minimising waste of resources and squandering of funds.15 The beginnings of progress in some of these areas have occurred. Health management is stronger in some provincial health services and hospitals now than it was 10 years ago, partly as a result of structural reforms and support and mentoring for management capacity provided by the AusAID-funded Health Sector Support Program. More needs to be done, but sustainable change will only occur slowly, tailoring strategies to individual situations — an approach that is at odds with some aid projects, whose designers often propose a “one size fits all” formula for rolling out the latest Big Idea, with little critical evaluation of outcomes. Equity and conditionality as principles of aidConditional aid, as Hughes suggests,11 might be a useful strategy, providing direct funding to carefully selected high-priority areas, with an agreement that certain process milestones will be reached. Potential examples might be Australian government funding of Hib vaccine, conditional upon completion of the national supplemental immunisation activities16 and achieving coverage of over 80%; or subsidising the purchase of snake antivenom, nevirapine and ceftriaxone, conditional upon improvements in drug procurement and national distribution systems. A further condition to ensure commitment and sustainability would be the understanding that the PNG government would take over responsibility for funding after a mutually agreed period of time. These targeted interventions would have broad benefits to the health service, would enable the implementation of new (to PNG) and highly effective interventions, and would enhance equity within PNG and between our two countries. However, there are some risks with conditional agreements. The withholding of interventions if conditions are not met would continue to hurt the people who are innocent of any waste or corruption — nurses and doctors who struggle every day to provide good healthcare, and the patients who suffer from the effects of a lack of quality services. Support should be given to local training institutions rather than aid projects running unsustainable training programs. A portion of the aid budget could be provided to build key areas of capacity by financially supporting individuals or groups committed to collaboration in ways that are appropriate to Melanesian society. AusAID and the PNG Health Department are currently proposing a step in this direction by establishing a Capacity Building Service Centre, which will place more emphasis on engaging locally successful individuals to act as mentors, build capacity, and result in significant changes to external contracting. The approaches outlined above are complementary and would reduce inequity between Australia and its Pacific neighbours. In some ways, they would be a departure from some current large aid projects, whose economic benefits often spin back to the donor country, and whose resources are consumed by project infrastructure that duplicates government institutions. I can see little place in a country like PNG for health projects that are managed by overseas private consortia. International tendering for health projects in a country that has no structured health management organisations can scarcely improve equity. This model has worked better for some aid development projects, such as road and water supply contracts, in which local engineering companies have won contracts, thus contributing to local development, employment and economic growth. However, the idea that health aid should be corporatised in a country that desperately needs an effective public health system is fundamentally flawed. No easy answersThere are no easy answers to how Australia can best assist regional countries. Ongoing engagement remains necessary at many levels — between governments, professional societies, institutions, and individuals. Without this there can be no mutual understanding, which provides the basis for progress and is crucial for regional peace. Some of the best examples of success suggest that sustained, quiet and modest-budget collaboration by committed groups or individuals who treat each other as equals will be the most effective strategy. As yet I have not addressed the problems of child mortality in the worst-affected country in the region — East Timor. A sustained collaborative approach would be of great benefit to this small country (Box 2). The view of PNG as a “failed state” is wrong. Progress is being made in many areas. Now is not the time for Australia to abandon PNG or our closest Pacific neighbours, but to learn from institutions and areas that have achieved much, to support them to do more, and to tailor approaches to specific situations. Australia also has much to learn from Pacific countries — quiet persistence, patience and a sense of community are qualities that might help us have a more realistic view of what progress really means. 1 Trends in mortality in children under 5 years (per 1000 live births) in the Asia-Pacific region over the past 50 years1-3 * In a Demographic Health Survey (DHS) in East Timor in 2003, the mortality rate in 2003 among children under 5 years of age was estimated to be 107 per 1000 live births. Mortality rate estimates from the previous eras, represented on the graph, are also based on retrospective data from the 2003 DHS, so the accuracy of these trends is uncertain. Reliable data from previous years are not available. 2 Increasing East Timor’s capacity to meet its child health needs The problems of capacity in East Timor are even deeper than in Papua New Guinea (PNG), and the child health system is in a much more embryonic stage of development. Currently, there are no East Timorese paediatricians, which is a major impediment to sustainable progress, local leadership, autonomy and direction. However, collaboration between the East Timorese Ministry of Health, the University of PNG and the Royal Australasian College of Physicians (RACP) will hopefully see East Timorese doctors trained in child health, largely in PNG, with some additional clinical experience in rural hospitals in Australia, over the next 5–10 years. This will provide training in settings that are similar to those of East Timor, foster personal and institutional connections between two developing countries, promote a developing-country university as a regional centre for high-quality specialist training, and minimise the risk of “brain drain” that would exist if specialist RACP Fellowship training were done in Australia.

Trevor Duke MD, FRACP, FJFICM

At seventy-seven it is time to be in earnest Samuel Johnson — A journey to the Western Isles of Scotland Nothing about my life has been planned, including medicine. When, to my surprise, I obtained one of the rare scholarships then available to the University of Sydney after the Leaving Certificate, I asked my father what I should do. “Medicine”, he said, “that’s a good career for a woman”. So, despite having no sciences and braving the fierce opposition of my Latin teacher, I obeyed. Nor did I know, even after graduating, what field of medicine to aim for, having spent much of my undergraduate years at Arts lectures and playing bridge. After doing the odd locum and a bit of general practice, I married a naval aviator and had six children. This removed me from medicine for 13 years. Returning to Sydney from Perth (following the fleet) and being short of money, I went to Royal North Shore Hospital (RNSH) and asked to do a refresher course by attending outpatient clinics. Although feeling like a middle-aged frumpish housewife, I was treated by each of the senior consultants, all men, with the utmost courtesy. I have honoured RNSH ever since. It was not easy to get a job. I worked first at Grosvenor Diagnostic Centre, assessing children with intellectual disability. The medical officers were at the fringe of a revolution in genetics, constantly learning about recently discovered syndromes and how to identify these as the underlying causes of the conditions in the people we saw. Yet, we were not esteemed by the medical profession, who referred to us as “guardians of the waiting list”, because we assigned priority to those most urgently in need of the few residential care places available. Our chief concern, however, seemed to be for the parents, and how to reconcile them with the pain of accepting that their children were “different”. From institutions to community careWhen my husband was posted to Melbourne, I worked in a large institution in Victoria, which taught me a lot about institutions and the danger of just accepting what occurred in them. I remember admitting a teenage boy, clinging to his tearful mother. She was at last persuaded to leave, too soon to notice that his bed had no pillow. I asked for one, but the busy charge nurse’s reply was, “I won’t allow pillows in my ward. They might fight with them or smother themselves”. Of course, we were understaffed, the few staff we had were overworked, and the residents had little supervision. So little, in fact, that one girl wandered out of her ward one night and fell into an uncovered hole containing a steam pipe — she was scalded to death. When I recollect this tragedy, I find it hard to accept the pious phrase “the dignity of risk”, which is too often used to justify neglect of people in residential care. Returning to Sydney, I was lucky to be at the start of the deinstitutionalisation program in New South Wales, but soon realised that this was not to be an easy path. Among the first people to move were a group from a large institution on Peat Island. They moved into a small cottage in Hornsby, and soon the neighbours were complaining, not because of discrimination, but because of the frequent noisy quarrels among the four residents about who should do the dishes! Human nature is no different whatever the IQ level. This same quartet looked marvellous — dressed for the first time in dinner jackets and evening gowns — for their first formal, a ball in Hornsby. As I grew older, I became interested in exercise and nutrition. I started to jog in the streets near where I lived, embarrassing my children and husband. It felt so good that I wondered how exercise would work for people with a disability. I obtained a Master of Public Health degree by doing a simple research project on this subject. Then RNSH allowed me to start a health promotion clinic for adults with developmental disability. This was soon enhanced by the arrival of a dietitian, Lyn Stewart, and an exercise physiologist, Caroline Bruce, and we became very busy. It was obvious to me that my colleagues, using nutrition and exercise, improved health faster than I did. Caroline also organised the people into teams and they went for trips at weekends, playing indoor cricket and soccer, and returned with amazing stories of their hijinks. This was a time of fanatical adherence to the philosophy of normalisation — all people with disabilities should live in the community, whatever their special needs, and participate in all community activities. Our staff struck some unrealistic expectations, including carers who refused to be involved in our sports programs, one proclaiming, “We’d rather our residents sat at home all day and never exercised, than take part in segregated activities.” We ignored these thought police, and took one group ourselves for their first sight of snow to luxurious quarters donated by a generous hotelier. At breakfast they sat down to silver and snowy table linen. “Oh look!” said one delighted young man, “we are going first class!” A trip to the snow Royal North Shore Hospital Health Promotion Clinic for Adults with Developmental Disability enjoying a weekend in the mountains. Latin and the logic of epidemiologyThe best teacher I ever had was a Dominican nun, Sister Anselm. She made me love Latin as much as she did. I later took the same delight in epidemiology, the closest thing I have found to thinking in Latin. This prompted my postgraduate studies in public health, completed with a part-time scholarship (awarded to promising public servants in the enlightened practice of the day). I applied epidemiology to the little-studied burden of disease in our patients, in whom I noticed diverse chronic and complex health problems. I obtained a Research and Development Grant from the Commonwealth Department of Community Services and Health for the first population study of health disorders in people with intellectual disability. This showed that, of a random sample of 202 adults with intellectual disability, each had an average of 5.4 medical disorders, half of which had not previously been detected.1 Colleagues in Victoria and Queensland reported that these findings supported their argument for specialised health clinics in those states. Not so enlightened were authorities in NSW, who closed the RNSH Health Promotion Clinic, in the face of many objections. The Department of Community Services’ mys-terious decision ended what was, as far as I know, the first health promotion clinic of its kind in the world. Since then I have tried unsuccessfully to reopen this clinic. An attempted retirementAt that stage, RNSH enforced retirement at the age of 65 years. I was a bored, cross, retired person, so I leapt at the chance to work for a while at Stockton Centre, a large NSW institution for people with intellectual disability. The enlightened administrator at the time, Lorraine Yudaeff, asked if I could find someone to assess the nutrition of the residents. I recruited Lyn Stewart, who had worked with me at RNSH. Lyn ran a tape-measure over some emaciated residents and recommended an enriched diet. This resulted in another study showing that 69 of the multiply-disabled residents in this 550-bed institution were severely underweight, with low levels of vitamin D, iron and folate. They were given a diet with increased caloric density for 12 months, with significant improvements in weight, in serum calcium and vitamin D levels, and in haematological indicators.2 We succeeded in increasing the weight of some very hungry people, but not without protest: one carer said we had ruined the quality of life of an adult resident who now weighed more than his previous 20 kg. He required two people, instead of one, to lift him, and was considered too heavy to take on outings, as they had no hoists. However, the noble staff of Stockton rose to the challenge. Several residents now verge on the overweight, not underweight! As a result of this work, there is now a policy of screening the nutritional and swallowing status of all people with intellectual disability in residential care in NSW. Microarrays — miniaturised assay systems allowing the structure and expression of thousands of genes to be evaluated My mentors and medical detective work I first met Professor Gillian Turner as her locum at Grosvenor. Gillian is now known internationally as a geneticist and has done the fundamental work on identifying the Fragile X syndrome, the most common inherited genetic cause of intellectual disability. This work began when Gillian was a medical officer at Grosvenor and introduced me to the intellectual fascination of dysmorphology and genetic disease. I enjoyed being a medical detective and identifying syndromes. The explosion then occurring in genetics is about to recur, with new technologies such as microarrays (Figure) that will make diagnosis more accessible. Given that a diagnosis can make all the difference to prognosis and treatment of associated physical disease or behavioural phenotype, a group of people much ignored by medicine will be taken more seriously in the future. I once excitedly asked Associate Professor Aidan McElduff (Endocrinologist) in the corridors of Royal North Shore Hospital whether a patient I had referred to him could have Kallman’s syndrome. Aidan looked surprised and said he supposed she could. This turned out to be the underlying aetiology. I was in awe of Aidan’s many qualifications and his far greater knowledge of medicine, but he has since become a mentor, a coauthor of published articles, a collaborator in studies on osteoporosis and hypogonadism, and an expert on the endocrinology of intellectual disability. Aidan once thanked me for introducing him to a new medical specialty, Intellectual Disability Medicine. Battling medical nihilismIt was generally considered inevitable that people with intellectual disability die young, which prompted Seeta Durvasula (Medical Lecturer in Developmental Disabilities, Centre for Developmental Disability Studies, University of Sydney), Wes Baker, Senior Planning Officer, Northern Sydney Health, and myself, to investigate mortality rates in a previously identified cohort of 693 people with intellectual disability in northern Sydney.3 We found that the death rate was five times higher than that of the general population of Sydney’s Lower North Shore.4 Furthermore, the causes of death were quite different from those in the general population, being predominantly respiratory disease and accidents. Seeta Durvasula recently presented data from this ongoing study at an international conference, showing that up to a quarter of these deaths were preventable. Contributory factors, such as inadequate supervision, delayed presentation and delayed diagnosis of illness, were identified. The challenge is now to reduce premature mortality and to treat remediable disease. The NSW Ombudsman is charged with the responsibility for reviewing all deaths of people with disabilities in care, looking at the causes and patterns of death and recommending ways of improving services to reduce early or preventable deaths. This important initiative has been noted internationally and may be replicated in Scotland. We also need to beware of medical nihilism. It is one thing to strive officiously to prevent the demise of an elderly person ravaged with disease. It is another thing to deny treatment to a young person with spastic quadriplegia who is enjoying life but swallows unsafely. I am reminded of a senior consultant with whom I discussed the need for supplementary feeding in some young individuals. “Why treat them”, he said, “aren’t they just vegetables?”. An international movement in intellectual disabilityI presented papers at meetings of the International Association for Intellectual Disability (IASSID) every four years, but found health professionals at these conferences often cowed by our non-medical colleagues, who considered us relics of the past, detested institutions. Encouraged by the then Australian President of IASSID Professor Trevor Parmenter (now Foundation Chair and Director, Centre for Developmental Disability Studies, University of Sydney), a Dutch physician Professor Heleen Evenhuis and I formed the Health Special Interest Research Group of IASSID. This Research Group now has yearly international meetings, and its achievements include developing health targets for adults with an intellectual disability.5,6 These targets address conditions that are highly prevalent, easily identified and amenable to available treatments (eg, regular assessments of hearing, especially if communication problems exist, and of dental and ocular health). The targets have been accepted by IASSID and presented to the World Health Organization for ratification. The future: developmental disability medicineA medical specialty will be established in this field. In The Netherlands, such specialists already exist, while, in the United Kingdom, psychiatrists who have specialised in learning disability are often attached to multidisciplinary teams working with people who have learning disabilities. It is clear, too, that doctors with such specialist knowledge must collaborate with nurses, psychologists, dietitians, speech pathologists, physiotherapists and occupational therapists. If it is possible to have multidisciplinary teams in aged care, such teams should also be available for people with disabilities. Of Australia’s total population, 1.86% have an intellectual disability.7 Thus, this group of people constitutes a population about the same size as our Indigenous population. In my opinion, a specialist clinic at each teaching hospital in Australia is required to support general practitioners caring for people with intellectual disability. In Victoria and Queensland, at least, university-affiliated academic centres for developmental disability provide government-funded medical services. In NSW, the Centre for Developmental Disability Studies at the University of Sydney is not so funded, but has helped me to establish a medical clinic with two other doctors, funded by billing Medicare. Our six-month waiting list illustrates the level of unmet need. Australians with disabilities —predominantly receiving pensions and with no political clout — are caught in a dysfunctional system. Formal responsibility for health and other services has largely passed from the federal to the state governments, with further buck-passing between health and social service departments within the states. Yet, much of their healthcare rests with GPs, funded by the federal government. I was founding chair of the NSW-based Association of Doctors in Developmental Disability (ADIDD), which lobbied for people with disabilities and their need for specialised health services. As it became obvious that this was a national problem, we have now formed the Australian Association of Developmental Disability Medicine (AADDM), which aims to establish national standards in healthcare delivery, lobby federal politicians, issue policy documents and position statements, and, eventually, train specialists in this field. I am lucky to have been present at the beginning of a new branch of medicine. I hope that advances in genetics will eventually lead to a therapeutic revolution for people born with intellectual disability. Meanwhile, we need more medical champions for this vulnerable but silent minority. Receiving an award Member of the Order of Australia (AM) in 2004, receiving the award from Her Excellency Professor Marie Bashir, Governor of New South Wales (left).

Helen P Beange AM, MB BS, MPH, FAFPHM

Objective: To determine (i) whether people advertising themselves on a dating website were more likely to be smokers than members of the general population; and (ii) whether attractive advertisers (those whose ads were viewed most often) were less likely to smoke than all advertisers.Design: Comparison of the number of advertisers who smoke with survey data on national smoking status.Setting: “RSVP”, Australia’s largest web-based dating site (455 196 members on 12 October 2004).Participants: 132 176 advertisements accessed on 10 February 2004.Main outcome measures: Smoking status; and “votes” for advertisers’ attractiveness based on how often visitors to the site accessed individual advertisements.Results: In every age group, there were higher proportions of women smokers among the advertisers than in the general population (P < 0.05), and this was also the case for men aged 50 years and over. There was a higher proportion of non-smokers in the “Top 100” men or women advertisers aged 20–29 years (82%) compared with total RSVP advertisers in this age group (67%) (P < 0.001). 85% of the men and 78% of the women in the two “Top 100” groups were non-smokers, with only 2% of both sexes claiming to be regular smokers.Conclusions: Compared with the general population, a higher proportion of women and older men who advertise themselves on a dating website are smokers. Smokers may be perceived as less attractive.

Simon Chapman PhD · Melanie A Wakefield PhD · Sarah J Durkin PhD

Publications on climate change and the health of populations are burgeoning,1,2 and the relationship between climate change and government actions continues to provoke heated international debate.3,4 Climate is well known to affect the mental health of individuals.5,6 In addition, and of relevance to governments, the relationship between a sense of health and well-being and voter behaviour has been examined.7 However, although it is recognised that climate can affect voter turnout, and elections have been disrupted by inclement weather,8,9 the link between climate and government change has hitherto received no attention in the international literature. MethodsUsing a quasi-semi case–control study design (sans controls), I studied interim results of the October 2004 Australian federal election and weather patterns on election day to test the hypothesis that there is a relationship between weather and voter behaviour, and that it is significant enough to have an electoral impact. I obtained information about the electorates in which the sitting party was replaced from the website of the Australian Broadcasting Corporation.10 The weather predicted by the Australian Bureau of Meteorology for voting day in the electorates which changed hands was obtained from a national newspaper.11 ResultsIn general, voters across Australia enjoyed fine weather on election day (9 October 2004). There was a swing of over 3% to the incumbent Liberal Coalition Government.12 However, the swing was not uniform, nor in one direction. Thirteen of 150 electorates changed party (Box). For three of the five electorates with a swing to the Labor Opposition sufficient to change hands, the weather was not fine, and indeed was predicted to worsen during the day. This weather pattern contrasts dramatically with electorates which recorded a swing to the Liberal Coalition Government sufficient to change hands. In six of these eight electorates (75%), the weather was fine. In the remaining two, the weather was forecast to clear during the day. DiscussionThis study suggests that weather on the day of an election may influence voter choice. However, the limitations of the study do not allow a causal statement. The limitations include the assumption that fine weather is universally welcome, the small sample size, and the imprecision of weather records. Nevertheless, the findings of the study may have relevance to electoral campaigning — and therefore to political and subsequently population health outcomes. Possible improvements to the study include use of a historical cohort design, in which weather data are collected for each electorate on serial election days and compared between electorates which changed party and those that did not. The method could be adapted for international comparisons, and the hypothesis tested over time in other electoral systems. Subsequently, if the findings are very strongly suggestive, and resources and technology emerge to facilitate it, researchers could randomise similar electorates to receive “usual” weather or “enhanced” weather. This could answer definitively whether weather, and what weather, wins votes. Importantly, a proven relationship between climate and government change would stretch the horizons of scholarship. Incumbent governments could research and use evidence-based physical and spiritual interventions to exploit the vast campaign resource potentially provided by fine weather. Conversely, parties in opposition seeking office could develop behaviour-change strategies to convince key voters that although they think the weather is fine, it is only a matter of time. In any event, this research highlights the possibility for the diverse disciplines of meteorology, medicine, social psychology, political science and demography to explain electoral success — an outcome with potentially major impacts on health. Forecast weather in electorates that changed party in the Australian federal election, 9 October 2004* Electorate Sitting party Forecast weather Swing ALP gain Adelaide (SA) LIB Fine 1.9% Cunningham (NSW) GREEN Partly cloudy 0.8% Hindmarsh (SA) LIB Fine 1.0% Parramatta (NSW) LIB Becoming cloudy 1.9% Richmond (NSW) NAT Isolated showers later 1.9% Liberal gain Bass (TAS) ALP Fine 4.7% Bonner (QLD) ALP Fine 2.4% Braddon (TAS) ALP Fine 7.1% Greenway (NSW) ALP Fine 3.7% Hasluck (WA) ALP Clearing showers 3.6% Kingston (SA) ALP Fine 1.4% Stirling (WA) ALP Clearing showers 3.6% Wakefield (SA) ALP Fine 1.9% * Electoral information was obtained from www.abc.net.au/elections/federal/2004/results/changing.htm10 (accessed 10 Nov 2004), and forecast weather from the Bureau of Meteorology (published 9 Oct 2004 in The Weekend Australian11). ALP = Australian Labor Party. GREEN = Australian Greens Party. LIB = Liberal Party. NAT = National Party. NSW = New South Wales. QLD = Queensland. SA = South Australia. TAS = Tasmania. WA = Western Australia.

Rosemary Aldrich BA (Comm), MPH, FAFPHM

Objectives: (1) To assess the number and severity of episodes of Irukandji syndrome in Broome, Western Australia. (2) To correlate demographic, seasonal, geographic and climatic features of Irukandji stings. (3) To assess treatment of Irukandji syndrome at Broome Health Service. (4) To assess the public health impact.Design and setting: (1) A retrospective analysis of jellyfish data forms and charts of 111 patients, identified from Broome Health Service Emergency Department with a discharge diagnosis of marine sting between 1 January 2001 and 1 July 2003. (2) Correlation between climate and Irukandji envenomation data.Main outcome measures: Number of patients with Irukandji syndrome; their demographic and environmental features; the clinical syndrome; treatment requirements.Results: 111 patients were prospectively identified with marine stings; 88 were identified with Irukandji syndrome. Non-Irukandji syndrome data were excluded for analysis. The “jellyfish season” extends from January to May, although stings occur all year round. Only 38% of patients had vinegar applied to the sting site before hospital presentation. Signs and symptoms were variable between individuals, with 20% having no signs of sting at all and welts found in 16%. Fifty per cent of patients were hypertensive at presentation. Distress was found in the majority of patients, with 90% requiring opioid analgesia (morphine equivalent: mean, 20 mg; median, 13 mg) and 17% requiring admission. There was one evacuation to Perth with cardiotoxic marine envenomation resulting in pulmonary oedema, which necessitated 4 days in intensive care. Stings were significantly more common when the ambient median temperature was greater than 28.3°C, after midday, on an incoming high tide and on windy days.Conclusion: The rate of envenomation in northern WA is likely to be the highest currently documented in Australia. There is syndromic variability when compared with the north Queensland experience. This implies different causative jellyfish species that are not yet identified. Stings in Broome can be severe and life threatening; there are significant commercial and public health implications as a result. Management at Broome Hospital is contemporary and effective.

Conrad J Macrokanis MB BS, FRACGP, BSc(Hons) · Nicole L Hall · Jacki K Mein MB BS, FACCHP, MAE

To the Editor: We report an unusual case of Ross River virus (RRV) disease in a 7-year-old child. The patient presented to her general practitioner with fever, rash and pain in the lower limbs. Swelling of the joints of the hands and left knee was found, with a widespread rash that covered the trunk, limbs and face. The rash comprised lesions of varying types, including maculopapular, vesicular and petechial lesions (Box). Rash in a child with Ross River virus disease The general practitioner transferred the patient to the state tertiary paediatric service. No antibiotics were given before transfer. On arrival at Princess Margaret Hospital for Children, Perth, the patient was unwell, with a fever of 38°C. A provisional diagnosis was made of septicaemia (probably meningococcal), and treatment was begun with intravenous ceftriaxone. Extensive investigations were performed, but results of all initial serological, polymerase chain reaction and culture investigations were negative. Rheumatology review was requested because of the prominent arthritic component of the illness. This revealed widespread polyarthritis, and the illness was felt to be a reactive or post-infectious process. The child’s family raised the possibility of RRV disease, as her grandmother had had this disease several years previously, and the child had stayed overnight at her grandmother’s home in a coastal lake area 2 weeks before disease onset. The area had abundant mosquitoes, as well as kangaroos, which are vertebrate amplifiers for RRV.1 Serological tests for RRV were performed 3 days after admission, and were negative for IgG and positive for IgM. Repeat serological testing during convalescence showed a fourfold rise in IgG titre (from 80 to 320), confirming the diagnosis of RRV disease. The patient’s rash decreased over several days. She had persistent synovitis in the left knee at review 3 weeks after admission. At review at 8 weeks all symptoms and signs had resolved, and she had full function. This case highlights the fact that, while RRV disease with severe symptoms and arthritic manifestations is uncommon in children, it nevertheless should still be considered in the differential diagnosis of children with a febrile and arthritic disease.1,2 This child’s illness appears to have been a reactive vasculitis and polyarthritis, which, while well recognised with other infections, is not well described in association with RRV disease in children. RRV arthritis is caused by joint infection, and treatment is currently based on empirical anti-inflammatory regimens. During the recent RRV disease epidemic in Western Australia, 1174 notifications for RRV disease were received between 1 October 2003 and 31 March 2004. Of these, 21 patients were aged 15 years or younger. Thus, while RRV disease is an infrequent illness in children, it does occur, and should be considered in the differential diagnosis of a child who presents with a febrile illness, rash and joint symptoms from an area with known autochthonous transmission of RRV.

Kynan T Feeney · Kevin J Murray · Amanda J Whittle · Gary K Dowse

Weight loss occurs in the short term, but not enough is known to recommend long term use After health professionals have promoted a low fat, high carbohydrate model of eating for more than 20 years, the prevalence of overweight and obesity in Australia (as elsewhere) has climbed.1 Very few people are able to attain and maintain a truly low fat eating plan, but that has not stopped the low fat orthodoxy being blamed for the obesity epidemic.2 Yet, it is not sufficient to focus on a single aspect of diet — low fat diets are not intrinsically “healthy”, especially if they contain high levels of simple sugars, low levels of complex carbohydrates and are nutrient poor. In contrast to the low fat, high carbohydrate diet, a popular approach to weight loss is the Atkins diet,3 a “controlled carbohydrate” dietary regimen. One of the many reasons for its popularity is that, as society has become increasingly concerned about body image and weight, the Atkins regimen promises quick weight loss without hunger, allows a wide range of foods and has simple “rules”. All this is supported by consumer “how-to” books, celebrity endorsement, and food product innovation and marketing. The Atkins diet — “kerbing the carbs”Atkins’ theory rests on a belief that a high intake of refined carbohydrate, especially simple sugars, causes overstimulation of insulin and results in uncontrolled hunger and eating, while the excess insulin also favours fat storage. Thus, the Atkins diet relies primarily on controlling carbohydrate intake and progresses through four phases. The strict induction phase, intended to produce ketosis, allows only 20 g of carbohydrate a day for a minimum of 2 weeks. Fruit, bread, grains, starchy vegetables or dairy products other than cheese, cream or butter are eliminated. Sugar and alcohol are not allowed, and caffeine is discouraged. Mineral and vitamin supplementation, dietary fibre, and eight glasses of water a day are recommended. During this restrictive phase, weight loss is rapid. While this initial weight loss may be due in part to water loss as body glycogen stores are depleted, low carbohydrate diets also result in a reduced caloric intake.4-7 Factors contributing to the lower caloric intake may be the satiating effect of a high protein diet, a lower absolute fat intake due to restricted food choice, and possibly appetite suppression due to ketosis.8-10 However, the exact mechanisms of the weight loss are as yet unknown.10 The second and third phases of the diet allow a gradual liberalisation of food intake by an incremental increase in total carbohydrate: fruits, nuts, more vegetables and some cereal foods are added. The final, maintenance phase is intended to be permanent, and aims to keep daily dietary carbohydrate intake to a known (relatively low) amount. Advice for patients wanting to follow the Atkins diet While low carbohydrate diets appear to work for weight loss in the short term (6 months), not enough is known to recommend them in the long term. All weight-reduction diets are difficult to follow over a long period of time and have limited long term success. Follow the complete Atkins plan (not only parts of it), including regular physical activity, vitamin and mineral supplementation, a daily fibre supplement, eight glasses of water a day, and minimally processed foods. Maintain a high daily intake of fruit and vegetables (at least two serves of fruit and five serves of vegetables from the “allowed” foods) and avoid saturated fats. A dietitian can help with your dietary intake plan if you are having difficulties. Does the Atkins diet work?If weight loss is the goal, the answer appears to be a qualified “yes”. For obese people, it works a little better than a low fat diet over 6 months. Recently, four randomised controlled trials in obese men and women (two lasting 6 months, two lasting 12 months) compared a low carbohydrate diet to a conventional low fat weight-loss diet.5-7,11 Although the studies differed in design and had different subjects, in each study the weight loss at 6 months was 4–6 kg greater for the low carbohydrate group than for the low fat group. However, the weight loss difference between groups at 12 months was no longer statistically significant.6,11 The dropout rates in all of the trials were high (21%–43%), with a general non-significant tendency for better retention in the low carbohydrate group. So, in the long term, low carbohydrate diets do not necessarily offer better weight control than lower fat, higher carbohydrate diets. Is the Atkins diet safe?During weight loss, a low carbohydrate regimen appears to have no adverse effects on cardiovascular risk factors such as serum lipid levels (total and low-density lipoprotein cholesterol) or blood pressure, or on fasting glucose and fasting insulin levels.6,7 In fact, randomised controlled trials comparing a low carbohydrate diet with a low fat diet up to 12 months consistently indicate a beneficial effect on serum triglyceride and high-density lipoprotein cholesterol concentrations. However, the low carbohydrate regimen is associated with a greater incidence of constipation, headache, halitosis, muscle cramps, diarrhoea, general weakness and rash.5 Strictly limiting carbohydrates could also reduce intake of plant-based foods rich in phytochemicals, bioflavinoids, carotenoids and other micronutrients now regarded as important in a healthy diet.12 The regimen developed by Atkins3 encourages fruit and vegetable intake, and minimally processed food, so a low carbohydrate diet should not necessarily imply an intake low in fibre and low in plant-based food. Low carbohydrate diets may also be beneficial by removing simple sugars and sugary foods, including fructose sweeteners, which could be responsible for excess energy intake.8 Overall, however, the safety of low carbohydrate diets beyond 12 months is largely unknown, and there is speculation that the regimen may have adverse health implications for cardiovascular disease, renal function (through an observed cross-sectional association of high dietary protein intake with proteinuria) and bone health (through relatively low calcium intake and the association of high protein intake with hypercalcinuria).13 Information is also lacking on the long term effect of a low carbohydrate regimen for the young, the elderly, people of normal weight (or for people who are not losing weight), and those with chronic conditions, such as diabetes or cardiovascular disease. As with many dietary regimens, the nutritional quality of low carbohydrate diets varies according to how the dietary rules are applied. The Atkins diet calls for a drastic dietary reduction of foods with a significant starch and sugar content — in doing so, the intake of many energy-dense but micronutrient-poor foods is reduced. There is the potential for these to be replaced with foods that are moderate in energy intake, and rich in fibre and micronutrients. However, in any regimen to reduce or control weight, particular attention should be given to ensuring that the reduced food intake is of high nutritional quality. A sensible way to follow an Atkins diet is to include plenty of the allowed fruits and vegetables, and to prefer food sources of unsaturated fat over those with saturated fat.

Malcolm D Riley PhD · John Coveney PhD

To the Editor: Pertussis (whooping cough) is a readily transmissible respiratory infection that may cause severe respiratory illness. The burden of severe pertussis affects infants, often resulting in hospitalisation (especially those aged under 6 months) and death (1 in every 200 patients aged under 6 months).1,2 In Australia, there were nine deaths from pertussis between 1993 and 1997, predominantly in young infants, and a further five young infant deaths during the 2001–2002 epidemic.3,4 Epidemics occur every 3 to 4 years.2 Pertussis cases and hospitalisations in children aged under 6 months continue to occur in south-east Queensland, with 19 notifications since January 2003. There has been a shift in the epidemiology of pertussis in Australia and the United States, from a disease of young children to a disease of adolescents and adults of child-bearing age.1,5 In Australia, there has been a preponderance of pertussis notifications in adult females.5 Pertussis vaccine is already provided free to children at ages 2, 4 and 6 months, 4 years and 15 years, as part of the National Immunisation Program.2 However, young infants remain incompletely protected by vaccination, as the third, completion dose of the primary course of pertussis vaccination is not given until 6 months of age. A national study of hospitalised infant pertussis cases in 2001 indicated that parents were the presumptive source of pertussis infection for their children in more than 50% of cases.6 This has led the National Health and Medical Research Council to recommend that both parents should receive a (once-only) adult booster dose of pertussis vaccine, either when planning pregnancy or as soon as possible after delivery of an infant.2 The cost of the vaccine is about $30. As yet there is no suggestion that funding will be made available to provide this vaccine to all new parents as part of the National Immunisation Program. However, the amount is not a high price to pay for the protection of a new baby and its parents, particularly now that new parents will receive additional financial support from the federal government. The potential exists to promote opportunistic maternity-ward-based administration of this vaccine to post-partum mothers and their partners. We encourage all medical practitioners, especially obstetricians and paediatricians, to discuss this important issue with parents.

Brad J McCall · Rod P Davison · Michael D Nissen · Clare B Nourse