Environmental health

Although some vaccines new to the childhood schedule are not free, they are strongly recommended In September 2003, the National Health and Medical Research Council (NHMRC) approved the new Australian Standard Vaccination Schedule recommended by the Australian Technical Advisory Group on Immunisation (ATAGI) (Box). The schedule includes inactivated poliomyelitis vaccine (IPV), varicella vaccine and seven-valent pneumococcal conjugate vaccine (7vPCV) for infants and young children. Earlier, in late 2002, routine meningococcal C conjugate vaccine was approved and funded for children aged 12 months, together with a cross-sectional catch-up program for young people to the age of 19 years (media release, Senator Kay Patterson, 24 November 2002). For the first time since 1994 — when all vaccines recommended on the schedule were funded for children vaccinated by both private and public providers under the National Immunisation Strategy1 — the childhood schedule recommended by NHMRC contains vaccines (IPV, varicella and 7vPCV) not available free of charge to parents. As well as adding these four vaccines to the childhood program, the NHMRC also approved changes to the pertussis vaccination schedule. Since the diphtheria–tetanus vaccine was replaced by a combined diphtheria–tetanus–acellular pertussis (DTPa) vaccine at 4–5 years in 1995, the peak age of pertussis has progressively risen to 13–18 years.2 Based on recent evidence that three doses of DTPa in the first year of life provide good protection until the age of 6 years,3 it was decided to adjust the schedule so that the fifth dose is now given to adolescents at 15–17 years, using an adult-formulated vaccine (dTpa). This was done by removing the 18-month dose, thus making the 4-year dose the fourth dose. This is not expected to lower preschoolers’ protection from pertussis,4 but should help reduce the number of large local reactions seen when the dose was given at 18 months.5 Inactivated poliomyelitis vaccine was recommended because it does not cause the extremely rare (1 in 2.4 million doses) live-vaccine-associated paralytic polio. The United States has already changed to inactivated vaccine,6 and other countries are considering doing so. The change to this vaccine in Australia may take time, as it is many times more costly than the oral vaccine and has had limited availability. Although various combinations of IPV with diphtheria, tetanus, acellular pertussis, Haemophilus influenzae type b and hepatitis B vaccines are licensed in Australia,7 they are not yet available, as the companies producing them are uncertain of the potential market. In the interim, the Australian Government’s National Immunisation Program will continue to provide free oral live-attenuated poliomyelitis vaccine. In making recommendations about the inclusion of each new vaccine in the childhood vaccination schedule, ATAGI took into account a wide range of factors. These included: vaccine safety and efficacy; the preventable burden of the disease targeted by the vaccine; the ease with which the vaccine could be integrated into the existing schedule; any likely effects on herd immunity, reduction in antibiotic resistance or impact on disease epidemiology; and cost-effectiveness and equity issues. Some of the information used by ATAGI as the basis for its recommendations is contained in the The Australian immunisation handbook (8th edition), while the levels of evidence for the new recommendations are available on the Internet and on CD-ROM.7 NHMRC resolved that the benefits of these vaccines were sufficient for them to be included in the schedule, irrespective of the provision of public funding. These new vaccines are more costly than any previous additions to the vaccination schedule. In the private market, three doses of conjugated pneumococcal vaccine cost far more than $300, one dose of varicella vaccine more than $40 and combinations with IPV more than an extra $18 for the IPV component. At the government level, the total annual cost of adding IPV, varicella vaccine and 7vPCV to the schedule would be about $100 million, and would almost double the current cost of all other childhood vaccines. This is a large expenditure. The cost-effectiveness of these three vaccines in Australia is therefore important.8-10 Changing to IPV (at $14 per dose) is estimated to prevent one case of vaccine-associated paralytic polio every 2–3 years, a cost of $17 million per case averted.8 This must be considered in the context of the maintenance of public confidence in immunisation programs. For varicella vaccine (at $53 per dose), universal vaccination of infants could prevent 450 hospitalisations each year, at a cost of $21 000 per hospitalisation averted, and one death per year, at a cost of $10 million per death averted, over a 30-year period.9 This does not include the out-of-pocket costs to families of a child having varicella, which make vaccination cost-effective in the United States.11 Universal use of 7vPCV (at $90 per dose) could prevent two to three deaths, 13 cases of meningitis, 110 cases of invasive pneumococcal disease, 800 cases of pneumonia and 14 600 cases of otitis media which would otherwise occur annually in each birth cohort of about 240 000 non-Indigenous Australian children by their fifth birthday.10 The cost per death averted and the cost per life-year saved by 7vPCV is estimated to be $5 million and $230 000, respectively.10 This does not take into account the impact of universal 7vPCV on adult pneumococcal disease or pneumococcal antibiotic resistance, as documented in the United States.12 However, these economic data were only part of the many reasons that ATAGI and NHMRC recommended that all children receive these vaccines (see above). Parents should be strongly encouraged by their physicians to have their children vaccinated. Conjugated pneumococcal vaccine is funded for a small group of children with medical conditions placing them at high risk of disease, as well as for Aboriginal and Torres Strait Islander children.7 For some parents the NHMRC recommendation will be sufficient; for others further discussion of the vaccine costs and benefits will be needed. Detailed fact sheets to assist providers and parents are available on the website of the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases <www.ncirs.usyd.edu.au>. Until all recommended vaccines are available free at the point of service, there is a dilemma for the community and for policy makers. The objectives of high childhood vaccine coverage and of equity for children could be at stake. This will be a continuing issue over the next 5–10 years as more new vaccines become available. These include rotavirus vaccine, live attenuated intranasal influenza vaccine, and other live vaccines targeting viral respiratory pathogens. Until now, vaccines have had a very high cost–benefit ratio, often being cost-saving,13 in contrast to many other prophylactic and most curative treatments. We can no longer expect vaccines to be cost-saving, with the increasing cost of the large clinical trials now needed to measure impact on rare diseases and to exclude rare adverse effects. Nevertheless, despite the fall in cost–benefit ratio in absolute terms, the economic benefits of vaccines relative to pharmaceuticals will persist.13 We now need greater public awareness of the current and potential benefits of disease prevention from vaccines, leading to greater public advocacy. Maximal benefit from vaccines can only be obtained by ensuring their availability and use across all age-eligible members of the population. Australian standard vaccination schedule7

Margaret A Burgess MD, FRACP, FAFPHM · Peter B McIntyre FRACP, FAFPHM, PhD

Cannabis use and dependence: public health and public policy. Wayne Hall and Rosalie Liccardo Pacula. Melbourne: Cambridge University Press, 2003 (xiv + 298 pp). ISBN 0 521 80024 2. “Wayne Hall and Rosalie Pacula have written the first honest book on cannabis addressing the whole range of issues that need to be considered for a sensible policy discussion.” No, the source of this quotation is not the publisher’s advertising department. Rather, these are the words of the author of the book’s preface, Peter Reuter, one of the most perspicacious international scholars in the area of psychoactive drugs policy. Honesty and comprehensiveness are features too often lacking in debates on illicit drugs policy. Hall and Pacula (Australian scholars with outstanding reputations in the drugs field) have taken this head on, aiming “to improve the quality of public policy debate on cannabis by ensuring that all relevant issues are addressed” (p3). The book certainly is comprehensive, striking an excellent balance between reviewing and assessing the evidence about the health, psychological and social consequences of cannabis use and, importantly, the costs and effectiveness of cannabis prohibition. This volume is beautifully designed, making its contents accessible to both the busy professional and the student. This is achieved by the use of many subheadings, chapter summaries and a final topic-by-topic summary chapter. Cannabis use and dependence is a book that I will refer to frequently. It is a wonderful resource, providing in one place a sound presentation and evaluation of the current literature about the impacts of cannabis use and of society’s responses to cannabis and its use, and suggesting pathways towards sounder, more evidence-based public policy on cannabis. It fills a significant gap for students and their instructors, as no other volume provides reliable information and assessment in such a package. People of influence in public health and government, involved in the contested field of evolving policies on cannabis, should also find this an invaluable resource. As Peter Reuter said, it is both honest and comprehensive — quite an achievement! David McDonaldConsultant in Social Research andEvaluation Canberra, ACT

David McDonald

Wenbiao Hu,* Anthony J McMichael,† Shilu Tong‡ * PhD candidate, Centre for Health Research, Queensland University of Technology; † Director, National Centre for Epidemiology and Population Health, Australian National University, Canberra; ‡ NHMRC Senior Research Fellow, School of Public Health, and Centre for Health Research, Queensland University of Technology, Kelvin Grove, QLD 4059. s.tongATqut.edu.au To the Editor: We examined the possible association between the Southern Oscillation Index (SOI) and the occurrence of hepatitis A in Australia using a Seasonal AutoRegressive Integrated Moving Average (SARIMA) regression model.1 Our results indicate that the SOI is statistically significantly associated with the transmission of hepatitis A. We obtained data on the monthly counts of hepatitis A cases in Australia and the monthly SOI between 1 January 1991 and 31 December 2000 from the Commonwealth Department of Health and Ageing and the Australian Bureau of Meteorology, respectively. Data on population sizes were obtained from the Australian Bureau of Statistics. Cross-correlations were used to compute a series of correlations between SOI and the incidence of hepatitis A over a range of time lags (defined as the time span between the SOI and the incidence of hepatitis A). A SARIMA model was used to estimate the independent contribution of SOI in our study. We adjusted for seasonality by “seasonally differencing” (ie, replacing each observation by the difference between it and the observation from the previous year). In the modelling process, attention was paid to observations well outside the main body of the data (outliers) and the only outlier was excluded in the final SARIMA model. We used the SARIMA [1,0,0] [1,1,0]12 model (ie, first-order autoregressive combined, first-order seasonal autoregressive, after adjustment for first-order seasonal integration) to assess the association between SOI and the incidence of hepatitis A. We found that a decrease in the SOI (ie, warmer and drier conditions) was statistically significantly associated, at a lag of 1 month, with an increase in the monthly incidence of hepatitis A (β = − 0.01; P = 0.001). Two El Niño events (1991–92 and 1997–98) were also clearly associated with an increased incidence of hepatitis A (Box). The results suggest that there was an increase of about 360 cases per year in Australia for an, on average, interquartile range decrease in the SOI. The residuals in the model fluctuated randomly around zero, and there was no apparent autocorrelation between residuals at different lag times (data are available from the corresponding author). These results indicate that the model fitted the data well, with no violation of assumptions. The significant association between SOI and the incidence of hepatitis A remained when the outlier was included in the model (β = − 0.013; P = 0.001). El Niño Southern Oscillation (ENSO) has been found to be related to various health outcomes, including waterborne disease, vectorborne disease, and natural disaster-related deaths (eg, floods, bushfires and cyclones).2-4 Our study adds further evidence of ENSO-related health effects. Infectious diseases are, in general, sensitive to climate variability, as climate can influence the development and transmissibility of pathogens, and can also affect people’s behaviour.3,5 If the relationship between ENSO and hepatitis A is confirmed by other studies, these findings may facilitate the development of early warning systems for controlling and preventing this widespread communicable disease. Incidence of hepatitis A in Australia and the Southern Oscillation Index between January 1991 and December 2000 Negative values of the SOI are associated with El Niño conditions (dry and warm in Australia), and positive values with La Niña conditions (wet and less warm in Australia).

Wenbiao Hu · Anthony J McMichael · Shilu Tong

Medicines out of control? Antidepressants and the conspiracy of goodwill. Charles Medawar and Anita Hardon. Amsterdam: Aksant Academic Press, 2004 (x + 258 pp) ISBN 90 5260 134 8 When Charles Medawar, a professional consumer advocate in the UK specialising in medicines policy and drug safety issues, first made The antidepressant web available on his Social audit website in 1998, the kinds of concerns he was expressing about antidepressants were very much on the fringe. In 2004, with the publication of Medicines out of control?, the mainstream has moved significantly towards Medawar’s stance. Together with Ralph Nader, Medawar began his career as a consumer advocate in the United States some 30 years ago, and experience has taught him the need for persistence and assertiveness in challenging the prevailing view in psychiatry. Recent scientific publications have largely vindicated his claims that the newer antidepressant drugs cause dependence and suicidal behaviour, and have poor efficacy; that the pharmaceutical industry is in the business of disease promotion; and that much “expert opinion” is compromised. He and his coauthor, Anita Hardon, an anthropologist, begin with a historical overview of psychotropic medications. They describe a recurrent pattern of new “wonder drugs” first hailed as the answer to mental illness, or to addiction, and eventually discarded as ineffectual, habit-forming, or frankly dangerous. The focus then shifts to the newer antidepressants, and the authors discuss the problems of patients who become dependent on the medication; the manipulation by the pharmaceutical industry of the public perception of the need for antidepressants; and the way in which regulatory authorities have failed public health. Medawar was instrumental in drawing attention to the real and significant adverse effects of these newer antidepressants, paroxetine in particular, and for this he deserves praise. One quibble is that he does not always show the same level of healthy scepticism to some of the reports of the apparent side effects of these drugs as he does to their apparent benefits — their capacity to be a “nocebo” does not get as much attention as their placebo qualities. Jon N JureidiniHead, Department of Psychological Medicine Women’s and Children’s Hospital, Adelaide, SA

Australian health care system. 2nd ed. Stephen J Duckett. Melbourne: Oxford University Press, 2004 (xxv + 341 pp). ISBN 0 19 5517458. THE AUSTRALIAN HEALTHCARE SYSTEM The Australian healthcare system is dauntingly complex. To understand it you need a good map, and this book, now updated to a 2nd edition, is an excellent map. Most structural aspects, such as funding arrangements; provider configuration including hospitals, primary care and public health; and policy issues such as workforce and health system design, are described clearly and concisely using a systems framework. Arguably, there is no one else who has had the range of experience of travelling through and, on occasion, steering the Australian healthcare system than the author. Professor Duckett is a leading health services academic and has been our most senior health bureaucrat. He brings an operations research, economic, managerial, policy and a particular political perspective to the task. No one, of course, writes a book exactly as a reviewer would have. Given the author’s background, I would have appreciated more on his perspective of the role of politics and process in shaping the health system over the past 20 years. Perhaps that will be another book — a 21st-century version of the seminal 1984 book by the late Sydney Sax, A strife of interests: politics and policies in Australian health services (Sydney: Allen and Unwin, 1984). The present work will contribute most as a textbook for postgraduate students in public health and health services management, for whom it is already a standard text. However, all clinicians would benefit from a deeper understanding of the Australian healthcare system and how it provides the construct for their clinical work. This book is a good place for them to start that journey. Johannes U StoelwinderOrthopaedic Surgeon Chair of Health Services Management Alfred Hospital, Melbourne, VIC

Johannes U Stoelwinder

Project management in health and community services Judith M Dwyer, Pauline Stanton, Valerie Thiessen. Sydney: Allen and Unwin, 2004 (xxi + 200 pp) ISBN 1 74114 055 2. Would I be interested, the polite letter from the Journal asked, in reviewing a book about project management? I turned the letter over gloomily — I couldn’t think of a less interesting title. The sub-text, however, Getting good ideas to work, was a bit of a pull, as I have a big project just starting. One of the frequent deficits of doctors when they assume levels of seniority is a thorough incompetence at management. We are trained with quite different skills in mind, like caring for individual people. Project management is not always well done, even for medicos involved in research — projects often fizzle out not because of problems with design, or messing up the sample, but because of pragmatic failings. So this book might have relevance to all of us involved with projects, and — look! — written for us health folk, and by true-blue Aussies. The book comes in two parts: some of the research and thinking behind projects, and where they fit in organisations and their strategies. There is quite a bit of theory, but few pragmatic data on what works. The theory is littered with technical stuff: it was good to get my head around things I had come across but wasn’t really sure about, like PERT (Project Evaluation and Review Technique), Gantt Charts, WBS (Work Breakdown Structure) and PMBOK (Project Management Body of Knowledge). There isn’t anything here that is intellectually tricky. Don’t worry, they say, about all the technical stuff. Forget the acronyms, all you really need is buckets of common sense. We are introduced to tools (mostly software) that help manage projects, but the finger is wagged in our faces about not relying on them, and the plans they generate. “Project management is an art not an algorithm” (p63). So does any this stuff work? Empirical research is weak, but suggests the usual suspects for failure: insufficient planning, buy-ins from the organisation, planning and so on… The second part of the book is more of a workshop manual. What to do, and, more pertinently, what not to forget. It suggests telltale signs of things going wrong; how to spot the folk who might cause you problems (like the white-ant); and what to do about them. This is the sort of book in which you might pause, smile in recognition, and read on again. There are examples — some real — from Australian hospitals, community health settings, and also Divisions of General Practice. A good book. I am the better for having read it. I think. Christopher B Del MarDean Health Science and Medicine Bond University Gold Coast, QLD

Christopher B Del Mar

Re: “Overweight and obesity in Australia: the 1999–2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab)”, by Adrian J Cameron, Timothy A Welborn, Paul Z Zimmet et al in the 5 May 2003 issue of the Journal (Med J Aust 2003; 178: 427-432). In Box 3 and Box 4 (pages 429 and 430), the row headings for the weekly income categories were reversed — the reference category should have been the lowest (rather than the highest) income group. These sections of Boxes 3 and 4, as they should have appeared, are shown below. This reversal affected our interpretation of the results of the study. In the Results section (page 431), we stated that “Increasing income increased the risk of obesity in women. Although no such association was significant for men, both the BMI and waist circumference data suggested that middle-income men tended to be more obese than the lowest income group.” This should have read: “Increasing income decreased the risk of obesity in women. Although no such association was significant for men, both the BMI and waist circumference data suggested that middle-income men tended to be more obese than the highest income group.” In the Discussion section (page 432), we stated that “In men, minor trends for middle-income groups to be more obese and the least affluent to be thin were observed, although these were not significant. Women, by contrast, showed a strong positive graded association between income and obesity.” This should have read: “In men, minor trends for middle-income groups to be more obese and the most affluent to be thin were observed, although these were not significant. Women, by contrast, showed a strong negative graded association between income and obesity.” The association between obesity and income was not a major outcome of the study, with the results focusing on the prevalence of obesity and the association of obesity with physical activity and television viewing time. The html and pdf versions of the article published in the eMJA were corrected on 20 March 2004. 3: Association between obesity (measured using body mass index [BMI]* [n = 4996] and waist circumference* [n = 4984]) and potential risk factors among Australian men Body mass index Waist circumference n Adjusted odds ratio† (95% CI) n Adjusted odds ratio† (95% CI) Smoking status Non/ex-smoker 4048 1.00 4041 1.00 Smoker 865 0.71 (0.48–1.04) 860 0.63 (0.51–0.78)‡ Physical activity§ Lowest quintile 946 1.00 946 1.00 Highest quintile 1021 0.70 (0.46–1.06) 1022 0.56 (0.42–0.75)‡ Television viewing¶ Lowest quintile 784 1.00 783 1.00 Highest quintile 1094 1.86 (1.30–2.67)‡ 1093 1.97 (1.48–2.63)‡ Education University/Further education 2089 1.00 2086 1.00 Completed high school 901 1.14 (0.92–1.42) 900 0.93 (0.69–1.27) Some high school completed 1693 2.19 (1.6–3.01)‡ 1684 1.65 (1.17–2.33)‡ Primary school/never attended school 309 2.40 (1.59–3.61)‡ 310 2.31 (1.69–3.15) ‡ Country of birth Australia/New Zealand 3727 1.00 3713 1.00 United Kingdom/Northern Ireland 612 0.92 (0.65–1.29) 611 0.89 (0.68–1.16) Rest of world 653 0.85 (0.67–1.08) 656 0.60 (0.40–0.92)‡ Weekly income (A$) 0–199 502 1.00 502 1.00 200–399 1541 1.18 (0.80–1.74) 1533 1.30 (0.93–1.81) 400–599 1162 1.12 (0.78–1.60) 1157 1.29 (0.91–1.82) 600–799 1133 1.07 (0.77–1.50) 1134 1.23 (0.84–1.80) 800–1499 571 1.06 (0.70–1.62) 573 0.97 (0.69–1.36) 1500+ 37 0 .68 (0.22–2.07) 36 0.51 (0.17–1.54) Occupation** Skill level 1 1243 1.00 1244 1.00 Skill level 2 540 0.65 (0.46–0.93)‡ 534 0.74 (0.49–1.14) Skill level 3 658 0.48 (0.32–0.72)‡ 659 0.43 (0.26–0.70)‡ Skill level 4 604 0.95 (0.63–1.43) 602 0.84 (0.58–1.21) Skill level 5 304 0.93 (0.52–1.63) 304 0.92 (0.46–1.84) Others 1629 0.56 (0.35–0.89)‡ 1623 1.07 (0.66–1.72) * Obesity defined as BMI ≥ 30 kg/m2, or waist circumference ≥ 102 cm. † Model adjusted for age and all other risk factors in the table. ‡ Significantly different from reference (P < 0.05). § Quintiles of physical activity: < 30 minutes = lowest, ≥ 550 minutes = highest. ¶ Quintiles of television viewing: < 300 minutes = lowest, ≥ 1260 minutes = highest. ** Skill levels: 1 — managers, administrators and professionals; 2 — associate professionals; 3 — tradespersons, advanced clerical and service workers; 4 — intermediate clerical, sales and service workers, intermediate production and transport workers; 5 — elementary clerical, sales and service workers and labourers; and others — students, retirees, pensioners and unemployed. 4: Association between obesity (measured using body mass index [BMI]* [n = 6071] and waist circumference* [n = 6075]) and each of the potential risk factors among Australian women Body mass index Waist circumference n Adjusted odds ratio† (95% CI) n Adjusted odds ratio† (95% CI) Smoking status Non/ex-smoker 5123 1.00 5128 1.00 Smoker 857 0.70 (0.51–0.97)‡ 858 1.03 (0.76–1.39) Physical activity§ Lowest quintile 1254 1.00 1255 1.00 Highest quintile 1221 0.47 (0.31–0.72)‡ 1221 0.53 (0.34–0.80)‡ Television viewing¶ Lowest quintile 992 1.00 994 1.00 Highest quintile 1292 1.82 (1.19–2.76)‡ 1295 2.27 (1.55–3.32)‡ Education University/Further education 1985 1.00 1985 1.00 Completed high school 1185 1.04 (0.77–1.40) 1185 1.31 (1.01–1.70)‡ Some high school completed 2481 1.48 (1.19–1.83)‡ 2487 1.47 (1.19–1.82)‡ Primary school/never attended school 419 2.12 (1.18–3.80)‡ 417 2.68 (1.64–4.36)‡ Country of birth Australia/New Zealand 4672 1.00 4677 1.00 United Kingdom/Northern Ireland 644 0.95 (0.68–1.34) 646 1.01 (0.69–1.49) Rest of world 754 0.80 (0.66–0.97)‡ 751 0.72 (0.57–0.92)‡ Weekly income (A$) 0–199 1034 1.00 1034 1.00 200–399 2046 0.85 (0.67–1.08) 2046 0.93 (0.74–1.19) 400–599 1270 0.87 (0.66–1.15) 1274 0.79 (0.62–1.02) 600–799 1064 0.57 (0.40–0.82)‡ 1062 0.62 (0.46–0.83)‡ 800–1499 499 0.67 (0.48–0.93)‡ 501 0.59 (0.37–0.94)‡ 1500+ 20 0.63 (0.19–2.11) 20 0.46 (0.13–1.65) Occupation** Skill level 1 990 1.00 989 1.00 Skill level 2 390 0.82 (0.41–1.65) 389 0.80 (0.48–1.34) Skill level 3 354 0.88 (0.55–1.40) 355 0.93 (0.58–1.48) Skill level 4 886 1.11 (0.72–1.71) 884 0.74 (0.53–1.05) Skill level 5 549 0.84 (0.45–1.57) 551 0.90 (0.60–1.36) Others 2869 0.94 (0.54–1.63) 2874 1.08 (0.71–1.64) * Obesity defined as BMI ≥ 30 kg/m2, or waist circumference ≥ 88 cm. † Model adjusted for age and all other risk factors in the table. ‡ Significantly different from reference (P < 0.05). § Quintiles of physical activity: < 20 minutes = lowest, ≥ 390 minutes = highest. ¶ Quintiles of television viewing: < 240 minutes = lowest, ≥ 1200 minutes = highest. ** Skill levels: 1 — managers, administrators and professionals; 2 — associate professionals; 3 — tradespersons, advanced clerical and service workers; 4 — intermediate clerical, sales and service workers, intermediate production and transport workers; 5 — elementary clerical, sales and service workers and labourers; and others — students, retirees, pensioners and unemployed.

Adrian J Cameron MPH · Paul Z Zimmet MD, FRACP FAFPHM · David W Dunstan PhD · Marita Dalton GradDipEpidemiol · Jonathan E Shaw MD, MRCP · Timothy A Welborn MB BS, PhD · Neville Owen PhD · Jo Salmon PhD · Damien Jolley MSc

National water-recycling guidelines will address both health and environmental risks Separating drinking water from sewage may seem obvious now, but the idea that sewage could affect health was not understood until the 19th century. Dr John Snow (1813–1858) was one of the first to make the connection when investigating a cholera outbreak in London. He noted that most of the people who were sick had consumed water from a pump in Broad Street, Soho, that was contaminated by sewage. When the pump’s handle was removed, the spread of cholera dramatically stopped. But it was not until the early 1900s that adequate separation of water supplies from sewage routes was achieved (at least in developed countries), resulting in substantially fewer cases of waterborne disease. . . . water is used for gardens, toilets and laundry, where water of lesser quality would suffice. In Australia, in 2004, we are 6 years into another drought, and water shortages and increasing climate variability are behind efforts to reduce water consumption and find other, sustainable ways of utilising all available water. While current efforts concentrate on reducing per-capita water use through more efficient appliances and water restrictions, other, longer-term strategies are also needed. These pressures are leading the community to consider alternative sources of water for some household uses. At present, potable-quality water is supplied for all household purposes. But more than 50% of this water is used for gardens, toilets and laundry, where water of lesser quality would suffice. The domestic use of alternative water sources — rainwater, stormwater, greywater and sewage — has the potential to expose large populations to pathogens and chemical contaminants unless the water is appropriately treated and managed. These treatments can be complex, and, to further confound the issue, permissible applications vary by jurisdiction. There are also many gaps in the regulations for urban domestic uses. Reports of health outcomes from reusing water predominately concern sewage reuse. These studies focus on the health of wastewater workers,1 farm workers and surrounding communities.2 Many of the studies are poorly designed and examine reuse of untreated sewage,3 which means they are of limited relevance to Australia. Because of the paucity of relevant studies on the health effects of other water sources, water quality is used as a proxy health-risk measure. Furthermore, much of the information on urban use of alternative water sources is in literature that is not readily accessible and often not peer reviewed. Thus, there is a pressing need for more rigorous scientific evidence to inform regulation. Rainwater collected from roofs is mixed with debris (eg, leaves and animal droppings) from the roof or from the guttering, and possibly contaminated by dead insects, trapped animals and leaf litter in the tank itself. Additionally, heavy metals from roofing materials, airborne pollutants from traffic emissions and industrial exhaust, or agricultural chemicals can contaminate rainwater supplies.4 It is widely accepted that rainwater can safely be used for bathing, laundering and watering the garden,5 and only in situations where a treated reticulated water supply is not available is it endorsed as a primary source of drinking water. Rainwater is generally considered safe to drink for most members of the community if it is clear, has low odour and taste, and the tank and roof are well maintained.5 Stormwater is rain that drains into the stormwater system from roofs, roads, footpaths and other ground surfaces and is channelled, untreated, directly to local waterways. The water carries rubbish, animal faeces, motor oil, petrol, tyre rubber, soil and debris. Use of this water has been limited to date, partly because of its seasonal variability in volume and the need for large-scale storages. However, in New South Wales, it has been proposed that stormwater from local residences be redirected to irrigate local sports fields, wetlands6 and parks.7 Greywater is sourced from kitchen, laundry and bathroom drains but excludes toilet water. Some guidelines exclude wastewater from the kitchen, as it can contain higher levels of wastes.8 Greywater may contain urine and faeces from nappy washing and showering, in addition to kitchen scraps, soil, hair, detergents, cleaning products and fats and oils. Greywater contaminants can include substances such as boron and phosphates, and the water is often alkaline and saline.9 Treated greywater may potentially be used for toilet flushing, laundering and subsurface garden watering. However, reusing greywater for gardens can detrimentally alter the properties of soil and gradually kill plants sensitive to phosphorus, including Australian native flora. Sewage is water entering the sewerage system. It has all the contaminants of greywater, in addition to high concentrations of faecal material. This water can be reclaimed after rigorous treatment at a sewage treatment plant and piped to individual households, as part of a dual-reticulated water-supply system (additional to and separate from normal tap water), for uses such as toilet flushing, garden watering and washing of cars and outdoor surfaces. It may also be used for irrigating sports fields and public parks, as well as for fire control, sewerage flushing, dust suppression, topping up of ornamental ponds or irrigating agricultural crops. A number of such systems are currently in place across Australia and are the focus of long-term assessment.10-14 Some new urban developments are planning to incorporate alternative water sources, such as reclaimed sewage water at Rouse Hill in Sydney,10 but there are questions about the potential impact on public health, particularly if long-term regulation and governance issues are not adequately addressed. With the exception of good-quality rainwater, all of the above water types are unsuitable for drinking. However, if they are supplied to thousands of individual households, incidents of accidental ingestion are bound to occur. In addition, errors in plumbing installation may result in the non-potable water being “cross-connected” to potable water taps. Regulatory oversight, awareness by health professionals of the potential for waterborne diseases, and continuing surveillance programs will be required to monitor and minimise these risks. Recognising the need for better guidance for regulators and water suppliers, the Environment Protection and Heritage Council and the Natural Resource Management Ministerial Council have initiated the development of national guidelines for water recycling. These guidelines are intended to provide a unified approach across Australia, and will address both health and environmental risks, and be developed in collaboration with the National Health and Medical Research Council. In keeping with recent revisions to the Australian Drinking Water Guidelines,15 a risk-management approach will be adopted, emphasising the multiple-barrier principle and ongoing monitoring of the effectiveness of systems to protect public health.

Teresa Z Mitakakis PhD, BSc(Hons) · Martha I Sinclair PhD, BSc(Hons) · Karin Leder MB BS(Hons), FRACP, MPH

Objective: To assess the effectiveness of the Australian border entry screening program to detect arriving travellers with symptoms of severe acute respiratory syndrome (SARS).Design and setting: Descriptive study of outcomes of screening at Australian airports and seaports between 5 April 2003 and 16 June 2003. To determine the number of international travellers who were symptomatic on arrival in Australia but missed by screening, data were obtained on the number of arrivals screened and the number with symptoms (from the Australian Quarantine and Inspection Service [AQIS]), as well as the number of people investigated for SARS (from the Australian SARS Case Register).Results: There were 1.84 million arrivals into Australia during the study period, and 794 were referred for screening to AQIS staff. Of these, the findings in four travellers were consistent with the World Health Organization case definition for SARS, and they were referred by the Chief Quarantine Officers to designated hospitals for further investigation. None of these people was confirmed to have SARS. One person reported as a probable SARS case acknowledged being symptomatic on arrival, but had been missed by border screening.Conclusions: The low identification rate was attributed to the low prevalence of SARS, the use of exit screening by affected countries, and the subjective measures used in the screening process. With current knowledge about SARS, border screening should focus on educating incoming travellers, especially groups at high risk of transmitting the disease (the elderly and those with underlying chronic illnesses). Objective screening measures should be used during SARS outbreaks to prevent importation of the disease.

Gina Samaan BPsych(Hons) · Jenean Spencer PhD, MAppEpid · Leslee Roberts MB BS, PhD, MAppEpid · Mahomed Patel MB BCh, FRACP, FAFPHM

The sun protection factor (SPF) of sunscreens is determined by a testing protocol that specifies a sunscreen application rate of 2 mg/cm2 on the skin. Most people, for cosmetic and economic reasons, only apply enough sunscreen to achieve an SPF of about a third or even a quarter of the level stated on the product. To increase public awareness of the problem, manufacturers could be required to state both a “tested SPF” and an “expected SPF” (a third of the tested SPF) on product labelling. The “SunSmart” message could be modified to make the public more aware of the actual protection level they are achieving with sunscreen. Other aspects of the SunSmart message (eg, sun avoidance, wearing protective clothing) should also be reinforced.

Stephen R D Taylor MB ChB

Suzanne P McEvoy,* Mark R Stevenson† * Research Fellow, Injury Research Centre, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009; † Director, Injury Prevention and Trauma Care Division, Institute for International Health, University of Sydney, Sydney, NSW. scordovaATsph.uwa.edu.au To the Editor: Taylor et al found that: “Mobile phone use is common among Melbourne metropolitan drivers despite restrictive legislation” and suggest that this constitutes “a preventable exposure to injury risk”.1 This raises two questions: Does mobile phone use while driving affect road safety? If so, do hands-free devices reduce the risk? In their introduction, Taylor et al cited six publications to provide evidence that the use of a handheld mobile phone while driving increases the risk of a road crash. The studies by Lamble et al2 and McKnight and McKnight3 involved a hands-free device and examined driver impairment, not crash risk. The three papers by Violanti4-6 had significant limitations, including no phone billing information to demonstrate that drivers were using their phones at the time of the crash,4-6 reliance on police accident reports that may have involved more thorough investigations into fatal crashes than non-fatal ones,5 and small sample size with only 14 mobile phone users in one study.6 These limitations reduce the validity of the research. The best of the epidemiological studies was a case-crossover study of 699 drivers in collisions involving property damage only.7 However, the oft-quoted four-fold increase in risk comes from the analysis of mobile phone use in a 10-minute hazard interval before the collision. This does not provide conclusive evidence that these drivers were on the phone at the time of their crash and indicates a statistical association only. Although shorter hazard intervals were also examined, one needs to be wary of the potential for misclassifying post-crash calls as pre-crash calls because the time of collision may be imprecise, mobile phone use is common following a crash and a call to the emergency services may not be the first call made after the event. If we conclude that the data are valid despite these limitations, then the fact that hands-free models did not reduce the risk must be noted. Returning to our questions, although there is good evidence demonstrating driver impairment in laboratory-based studies, the epidemiological research has limitations that need to be dealt with to determine the real-world effect of mobile phone use while driving. We are currently undertaking two large epidemiological studies in Perth, involving about 2000 drivers over an 18-month period. The limitations have been addressed in the design of our studies. Furthermore, the evidence to date suggests that hands-free devices do not confer a safety advantage and this issue should not be ignored in driver education.

Suzanne P McEvoy · Mark R Stevenson

Ric Bouvier Community Safety Consultant, 200 Cotham Road, Kew, VIC 3101. ricbouvier7AToptusnet.com.au To the Editor: In “In this issue” of the Journal of 4 August 2003,1 you write regarding “Dialling drivers” that “the jury is still out on the health effects of mobile phones”. Well, the jury is back with a guilty verdict. In June 2003, Injury Prevention2 quoted an evaluation by the Harvard Center for Risk Analysis that “the use of cell phones by drivers may result in about 2600 deaths, 330 000 moderate to critical injuries, 240 000 minor injuries and 1.5 million instances of property damage in America per year”.3 Taylor et al suggest, “Further interventions aimed at decreasing mobile phone use among drivers should be considered.”4 Occupational safety professionals consider that a worker not complying with the safe practices for using a tool should be offered remedial education. If education fails, they stop the worker using that tool. Wise parents also consider taking away a child’s toy until the child can learn to use it safely. And so with mobile phones used while driving. Driver safety education is not very effective. Police have powers to impound items related to other offences, and so should have powers to impound mobile phones used when driving. The driver could then claim it, say, four weeks later, from the police station on payment of a fee-for-service to the police that covers, at least, the relative value of the expenses of the police. The driver would also incur demerit points. Repeated offences would mean they forfeit the phone or their licence.

Ric Bouvier

Graham J Chalker,* Kenneth H Joyner,† Kelly S Parkinson† * Chief Executive Officer; † Technical Advisor, Health and Safety Committee, Australian Mobile Telecommunications Association, PO Box 4309, Manuka, ACT 2603. kellyATkppr.com.au To the Editor: The claim made in the recent article that mobile phone use while driving is more dangerous than drink driving is misleading.1 The 1997 study by Redelmeier is often misinterpreted and cited for the proposition that driving while using a mobile is the same as driving drunk. However, Redelmeier wrote to the New England Journal of Medicine to correct this inaccuracy, saying, “. . . alcohol circulates in the blood for hours, whereas a telephone call lasts only minutes. The cumulative risks associated with intoxication are greater than those associated with cellular telephones”.2 This is supported by a recent Australian study, which compared the blood alcohol levels of drivers involved in real car crashes, rather than driving simulators, and found the risk of an accident was increased by 25 times at a blood alcohol concentration of 0.08.3 Mobile phones have not been shown to present this level of risk in any research. In 2002 in the United States, alcohol was a factor in about 41% of all fatal traffic crashes and in 6% of all crashes.4 In comparison, data collected by about 20 state highway authorities show that mobile phones were a factor in an estimated one half of one percent of all accidents in the US last year. Furthermore, mobile phone subscribers provide the extra eyes and voice for police in reporting aggressive, reckless or drunk drivers, accidents and other road hazards. Almost a third of all genuine calls to 000 are made from mobile phones.5 A recent US survey found that at any given time only 3% of drivers are actively using their mobile phones,6 although it is legal to use a handheld phone in almost all states. Therefore, Taylor’s overall result that less than 2% of Melbourne drivers use a handheld mobile phone, while illegal in Australia and undesirable, is not unexpected. However, the unrelated and misleading comparison made with drink driving is not supported by the facts. No one is questioning that mobile phone use imposes physical, visual, and cognitive demands on the driver. Although technology can help to address physical and visual factors, education is required to address cognitive factors. The Australian Mobile Telecommunications Association has developed 10 safety tips for mobile phones and driving (see www.amta.org.au) and, by adhering to these simple common-sense practices, drivers can make full, productive and safe use of mobile phones.

Graham J Chalker · Kenneth H Joyner · Kelly S Parkinson

David McD Taylor Director of Emergency Medicine Research, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050. David. TaylorATmh.org.au In reply: McEvoy and Stevenson raise some important issues. The first relates to the confusion between driver impairment and crash risk. Intuitively, this association seems valid, as any level of driver impairment could be expected to affect driving skill. However, they are correct to suggest that the two should not be used interchangeably without supporting evidence. Secondly, I agree that the quality of evidence directly linking mobile phone use with crash risk is poor.1-4 This largely relates to the difficulty in confirming mobile phone use at the exact time of the crash. Reported direct observation is uncommon, billing records are inexact, and self-report may be subject to prevarication bias. The use of hands-free devices was not examined in our study, mainly because of difficulties in detecting their use. There is anecdotal evidence of a trend towards the use of these devices while driving. However, while their use might avoid the need to physically hold the phone, they may not significantly diminish driver impairment resulting from distraction. Many questions remain, and I encourage McEvoy and Stevenson in their endeavour to more clearly evaluate the real-world risk of mobile phone use, both handheld and hands-free, by drivers. Chalker et al draw attention to the comparison of crash risk for mobile phone use while driving and drink driving. I acknowledge that interpretation of published studies is confusing. Redelmeier’s statement that alcohol circulates for hours and that a telephone call may last for only minutes relates to individuals. From the highway perspective, when one driver completes a call, another is likely to be starting one and effectively assuming the increased collision risk. This concept is consistent with our findings. Almost 2% of drivers were using mobile phones when they passed our observation points, and were therefore at risk at that time. The exact extent of this risk awaits clarification. Chalker et al provide US alcohol and mobile phone related crash statistics. Unfortunately, the latter were not referenced and their value is therefore questionable. Finally, Chalker et al are to be commended for publishing safety tips for mobile phone use while driving. However, their claim that common-sense practices can make mobile phone use safe is extraordinary and disregards emerging evidence. Indeed, this statement appears to contradict their first safety tip, which states “a hands free device can reduce the physical effort to make and receive calls; however, it alone doesn’t make using a mobile phone while driving safer”.5 At best, therefore, common-sense practices will not make mobile phone use while driving safe, only possibly safer.

David McD Taylor

Donna B Mak,* Graeme H Johnson,† Lewis J Marshall,‡ Jacqueline K Mein§ * Public Health Physician, Department of Health Western Australia, 189 Royal Street, East Perth, WA 6000; † Medical Officer, Derby Aboriginal Health Service, Derby, WA; ‡ Head, Sexual Health Service, Fremantle Hospital, Fremantle, WA; § Public Health Medical Officer, Kimberley Population Health Unit, Broome, WA. makhoATbigpond.com To the Editor: We were pleased to read Chen and Donovan’s editorial which highlighted sex-based inequalities in control of genital chlamydial infection and argued for more screening of men for this infection.1 In the Kimberley region of Western Australia, where rates of genital chlamydial infection are among the highest in Australia, control strategies encompass both sexes.2 Although chlamydial infection was not notifiable in WA until 1993, it has been part of the sexually transmitted infections (STI) control program of the Kimberley Public Health Unit (now the Kimberley Population Health Unit) since the 1980s. Since 1989, regional STI management guidelines have recommended that testing for chlamydial infection (and gonorrhoea, syphilis, hepatitis B and HIV infection) be offered to all patients presenting with STI symptoms or as a sexual contact of an STI patient, and as part of antenatal, prison and well-person’s screenings.3,4 In 1996, empirical treatment for chlamydial infection with single-dose azithromycin (funded by the Kimberley Public Health Unit) was added to the standard treatment regimen, and antibody testing and culture were replaced by nucleic acid testing, which is more transport-robust and sensitive. This led to the introduction in 1997 of active health-service-initiated contact tracing for chlamydial infection (ie, sexual contacts reported by patients with chlamydial infection are actively sought by health staff and offered an STI consultation and empirical treatment). Between 11 June 2001 and 29 June 2002, WA Health Department staff (who contribute over 70% of the region’s STI notifications) notified 94 cases of chlamydial infection in female patients and 56 in male patients.5 Coinfection was common, with 61 patients (41%) also having gonorrhoea and four (3%) also having syphilis. Of the female patients, 30% were tested for chlamydia because they had self-presented with STI symptoms, 32% as part of antenatal or well-person’s screening, 36% because they had been reported as a sexual contact of a patient with STI, and 2% for unknown reasons. The corresponding proportions in male patients were 45%, 7%, 45% and 4%, respectively (Pearson χ2 = 12.6, df = 3; P = 0.006). Prevalence of chlamydial infection in the Kimberley antenatal population (69% of whom are screened for chlamydia) is 3% (95% CI, 2%–6%).6 Prevalence in 93 Kimberley men screened consecutively on admission to prison during 18 weeks in 1998–1999 was also 3% (95% CI, 1%–9%). During this same period, prevalence among 59 Kimberley men and 68 women presenting consecutively as STI contacts was 19% (95% CI, 11%–31%) and 22% (95% CI, 14%–33%), respectively (Mak DB, unpublished data). These data demonstrate that contact tracing contributes significantly to chlamydial case-finding, and support the addition of azithromycin to the Kimberley’s empirical STI treatment regimen. Empirical treatment and contact tracing for gonorrhoea over more than 15 years have been associated with decreases in the rate of gonorrhoea and the male : female ratio of cases in the Kimberley (Box). Seven to 8 years after introducing empirical treatment and contact tracing for chlamydial infection, rates have increased in both sexes, as has the proportion of male notifications (Box). Further progress in control of chlamydial infection requires continued provision of STI screening, treatment and contact-tracing services that are acceptable and accessible to both men and women. Notifications of chlamydial infection and gonorrhoea in the Kimberley region, 1993–2002

Donna B Mak · Graeme H Johnson · Lewis J Marshall · Jacqueline K Mein

Rich countries must lead the fight against climate change affecting rich and poor in our global village It is nearly a tautology to say that poor people and poor nations generally act with short time horizons or, in the jargon of economics, high discount rates. Anecdote and analysis confirm it. Those who realistically fear potentially severe consequences tomorrow are less concerned about next year. At the family level, these attitudes can be understood as the consequence of natural selection acting on the propagation of genes. High discount rates are necessary to ensure one’s genes survive under short-term stress; when the ground is treacherous and the tiger is following, raising one’s eyes to the horizon is risky to survival, let alone procreation. Although even poor societies and nations generally act with longer time perspectives than their individual members, they too must acknowledge the demands of short-term survival.1 However, many human reactions honed through natural selection no longer serve us well. We crave dietary fat for the nutritional security it once brought, but in modern excess it kills rather than saves us. Equally, the scale of our impact on the environment now has effects on time scales much longer than those of typical human time horizons. The archetypal example is perhaps global pollution leading to global climate change. We are now well into a planetary experiment on the effect of injecting a bolus of warming pollutants, three to four times natural levels, during an instant of geological time. Nothing much happens at first, but analysts say that much more is set to happen unless we mend our ways soon.2 Still, it may be decades before the really bad things happen. Should we care? How much? And should how much we care depend on how poor we are? This issue is illustrated starkly by a graph developed from calculations by Hughes at the University of Edinburgh3 (Box). It shows the ratio of the cost of health and economic damage from local energy-derived air pollution (household indoor pollution from use of poor quality fuels and urban outdoor air pollution) to the cost of damage from climate change.4 A standard low discount rate is applied (3% per year) to convert future costs into the equivalent cost today. The graph shows that, in poor countries, short-term local pollution typically causes three to four times more health and economic damage than climate change. This occurs even though poor countries are expected to experience much more health damage from climate change than rich countries. In contrast, in rich countries, long-term damage caused by climate change is greater, even after discounting, because short-term pollution has been greatly controlled. Many in the climate-change debate argue that, because of the huge stakes involved, developed countries should use lower-than-standard discount rates and act today to reduce the long-term damage. This could even be at the cost of spending less on today’s problems. After all, developed countries can afford longer time horizons and produce most of the climate-changing emissions through their use of fossil fuels. However, it is difficult to put this argument to poor countries, which have many other pressing problems and have benefited little from the burning of fossil fuels that has produced most climate-changing emissions to date.5 However, the graph also reveals potential solutions. It shows the attractiveness of rich countries investing in poor countries to simultaneously reduce both local and global pollution. These “win–win” activities could benefit both countries because of their different discount rates and local impacts. An example is investing in clean household fuels that simultaneously halve the local health impact of air pollution and reduce climate-changing emissions.6 Recognising these “win–win” opportunities helps us set current priorities.7 Unfortunately, the climate-change debate no longer encompasses the option of total prevention. It is nearly certain that, no matter what we do, we are already committed to significant change and, indeed, are already experiencing the first stages. We must start planning how to live with this change. The principal health impacts are expected to include an increase in environmentally related infectious and vector-borne diseases in poor countries.8 However, climate change enhances rather than creates these diseases,9 offering another means of prioritising competing public-health needs. For instance, if climate change will increase malaria, we would benefit from spending more now on reducing the baseline malaria rate before serious climate change begins. This is a practical way to consider the long term, while addressing today’s serious problems.10 Perhaps the most important long-term benefit of the climate-change debate is that it illustrates, more than any other issue, that we live in a global village. Although one can argue, on humanitarian and other grounds, that an easily preventable child death in India impoverishes everyone, everywhere, such arguments do not go far in most policy forums. However, it is incontrovertible that greenhouse gases released anywhere affect us all, everywhere. In addition, no matter how much greenhouse gas we ourselves release, we are all subject to the same global climate and its changes. Thus, we are hostage to each other and will have to find ways to make the necessary decisions together to protect us all, rich and poor. Health and economic damage to nations from energy use * Ratio of cost of damage to nations from local energy-derived air pollution over cost of damage to nations from global climate change.3 † Poor = South Asia and Sub-Saharan Africa. ‡ Middle-income = East Asia, Middle East and Latin America; § Rich = nations belonging to the OECD (Organisation for Economic Co-operation and Development), eastern Europe/former USSR.

Kirk R Smith

Overweight and obesity are very common in Australian adults (56%) and children (27%). Rates of overweight and obesity are snowballing and will place greater burdens on health services for the treatment and care of chronic diseases. Prevention is urgently required from health, social and economic perspectives, but the response to date has been inadequate. A long-term, sustained action plan starting with a focus on young people is needed. This should particularly address the “obesogenic” environments causing the epidemic. Although whole-of-government action is required, support from and involvement by parents, carers, community leaders, healthcare professionals, teachers, childcare workers, urban planners, recreation managers, food manufacturers, employers, advertisers, and communicators is essential. The health sector should take the lead, but success will only come from concerted and integrated action across the whole of society. There are now signs of political commitment to addressing overweight and obesity. Doctors should get behind this and help mobilise community support.

John C Catford DM, FRCP, FAFPHM · Ian D Caterson MB BS, PhD, FRACS

Objective: To evaluate clinical measures of obesity for their ability to predict death from cardiovascular disease (CVD) and coronary heart disease (CHD), in parallel with conventional cardiovascular risk factors.Design, participants and setting: Cross-sectional analysis of an age- and sex-stratified sample of 9206 adults aged 20–69 years from Australian capital cities (1989 Australian Risk Factor Prevalence Survey). Blood pressure, fasting serum lipid levels, smoking, history of heart disease or diabetes, and obesity as measured by body mass index (BMI), waist circumference and waist–hip ratio were recorded. These data were linked with the National Death Index to determine causes of death of the 473 survey subjects who had died to 31 December 2000.Main outcome measures: Hazard ratios for the risk factors predicting CVD mortality and CHD mortality.Results: Of the modifiable risk factors, obesity, as measured by waist–hip ratio, is a dominant, independent, predictive variable for CVD and CHD deaths in Australian men and women. Self-reported angina/myocardial infarction in both sexes, and cigarette smoking in women, are also independent risk factors.Conclusions: Obesity assessed by waist–hip ratio is a better predictor of CVD and CHD mortality than waist circumference, which, in turn, is a better predictor than BMI. The recognition of central obesity is clinically important, as lifestyle intervention is likely to provide significant health benefits.

Timothy A Welborn PhD, MB BS · Satvinder S Dhaliwal MSc · Stanley A Bennett PhD, FSS

On 9 March 2003, during the New South Wales state election campaign, Premier Bob Carr announced that a re-elected Labor government would convene a state summit on alcohol. The 1999 NSW Drug Summit and the 2002 Obesity Summit were obvious models. The 1999 Drug Summit, also conceived during a state election campaign, was generally considered to have been successful. It developed a realistic policy framework and substantially increased funding to improve prevention, community and treatment services to reduce problems resulting from illicit drug use in NSW. However, the problems arising from alcohol greatly exceed those of illicit drugs, and, as our favourite drug provides both considerable benefits as well as sizeable costs, these problems are more complex for communities to grapple with. The Alcohol Summit was held in the NSW Parliament from 26 to 29 August 2003, and involved key government departments (including Health, Police, Gaming and Racing, and the Cabinet Office), as well as health professionals, such as Emeritus Professor Ian Webster, the doyen of the alcohol and drug field in Australia, and industry and community representatives. The Summit comprised plenary sessions with national and international invited speakers who are international authorities on the prevention of alcohol-related problems (eg, Professor Tim Stockwell, Director of the National Drug Research Institute, Perth; and Professor Sally Casswell, Chair of the World Health Organization Committee on the Prevention of Alcohol-Related Problems); 10 working groups addressing specific issues; and site visits to drug and alcohol services to enable parliamentarians to inspect treatment facilities at first hand. All members of the NSW Legislative Assembly and Council were invited to attend the Summit along with 131 delegates from diverse backgrounds. Two one-day satellite meetings preceding the Summit addressed alcohol problems in young people and Aboriginal people, respectively. BackgroundThe Summit began with expert reviews on several topics, including the history of alcohol in Australia, the epidemiology of alcohol problems and the evidence base for effective prevention of alcohol problems. About half the alcohol-related morbidity and mortality in Australia results from acute intoxication, and includes injury, road trauma and suicide. The remaining half results from chronic excessive consumption, and includes cirrhosis, stroke and other medical complications. A large proportion (39%) of the alcohol consumed in Australia is drunk at levels that confer moderate-to-high risk of chronic harm, while 51% of the alcohol consumed poses short-term risks to the drinker.1 Mr Ken Moroney, NSW Commissioner of Police, stated that people intoxicated with alcohol and perpetrating domestic and other violence account for up to 75% of the workload of the NSW police. Furthermore, alcohol-related problems are very unevenly distributed. For example, the NSW town of Walgett, with a total population of 2000, has 10 liquor licences and one in three of the adult male population has had at least one conviction for alcohol-related violence. The debateMany initiatives were reviewed, especially primary prevention methods to limit intoxication, such as increasing the price (by raising taxes) of cask wine and other beverages particularly associated with severe intoxication. Secondary prevention initiatives proposed included improving enforcement of existing laws concerning responsible service of alcohol. Enforcement of these laws was acknowledged by senior NSW police to be less than adequate, and penalties were generally considered to be insufficient. Installation of breathalysers in bars could enable patrons to test their breath alcohol level before driving home. Tertiary prevention measures were also considered, such as expanding measures focused on problem drinkers. These included ignition interlocks to reduce recidivist drink-driving by requiring participants to pass a breathalyser test before starting their car engine. Numerous delegates expressed concern about the ready availability of alcohol to under-age youth. The alcohol beverage industry rejected the evidence that under-age drinking is an increasing problem. Anecdotal reports suggested that provision of alcohol by adults to under-aged young people is widespread and quite widely accepted. To address this problem, education of adults and young people was proposed, along with a range of measures to increase enforcement of the law and to increase penalties for offenders (Summit communiqué resolutions 1.10, 8.8–8.23 and 10.1).2 Delegates heard that alcohol taxation is one of the prevention measures best supported by evidence of effectiveness.3 However, taxation of alcohol in Australia is riddled with inconsistencies and anomalies. A more public-health-oriented approach involves taxing alcoholic beverages according to alcohol content rather than beverage class or cost. One of the key recommendations of the Summit was to hold a national public inquiry into alcohol taxation (Summit communiqué resolution 2.9). Earmarking some additional tax revenue for prevention and treatment programs is supported by evidence of effectiveness, but was not supported by the Summit. At times, the debate became quite confrontational. Representatives of the alcohol beverage industry denied developing products designed to appeal to under-age drinkers and advertising inappropriately (including appealing to under-age drinkers). The alcohol beverage industry advocated retaining self-regulation of alcohol advertising, despite the evidence presented to the Summit that the current system does not prevent grossly inappropriate advertising. The industry argued vigorously that it already promotes responsible drinking. Curfews for young people were debated but not adopted. The industry expressed a strong interest in developing voluntary partnerships with health and community groups, but argued that funding should be drawn from existing alcohol taxes. Total federal, state and territory government revenue from alcohol exceeds $5 billion annually, not including income from the goods and services tax. Most of this revenue is generated by the federal government, and very little is directed towards preventing or alleviating the adverse effects of alcohol. The outcomeIn the final sessions, resolutions from the 10 working groups were collated into an interim report for debate. Most resolutions were not controversial: all the proposals of several working groups were adopted without significant change. There was strong support for improving the capacity and quality of treatment for people with alcohol-related problems, and for general practitioners to receive support in this endeavour. A fundamental issue for most delegates was the extent to which the alcohol industry should accept responsibility for the manner in which alcohol is consumed. For example, how can a server more reliably recognise intoxication and refuse further service? The final communiqué comprised 44 pages of recommendations, with 315 recommendations to reduce the burden of alcohol-related harms supported by a majority of delegates (Box).2 The outstanding achievement of the Alcohol Summit so far has been returning alcohol control policy to the public health agenda. The resulting policy changes have the capacity to achieve considerable future benefits for the community. However, it is critical that the NSW government maintains its focus on this field and injects new resources to ensure that the Alcohol Summit leads to tangible outcomes. Selected recommendations of the NSW Alcohol Summit* 1. A retailer alerts system should be developed to highlight breaches of the Voluntary Advertising Code. 2. There should be a national public inquiry into alcohol taxation to consider the health, economic, social and community costs and benefits of current and proposed alcohol excise and taxation measures. 3. The liquor industry should be required to set aside a proportion of its advertising budget for harm-minimisation programs. 4. The acceptability of inappropriate alcohol use at sporting events, by both participants and spectators, should be challenged. 5. The distribution of alcohol treatment services in NSW should be reviewed and adjusted to ensure equity of access. 6. The NSW police should investigate the feasibility of random breath testing on waterways. 7. Drink drivers convicted of more serious offences should be required to undertake an alcohol-related brief intervention program before licence reinstatement. 8. The NSW Vice Chancellors’ Committee should be asked to consider the development of additional postgraduate programs for professional and clinical staff in drug and alcohol treatment. 9. Intoxication should be defined in relevant legislation so that responsible service-of-alcohol requirements can be applied by both servers and the police. 10. Existing schemes to divert offenders from the criminal justice system towards treatment should be considered for extension to cover those with alcohol misuse problems, and adequate treatment places should be available to absorb court referrals. *Resolutions have been edited. The full text is available from the Summit website.2

Paul S Haber MD, FRACP · Katherine M Conigrave FAChAM, FAFPHM, PhD · Alex D Wodak FRACP, FAFPHM, FAChAM

State health departments bear considerable expenditure due to tobacco-related hospitalisations. We present a straightforward formula, based on aetiological fractions (attributable risks), with which to estimate tobacco-related expenditure in a way relevant and meaningful to state health departments and hospital managers. Tobacco was responsible for 43 350 hospitalisations in New South Wales in 1999–2000 alone, incurring $176 096 323 in hospital costs (nearly $482 456 per day). If the equivalent of a specified percentage of expenditure as calculated for one year were “invested” in tobacco control in the next year, then commitments to a substantive suite of health promotion programs could be made. For example, using our formula, a contribution of 3% would secure an annual tobacco control budget of $5 282 890 in NSW. Once securely funded, evidence-based tobacco control would reap dividends by reducing hospital expenditure and enhancing population health.

Seham T Girgis MB BCh, MPH · Jeanette E Ward MHPEd, PhD, FAFPHM

Pets probably do confer health benefits, but we don’t know precisely how In the current issue of the Journal (page 466), Parslow and Jorm1 reopen the debate about whether pets benefit human health. They give the results of a high quality Australian sample survey indicating that pet owners do not have lower blood pressure than non-owners, and, in this respect at least, are not at lower risk of heart disease. Their results run counter to an earlier Australian study,2 based on a large volunteer sample, in which pet owners were found to have lower blood pressure and cholesterol levels. . . . the benefits of pets appear linked to the human desire to be close to nature . . . Where are we up to in this debate — are we back to square one? The case I will present here is that we can be fairly confident that pets do confer health benefits, but we do not know exactly how. Several types of research by very different kinds of scientists — medical scientists and social scientists — have been conducted on this topic. These scientists have different understandings of causation (ie, of what it means to claim that pets cause their owners to have better health), and, because of this, it is difficult to have a meeting of minds. However, it can be argued that social science research forms a natural prelude to medical research, and that the social science evidence in favour of health benefits of pet ownership makes it worthwhile to mount a substantial medical research effort to discover how the benefits occur. Social science surveys in Australia,3 Britain,4 Germany5 and the United States6 during the 1990s have come pretty close (in social science terms) to establishing that pets produce health benefits. The first surveys were cross-sectional (ie, they provided snapshot evidence at one point in time). With some exceptions, they showed that pet ownership is associated with better self-reported physical and psychological health, and also fewer doctor visits. Controlling for the main demographic variables associated with health problems, including sex, age, marital status, education and income, did not change the results. Of course, social scientists recognised that causation might run the other way round, or even both ways. It was possible that people who were healthy and happy in the first place tended to acquire pets, rather than that having a pet caused better health. So, as a next step, efforts were made to design valid longitudinal studies (ie, studies following people over a period of time) to see whether owning a pet made a difference. The strongest positive evidence has come from the German Socio-Economic Panel Survey,5 which asked a sample of about 10 000 respondents about pet ownership in 1996 and again in 2001. Controlling for health status in 1996 (as well as for the usual demographic variables), it was found that people who continuously owned a pet reported the fewest doctor visits (in the 3 months before interview), and those who had acquired a pet during the 5-year period reported the next fewest number of visits. Both these groups went to the doctor about 10% less often than people who did not have a pet at either time, or who had ceased to have a pet. The German sample is very large and most of the questions are about income and work, so the respondents could not possibly have suspected that the researchers were looking for a link between pets and health. Similar results were found in a smaller Australian longitudinal study, although here the evidence was based on recall, not on repeated interviews.5 Because the German and Australian results came from national representative samples, it was possible to make preliminary estimates of savings in national health expenditure arising from lower use of medical services by pet owners. A second type of study is based on examining the effects of interventions (either natural or intentional), and thus takes the causal reasoning further. An American study of heart attack victims showed that those with pets at home were twice as likely to survive for a year.7 A British longitudinal study involved giving a pet to people who had not recently owned one and following their lives for 10 months.4 The new pet owners showed improvements in physical and mental health, and dog owners took more exercise. A control group who did not own pets showed no change. The study could perhaps be criticised on the grounds that the new pet owners might have known or suspected why they were given pets. The same cannot be said of an American longitudinal study of Medicare enrollees that measured the impact of adverse life events (eg, bereavement or marital separation) on mental health.6 Pet owners coped significantly better. But medical researchers want better evidence of causation than this. They want to know precisely which medical conditions, if any, are improved by pet ownership, and, ideally, they want to understand things at the molecular level. It has to be said that research along these lines has made only limited progress. The American heart attack study7 is relevant here, and, although criticised, has since been replicated.8 On the other hand, studies of blood pressure,1,2 and of the potentially anxiety-reducing effects of pets,9,10 have yielded contradictory results. Arguably then, the state of debate is that pets probably do confer health benefits, but we don’t know precisely how. Continuing medical research is needed to move things forward. At a fundamental level, the benefits of pets appear linked to the human desire to be close to nature and other living creatures. The famous zoologist Edward O Wilson has called the belief that humans need and benefit from closeness and companionship with other species “the biophilia hypothesis”.11 About 50% of adults and 70% of adolescents who own pets report that they confide in them.12 It is most unlikely that all this communication and companionship is wasted.

Bruce Headey PhD

Objective: To test the claim that pet ownership reduces cardiovascular risk.Design: Community survey.Participants: 2528 adults aged 40–44 years and 2551 aged 60–64 years who lived in the Australian Capital Territory and Queanbeyan, New South Wales, and were drawn randomly from the Australian electoral roll in 2000 and 2001.Main outcome measures: Sociodemographic measures, including pet ownership, and measures of physical health (including body mass index [BMI], alcohol and cigarette consumption, and levels of physical activity). Two readings of diastolic and systolic blood pressure were also taken.Results: While pet owners and non-pet owners had similar levels of systolic blood pressure, those with pets had significantly higher diastolic blood pressure. Pet owners also had higher BMI and were more likely to smoke. While those with pets undertook more mild physical activity, they continued to have significantly higher diastolic blood pressure after controlling for hypertensive risk factors.Conclusions: In this study, we found no evidence that pet ownership per se is associated with cardiovascular health benefits. Rather, pet owners had higher diastolic blood pressure than those without pets. It is likely that this increased health risk is linked to other hypertensive risk factors that are only indirectly associated with pet ownership.

Ruth A Parslow MPH, PhD · Anthony F Jorm PhD, DSc

Burden-of-disease and cost-effectiveness studies will help us realise better population health Over the past decade or so, there has been increasing demand for greater clarity about the major causes of disease and injury, how these differentially affect populations, and how they are changing. In part, this demand has been motivated by resource constraints and a realisation that better health is possible with more informed allocation of resources. At the same time, there has been a change in the way population health and its determinants are quantified, with a much closer integration of the quantitative population sciences (such as epidemiology, demography and health economics) to strengthen and broaden the evidence base for healthcare policy. As demand for healthcare grows, decisions about resource allocation and priorities for the healthcare sector will fall under increasing scrutiny. The first coordinated efforts to provide more relevant and comprehensive data on the health (as opposed to survival) of populations and on specific strategies for disease control were led by the World Bank, culminating in two seminal reports in 1993 on the state of global health and priorities for improving it.1,2 These reports have subsequently had a great influence on debates about health sector priorities and healthcare research needs. A fundamental outcome of this World Bank research has been a change in the paradigm for health accounting, from measuring death to measuring population health, using a single summary index that simultaneously incorporates information about age at death and the incidence and prevalence of disease and injury. A time-based metric, the disability-adjusted life-year (DALY), was used to capture both fatal and non-fatal health outcomes affecting populations. DALYs for over 100 specific diseases and injuries have been assessed within a “burden-of-disease” framework which constrains individual estimates and preserves epidemiological plausibility.3,4 The burden-of-disease approach gives estimates of DALYs from risk factors (eg, smoking) as well as diseases caused by known risk factors (eg, ischaemic heart disease related to smoking) and from other, unrelated conditions (eg, road traffic accidents, which have nothing to do with smoking).5 Thus, a single metric (the DALY) can be used to compare disease burden across a range of diseases, injuries and risk factors. Certainly, the data and information requirements for adequate measurements of the burden of disease in a population are not inconsiderable. They need information on age at death and cause of death, the age-specific incidence of disease and injury, the typical duration of life lived with the sequelae of diseases and injuries, and some quantification of the severity of disability assessed according to a commonly agreed framework. The ethical, philosophical and conceptual issues involved in quantifying states of health other than perfect health are still very much a matter of debate, and rightly so.6 However, the reliability, and hence the utility, of burden-of-disease studies for public policy depend much more strongly on the quality and availability of the underlying epidemiological data. A principal advantage of the burden-of-disease approach is that it entails a data “audit”, whereby the completeness, reliability and consistency of routinely collected data are assessed, and critical gaps in health data collection are identified. One implication is that periodic quality assessments of, say, routine cause-of-death data ought to be carried out to ensure their continued relevance and reliability for public policy. Another might be the need for a more rational assessment of priority data for the healthcare sector, placing greater emphasis on data collection and data linkage to facilitate burden-of-disease studies, rather than on routine collection of statistics of limited public health relevance. The burden-of-disease framework, based on the estimated epidemiological path of incident cases, would benefit greatly from wider availability of linked data sets on health outcomes and further research into health-state transition probabilities (ie, the probability that patients with a given illness or disability will get better or worse, and the severity of their current compared with their previous health state) from longitudinal studies.7 In parallel with the increased emphasis on more reliable and comprehensive assessment of population health, there has been a rapid expansion in knowledge about the cost-effectiveness of interventions for reducing the burden of disease. Packages of interventions to optimise health in populations at different levels of development were among the major research outcomes of the World development report 1993.1 Subsequent work by the World Health Organization identified evidence of cost-effectiveness as a key health research priority worldwide.8 The findings of a large international study of the cost-effectiveness of 170 interventions, primarily to reduce health hazards from unsafe water and hygiene, childhood undernutrition, tobacco use, unsafe sex, and high blood pressure and blood lipid levels were recently reported by WHO.9 The evidence base for setting health priorities is thus rapidly expanding. Yet, as the WHO report points out, there is still a large potential for realising better health through more informed and systematic application of this knowledge.9 As demand for healthcare grows, decisions about resource allocation and priorities for the healthcare sector will fall under increasing scrutiny. This is likely to lead to demands for more reliable and useful evidence about population health problems, and for affordable and effective measures to address them. Australian researchers have been at the forefront of these international developments, and have carried out local burden-of-disease studies that have been used to support policy development by the federal and state governments, particularly in Victoria.10,11 Australia is also well placed to provide technical support to neighbouring countries that are undertaking burden-of-disease and cost-effectiveness research to improve the efficiency of their healthcare systems. More than 5 years have now passed since the first Australian burden-of-disease study was undertaken, and much could be gained from a renewed appraisal of Australian healthcare information based on the methodological advances in burden-of-disease measurement in the interim. The School of Population Health at the University of Queensland has established a Centre for Burden of Disease and Global Health Research which has a mission to provide the technical and strategic leadership for priority-setting research in Australia and the entire Asia–Pacific region. Strong links to WHO, the World Bank, the National Institutes of Health in the United States, and other leading health research institutions worldwide, will ensure that efforts to improve the evidence base for healthcare reflect global advances in health research and development.

Alan D Lopez PhD

Heart failure prevalence is increasing because of the ageing of the population and the longer survival of people experiencing myocardial infarction and heart failure. The lifetime risk of developing heart failure in Western countries is about 20%. The increasing prevalence of overweight, obesity and diabetes is likely to accelerate heart failure incidence. While there have been major advances in treating heart failure, a preventive approach promises greater benefit to a larger proportion of the community. The medical strategy for heart failure prevention, based on calculation of individual risk, is focused on the minority of individuals who exceed an arbitrary risk threshold. A public health strategy targeting the whole population offers a greater prospect of reducing the incidence of heart failure and other cardiovascular disease. A multitiered approach, encompassing environmental determinants of lifestyle, legislation, and education about healthy lifestyles throughout life, in addition to aggressive control of risk factors in high-risk individuals, is likely to have the greatest impact.

Duncan J Campbell FRACP, PhD

Objectives: To investigate the effectiveness of telephone counselling as an adjunct to nicotine replacement therapy (NRT) by transdermal patch in smoking cessation.Design: Randomised controlled trial.Participants and setting: 854 smokers from New South Wales, aged 18 years and older, who had smoked at least 10 cigarettes per day for the past year and responded to newspaper advertisements between October 2001 and January 2002; the trial was conducted between October 2001 and August 2002.Interventions: Random allocation to either NRT alone or NRT plus telephone counselling (5 sessions spaced according to a relapse-sensitive call schedule).Main outcome measures: Self-reported abstinence assessed by telephone questionnaires at 1, 2, 3 and 6 months: 28-day continuous abstinence at 3 and 6 months, and 90-day continuous abstinence at 6 months.Results: 28-day continuous abstinence rates among participants receiving telephone counselling were significantly greater than among those not receiving telephone counselling at both 3 and 6 months (31.6% v 25.1%; P = 0.04 at 3 months; and 30.1% v 22.4%; P = 0.01 at 6 months). Similarly, 90-day continuous abstinence rates at 6 months were significantly greater for participants receiving counselling (26.7% v 18.6%; P = 0.004).Conclusion: Telephone counselling as an adjunct to NRT increases abstinence rates beyond the use of NRT alone.

Zane R Macleod BA(Hons), MPsych, MAPS · Veronica C Arnaldi · Ian M Adams BSc(Hons), MSc, MBA · Margaret A Charles BA, PhD, MAPS