Environmental health

Medical and public health services at the 1996 Atlanta Olympic Games: an overview Richard J Brennan, Mark E Keim, Trueman W Sharp, Scott F Wetterhall, R Joel Williams, Edward L Baker, John D Cantwell and Scott R Lillibridge Planning for the 2000 Sydney Olympic Games may benefit from the experience of the 1996 Atlanta Olympics. Excellent health promotion and prevention activities before and during the Games resulted in fewer medical and public health problems than anticipated. Despite this, there was room for improvement in the level of communication and cooperation between the many service providers to ensure the most appropriate and efficient responses. MJA 1997; 167: 595-598 Introduction - Medical care at the Olympic venues - Prehospital care - Hospital emergency departments - Public health - Disaster preparedness - Conclusion - References - Authors' details - - - ©MJA1997 Introduction The 1996 summer Olympic Games in Atlanta was the largest event in sporting history. With the influx of over 10 000 athletes from 197 countries and an estimated 2.2 million visitors, there were concerns that the city's health services and infrastructure would be strained excessively. Experience at previous Olympics and other mass gatherings had shown that issues of medical care for athletes and visitors, emergency services, public health and disaster preparedness would need to be addressed.1-6 Major anticipated medical problems included heat-related illness, foodborne and waterborne illness, and sexually transmitted disease. With 35 heads of state expected to attend, as well as many other world political and business leaders, disaster preparedness planning had to include the consequences of a terrorist attack with conventional, chemical, biological or nuclear weapons. We review the medical and public health preparation and services provided for the Atlanta Olympics, with emphasis on aspects relevant to the forthcoming Sydney Olympics. Medical care at the Olympic venues Responsibility for providing medical and first aid services for spectators and athletes was assumed by the Atlanta Committee for the Olympic Games (ACOG). Services were provided at all 35 Olympic sporting venues, at the Olympic Village (athletes' residences) and at Centennial Olympic Park (a community park open to the public). Services were staffed with the help of 4000 medical volunteers, including Red Cross personnel, emergency medical technicians, paramedics, nurses and almost 700 physicians from across the United States (US). A venue medical officer coordinated services at each site. Separate medical services and clinics were provided for athletes and spectators. For athletes, in addition to the Polyclinic at the Olympic Village, there was a medical clinic at each sports venue, coordinated by the athlete medical director. Medical care for spectators was provided by: First responders -- Red Cross volunteers, trained in first aid and basic life support, and stationed in the crowd. Advanced life support teams -- teams of two volunteers, at least one of whom was a paramedic, who could be alerted by first responders. They were able to provide advanced medical care on scene, including defibrillation and endotracheal intubation. First aid stations and clinics -- at each venue, staffed by physicians, nurses, paramedics and emergency medical technicians. Medical care included minor suturing, short-term intravenous therapy and basic analgesia. Clinics were equipped with cardiac monitors and defibrillators with pacing capabilities to facilitate management of cardiac and other medical emergencies before hospital transfer. Not all presenting patients required physician assessment, but all those who were reviewed by a physician had a medical encounter form completed to assist with public health surveillance. During the Olympics, more than 30 000 people sought medical assistance at first aid stations and clinics, and 10 723 were examined by physicians. The most common indication for physician examination was injury (34%); heat-related illness was diagnosed in 10%. The busiest medical facility was the Polyclinic at the Olympic Village, where 2474 Olympic staff and athletes were assessed, with many of those from other countries having routine dental and eye examinations (see Eaton et al., page 599 ). Prehospital care Ambulance services for patients who could not be managed at the Olympic venues were provided under agreements with ACOG by the 37 licensed emergency medical services (EMS) -- private ambulance companies -- that service the Atlanta metropolitan area. In addition, some emergency medical technicians used bicycles and motorised golf carts for rapid movement around heavily congested venues and pedestrian areas. A medical helicopter service was on stand-by. Each of the 37 EMS providers in Atlanta services a different metropolitan region. To facilitate the sometimes poor communication and coordination between these providers and regions, the State Emergency Medical Services Advisory Council issued them with uniform recommendations. These included uniform operational plans and procedures developed for the Olympics, agreements on enhanced lines of communication, protocols for management of heat-related illness, and guidelines for response to a mass casualty incident. A major issue for the emergency medical services was to provide quality care to athletes, spectators and visitors without depleting services to the general population. Most EMS providers cancelled employee leave. ACOG and the Atlanta Police Department developed a traffic plan that outlined expedient ambulance routes, and real-time traffic information was provided to the services. During the Games, emergency medical technicians from Atlanta Fire Services (the main first responders within the City of Atlanta) responded to 2163 emergency calls, an increase of 16.2% over usual. Interestingly, average response times did not increase. Use of medical golf carts in the "Olympic Ring", where most Olympic venues were located, was very successful in overcoming the problems of traffic congestion; average response time was an impressive 2.1 minutes for the 414 calls received (Don Hiett, Atlanta Fire Department, personal communication). One patient was successfully resuscitated after a cardiac arrest. Hospital emergency departments Most Atlanta hospitals began serious preparation many months before the Olympics. Staff were educated on heat-related illness, mass casualty incidents, patient overflow plans, traffic projections, and busy event days. Most medical facilities reviewed their disaster response plans and scheduled extra staff to work during the Olympic period. To optimise coordination of emergency and hospital services in case of a disaster, a baseline survey of Atlanta hospital resources was conducted a week before the Games. This determined staffed in-patient beds, emergency department capacities and specialty services. During the Olympic period, hospitals were asked to telephone or fax information on beds and other resources to the central coordinating centre, which generated an Olympic Bed Report twice daily. Most hospitals cooperated, with 68%-92% responding on each occasion (Ruth De Loor, RN, Area Emergency Manager, National Disaster Medical System Coordinator, Atlanta Veterans Administration Medical Center, personal communication). However, the efficiency and accuracy of this system could have been improved by computerised, real-time monitoring of bed status. Ensuring reliable communications among EMS providers, hospitals and coordinating centres was a major consideration. Extra radios were provided to EMS workers by state and federal sources. A communications protocol was distributed to hospital emergency departments in the week before the opening ceremonies. The major means of communication between hospitals and Emergency Operations Centers were routine telephone and fax lines, but about two-thirds of hospitals also had VHF radios as a back-up. Neither the four metropolitan nor the four non-metropolitan sentinel hospitals had a significant increase in emergency department presentations during the Olympics. The number of patients presenting with unintentional injuries and vomiting without diarrhoea increased slightly. The number seen for heat-related illness in metropolitan hospitals peaked at 18 on the second day of Olympic competition, 20 July. There were no increases in numbers of patients presenting with infectious diseases or with sexually transmitted diseases (STDs). Olympic athletes were referred to a single hospital near the Olympic Village, Crawford Long Hospital of Emory University. During the Games, 43 sought hospital care and 22 of these required inpatient admission (see Keim and Williams). Public health Public health services during the Olympic Games were coordinated by the Division of Public Health within the Georgia State Department of Human Resources. Services addressed the major public health concerns of heat-related illness, infectious diseases, food and beverage safety, and environmental health. Surveillance systems were set up to detect emerging outbreaks of infectious disease and unusual disease and injury patterns, and to measure health service use during the Games. Surveillance: Two complementary public health surveillance systems were established specifically for the Games. Surveillance inside Olympic venues was coordinated by ACOG with the assistance of the Centers for Disease Control and Prevention (CDC). Every physician encounter at Olympic venue clinics and first aid stations was documented, and records were faxed to the Olympic Medical Data Center for compilation and analysis. Daily and cumulative summaries were submitted to the ACOG medical coordinator and to state and federal health officials. Rates of illness could be determined for each venue, as attendance figures provided denominators, allowing health and medical interventions to be targeted. For example, the highest rates of heat-related illness were documented at the beach volleyball venue (24 cases/100 000 attendees) and the Horse Park (19.7 cases/100 000 attendees). This information allowed ACOG and public health officials to increase public awareness announcements at these venues, encouraging spectators to drink more fluids, to seek shade and to recognise the symptoms of heat-related illness.7 No unusual disease outbreaks or illness patterns were detected at Olympic venues. Surveillance outside the Olympic venues was coordinated by the State Division of Public Health. The pre-existing passive system for notification of infectious diseases and other significant conditions was augmented by: Active surveillance of medical presentations at eight sentinel hospitals (four in metropolitan Atlanta and four in other cities hosting Olympic events), with daily data transmitted electronically to the Division of Public Health. Daily reports from the Georgia public health laboratory and the state's busiest private laboratory. Encouragement to physicians and other health care providers to report unusual medical presentations directly to the state Division of Public Health. These data were compiled, summarised and reported daily to ACOG and to state and federal health officials. Heat-related illness: Atlanta's hot, humid summer weather, combined with overcrowding on the streets, on public transport and at Olympic venues, made prevention of heat-related illness a major challenge of the Olympics.7,8 An extensive media public awareness campaign was supplemented by pamphlets sent to ticket purchasers informing them of preventive measures. The Georgia State Division of Public Health, the Red Cross and the Salvation Army combined to provide shelter, water, wide-brimmed hats, fans, sunscreen and prevention information to pedestrians along corridors to Olympic venues. In addition, water misters attached to high velocity evaporative fans were placed at 25 of the most crowded sites to help cool spectators and pedestrians. State health officials distributed guidelines on recognition and management of heat-related illness to EMS providers and hospitals. Heat-related illness was less common than anticipated, diagnosed in only 10% of patients examined by physicians at Olympic venue clinics and first aid stations. This may have reflected the cooler than expected weather: average air temperatures and relative humidities during the 17 days of Olympic competition were 23.4¡C and 83% (0700), 29.4¡C and 63% (1300) and 27.7¡C and 67% (1900),9 and the temperature range was 20¡C to 37¡C (Southeast Regional Climate Center, personal communication). In addition, the impressive promotion and preventive activities probably contributed to the control of heat-related illness. Food safety and environmental health: The enormous influx of visitors made food safety and prevention of foodborne illness critically important. About 150 food and drug inspectors from throughout Georgia and other areas of the US were employed to inspect and monitor food vendors, who were required to comply with strict state health and safety regulations and to have an official licence. General environmental health services, such as water testing, sanitation services and solid waste disposal, were augmented by local and state public health officials. On the first day of Olympic competition, two unlicensed food vendors were detected in the Olympic Village, and were implicated in the development of diarrhoeal disease by two residents. However, food safety precautions were in general highly successful. According to the Department of Human Resources, the Atlanta Olympic Games were the first in the modern era to have no major outbreak of foodborne disease. A mosquito infestation at the Olympic Village was investigated by state environmental health officers and control measures recommended to ACOG. Infectious diseases: A large international gathering such as the Olympic Games may allow intercontinental transmission of microorganisms, which may be drug-resistant. 4 During a previous international sporting event in the US, a measles outbreak was traced to a visiting athlete.5 At the Atlanta Olympics, the active surveillance for unusual presentations and infectious disease outbreaks was designed to allow same-day medical and public health interventions. In addition, physicians and public health workers initiated a safe-sex campaign to limit the spread of STDs. Posters, pamphlets and buttons in 17 languages were used to communicate a "safe sex" message, and 50 000 condoms in Olympic colours were distributed at the Polyclinic. The surveillance system detected no outbreaks of any of the 40 diseases notifiable in the US, nor any increase in STD incidence in the Atlanta metropolitan area. Disaster preparedness Disaster planning was a key component of Oympic preparations. The City of Atlanta and the State of Georgia are prone to natural disasters, such as hurricanes and tornadoes; Hurricane Bertha had threatened the Georgia coast in the week before the Games, and state Disaster Medical Assistance Teams had been placed on alert. However, of greater concern was the potential for a major terrorist attack. The recent bombings in Oklahoma City and at the World Trade Center had shown that the US was prone to major terrorist incidents, while the 1995 sarin gas attack in Tokyo showed that terrorists had access to new weapons. Local agencies and institutions within Atlanta worked extensively on disaster planning. As well as revising disaster plans, many medical institutions developed educational programs to address mass casualty incidents. Over 1700 emergency room staff and prehospital personnel were trained in management of patients exposed to chemical, biological or nuclear agents, and disaster drills were conducted. However, the City of Atlanta and each of the seven counties within metropolitan Atlanta had separate disaster plans, and no centralised coordinating body was established to optimise use of the limited resources. State disaster preparedness was coordinated by the Georgia Emergency Management Agency and the Department of Human Resources. State officials, recognising they lacked the resources to deal with a major terrorist event, especially involving a chemical, biological or nuclear agent, officially requested assistance from federal agencies, including the US National Disaster Medical System. Urban Search and Rescue teams were brought to Atlanta from around the US to assist with extrication and care of victims of, for example, a building collapse. Five-member Disaster Medical Assistance Teams were stationed at key points around the city to facilitate a rapid medical response. The Marines deployed a highly skilled 300-member Chemical-Biological Incident Response Force. Forensic and laboratory services were provided by units from the Federal Bureau of Investigation, the US Army and the US Navy, Environmental Protection Agency, and CDC. In addition, members of these units were stationed at a specially convened Science and Technology Center at CDC to provide expert public health and emergency medical, toxicological and scientific consultation. The responsibilities of US federal government agencies in domestic disaster response are outlined in the Federal Response Plan. 10 For the Olympic Games, a supplementary document, the Federal Consequence Management Response Plan ,11 was developed. ACOG also developed a separate medical disaster plan to address incidents within Olympic venues and the Olympic Village. If a disaster within the Olympic "fence" exceeded the capabilities of ACOG, local, state and federal resources were to be mobilised. The bombing at Centennial Olympic Park on 27 July resulted in two deaths and 111 victims presenting to city hospitals. Most injuries were relatively minor, with only 24 victims requiring inpatient admission. The incident was handled with local resources, and the FBI was the only federal agency to respond. Although the medical care provided to the victims of the bombing was excellent, the incident demonstrated the difficulties of effecting a rapid disaster response despite extensive preparations. Coordination of EMS activities was suboptimal, as excessive numbers of ambulances were dispatched before adequate assessment of the scene, potentially depleting EMS services to other areas of the city and contributing to vehicular congestion around the scene. Fortunately, this lack of coordination had negligible effects on patient care and outcomes (Denis Lockeridge, District III EMS Co-ordinator, personal communication). Conclusion During the Olympics, the sheer volume of people visiting the host city poses significant challenges to medical and public health communities. Meeting these challenges requires the contributions of multiple agencies and service providers. Although there were several significant problems of communication and cooperation between providers at the Atlanta Olympics, the overall provision of medical and public health services was of the highest order. Excellent health promotion and prevention activities before and during the Games resulted in fewer medical and public health problems than had been anticipated. As Sydney prepares for the year 2000 Olympics, Australian health officials could do well to learn from the Atlanta experience. References Baker WM, Simone BM, Niemann JT, Daly A. Special event medical care: The 1984 Los Angeles summer Olympics experience. Ann Emerg Med 1986; 15: 185-190. Weiss BP, Mascola L, Fannin SL. Public health and the 1984 summer Olympics: The Los Angeles County experience. Am J Public Health 1988; 78: 686-688. Thompson JM, Savoia G, Powell G, et al. Level of medical care required for mass gatherings: the XV winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991; 20: 385-390. Stienbecker RS, Steinberg JP, Schwartz B, et al. Evaluation of travelers returning from the 1992 Olympics in Barcelona, Spain: did they acquire resistant pneumococci and meningococci? Clin Infect Dis 1995; 220: 731-732. Ehresmann KR, Hedberg CW, Grimm MB, et al. An outbreak of measles at an international sporting event with airborne transmission in a domed stadium. J Inf Dis 1995; 171: 679-683. Leonard RB. Medical support for mass gatherings. Emerg Med Clin North Am 1996; 14: 383-397. Centers for Disease Control and Prevention. Prevention and management of heat-related illness among spectators and staff during the Olympic Games -- Atlanta, July 6-23, 1996. Morb Mortal Wkly Rep 1996; 45: 631-633. Sparling PB. Expected environmental conditions for the 1996 summer Olympic Games in Atlanta. Clin J Sport Med 1995; 5: 220-222. Sparling PB. Environmental conditions during the 1996 Olympic Games. Clin J Sport Med . In press. Federal Emergency Management Agency. Federal Response Plan. Washington, DC: Federal Emergency Management Agency, 1992. Federal Emergency Management Agency. Federal Consequence Management Response Plan -- 1996 Summer Olympic Games. Washington, DC: Federal Emergency Management Agency, 1996. (Received 8 Jul, accepted 28 Jul, 1997) Authors' details Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Richard J Brennan, MPH, FACEM, Visiting Scientist, Emergency, Refugee and International Health, National Center for Environmental Health; Scott F Wetterhall, MD, Medical Epidemiologist, Office of Program Planning and Evaluation; R Joel Williams, DVM, MS, Epidemiology Intelligence Service Officer, National Center for Infectious Diseases; Edward L Baker, MD, Director, Public Health Practice Program Office; Scott R Lillibridge, MD, Associate Director, Emergency, Refugee and International Health, National Center for Environmental Health. Division of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Mark E Keim, MD, Fellow in Disaster Medicine. Headquarters, United States Marine Corps, Washington, DC, USA. Trueman W Sharp, MD, MPH, Preventive Medicine Officer. 1996 Centennial Olympic Games, Atlanta, Georgia, USA. John D Cantwell, MD, Chief Medical Officer. Reprints: Dr R J Brennan, Center of Excellence in Disaster Management and Humanitarian Assistance, 1 Jarrett White Road (MCPA-DM), Honolulu, HI 96814, USA. E-mail: brennanrATwebsite.tamc.amedd.army.mil - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Richard J Brennan · Mark E Keim · Trueman W Sharp · Scott F Wetterhall · Edward L Baker · John D Cantwell · Scott R Lillibridge

Mapping Australia's basic research in the medical and health sciences Paul F Bourke and Linda Butler The Institute for Scientific Information indexes most of the major international basic research journals in science in the Science Citation Index (SCI). Australia's presence in the medical and health sciences journals in the SCI and the citations its published research receives in these journals show that Australia's basic medical research has high international "visibility". Mapping the source of the most highly "visible" Australian medical research articles shows high impact research coming from several different sectors (research institutes, universities, hospitals, etc.), but with a concentration in the member institutions of the Australian Association of Medical Research Institutes (AAMRI). Published research from the AAMRI is cited at a rate two-thirds higher than the Australian average for medical and health sciences. (MJA 1997; 167: 610-613) Introduction - Data source - To what extent is Australian basic research in the medical and health sciences covered by the REPP database? - Where is the research being conducted? - Are patterns of medical authorship changing? - How "visible" is Australian medical research? - Where is Australia's most "visible" medical research being conducted? - Where are Australia's most highly cited medical articles produced? - Discussion - References - Authors' details - - - ©MJA1997 Introduction A very high proportion of the articles reporting the results of basic research in the medical and health sciences are in the journals indexed by the Institute for Scientific Information (ISI) in the Science Citation Index (SCI). The SCI is therefore an excellent tool for identifying the sources of Australian published research in this field, while the citations received by (or references to) these articles can also be used to identify the source of the most-cited research. We have focused on Australia's basic research output, not its applied research. Data source The Research Evaluation and Policy Project (REPP) at the Australian National University (ANU) has constructed a database of all Australian research published in ISI-indexed journals for the period 1981-1995. This database has been well documented in several of our published studies, and a description is available on the Internet.1,2 Our analysis of this database is based on the addresses shown on the publications, which we have "cleaned" down to the level of university department. This has been done by ensuring all variants of a departmental, faculty or institutional address (sometimes running into hundreds) are grouped together and given the same "standard" address. The database also contains details of the citations in ISI journals received by these Australian research articles; that is, the number of times Australian articles are in the reference list of other ISI journal articles. We also code the sector -- universities, hospitals, medical research institutes, government institutions, and "other" -- of each address. The medical research institutes sector comprises the 25 members of the Australian Association of Medical Research Institutes (AAMRI). Medical research in the Government sector comes primarily from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) and the State and Federal departments of health. The "other" sector includes industry and non-profit organisations. We acknowledge "grey areas" at the margins of these assignments to sectors. For example, where a research group based in a hospital with a university connection lists the university in the address, we consistently assign the publication to the university. Another example is the John Curtin School of Medical Research (JCSMR), a full-time medical research institute (though not a member of AAMRI), which is also a research school of the ANU funded from that university's operating grant. Its publications are assigned to the ANU and hence fall within the universities sector. Most publications can be unambiguously assigned, but some addresses are not precise guides to the source where the research was conducted. This arises particularly for researchers who hold conjoint or adjunct appointments in two institutions. If such an author nominates a single institution, we accept that this is the location of the research leading to that publication. If an author specifies two separate addresses, two records are created for that publication showing the two institutions (double-counting created by this procedure is removed for sectoral and national analysis, but remains when the individual institution is the focus of the analysis). If the address itself has multiple components, the publication can not be split into multiple records and has to be assigned to the apparent primary institution. Very few publications fall into this latter category, and their existence has little effect on the map of national, sectoral or institutional sites of research. We have used the standard bibliometric practice of ascribing an article to a particular field of research on the basis of the classification of the journal in which it appears. This procedure is not without problems, particularly in the case of analysis at the subfield level, but experience from our other studies has shown that the results are accurate if the data are being used to map research in a large field.3 To what extent is Australian basic research in the medical and health sciences covered by the REPP database? In this field, at least 70% of published research output from universities and medical research institutes is in the form of journal articles, and, of these, at least 70% appear in SCI journals.4,5 We therefore estimate that, as a minimum, the REPP database covers 50% of the published output in these two sectors. SCI coverage of research from the sectors hospitals and government institutions may be less complete in terms of their total research output, but their contributions to basic research will be well represented. In this article, we are using the REPP database to answer questions about the map of medical research in Australia, concentrating primarily on publications from 1990 onwards, but also introducing some time-series analysis. Where is the research being conducted? The sectoral distribution (Figure 1) shows that the bulk of Australia's basic medical research is located in universities and hospitals. Most of the research articles from the universities sector (75%) come from the 10 teaching medical schools and the JCSMR at the ANU. Our data also show that little has changed in the sectoral location of research over the past 15 years: the share of publications from the hospitals sector has remained constant, there has been a small drop in the universities share, and there has been a corresponding increase in the share from the medical research institutes. Are patterns of medical authorship changing? The REPP database enables us to distinguish publications by type of authorship, viz: Single author -- one author only (i.e., no collaboration); Group -- more than one author but sharing the same departmental address; Institutional -- more than one author from different departments/faculties; National -- more than one author from different institutions in Australia; and International -- more than one country listed in the author addresses. Figure 2 shows how the type of authorship of medical research articles has changed in the past 15 years. The two authorship types showing marked decline are "single author" articles, and "group" articles. Medical and health sciences in Australia appeared slow to exhibit the "internationalisation" of research apparent in other fields since the early 1980s, but the period since 1987 has seen a dramatic change. The proportion of publications involving international collaboration nearly doubled between 1987 and 1995. Collaboration with other Australian institutions has also become more common, increasing from 19% to 26% over the 15-year period. (A detailed analysis of Australia's international collaboration in basic research may be found in a monograph we prepared for the Australian Research Council.6 ) How "visible" is Australian medical research? We assess "visibility" by the number of research articles published and the citations those articles receive. Figure 3 plots Australia's share of "world" publications (i.e., of the total in the SCI) in the medical and health sciences and its share of all citations in SCI journals. The chart also plots Australia's Relative Citation Impact (RCI), which is calculated by dividing its share of "world" citations by its share of "world" publications. The most notable feature of this Figure is that Australia's share of publications in SCI medical journals increased by 25% between 1986 and 1995. The average RCI for the whole period was 1, indicating that Australian publications are attracting appropriate notice. Australia's RCI has not changed significantly over time, but remained at or marginally above 1. This is a strong performance as citation rates are influenced principally by publications from the major research centres of America and Europe. Where is Australia's most "visible" medical research being conducted? A standard measure used to compare the visibility of research in different sectors is the average number of citations received per publication (cpp). In Box 1 (below) we relate the number of publications produced by each sector in the period 1991-1995 to the number of citations those publications attracted in the same period. The leading position of the institutes making up the AAMRI is consistent with Richard Smith's impression of Australia's research institutes.7 Some of the differences in cpp rates can be attributed to the varied research profiles of different institutions. Data supplied by ISI enable us to quantify this, as we can calculate cpp rates for sets of journals. For example, articles in immunology journals for the same period attracted citations at the average rate of 6.21, while those in clinical sciences journals averaged 3.81. We would therefore expect hospitals, with their strong clinical focus, to have a lower cpp rate than those AAMRI establishments with a strong presence in immunology. However, the difference in cpp rates apparent in Box 1 (above) cannot be explained fully by differences in field concentrations; we calculate that differing citation rates across fields account for only a third of the gap in cpp rates between the AAMRI institutions and other sectors. The remainder is a measure of the differing visibility and impact of the research. Not all institutions within a given sector have similar visibility. In Box 2 we list the top five institutions (in terms of cpp rates) in each of the four sectors active in medical research. In the universities sector, we looked specifically at the teaching medical schools and for this reason have excluded JCSMR. The institutions in Box 2 are those with more than 100 SCI publications in the period. In this instance, we count publications in multidisciplinary journals such as Nature, Science and Proceedings of the National Academy of Sciences together with publications in medical and health sciences journals, on the assumption that for the listed institutions and faculties these articles would almost certainly relate to medical research. Sorting the institutions in Box 2 by cpp rates within sectors has the effect of allowing volume of publications to be moderated by impact. The consequences of the choice of the measure on which to rank institutions can be seen by a closer examination of the medical research institutes. While the Walter and Eliza Hall Institute of Medical Research has the largest number of publications and citations, and would be ranked first if these were the measures used, the Ludwig Institute for Cancer Research is top-ranked on the basis of average cpp rates. All three are measures of impact and visibility, but cpp rates take institutional size into account. We looked at the research focus of institutions to determine if the higher cpp rates of some institutions resulted from differing fields of concentration. Again, we found that while an institution's cpp rate was affected by the relative impact of the fields in which it was active, this accounted at most for only 30% of the variation in cpp rates between institutions in any given sector. Where are Australia's most highly cited medical articles produced? We identified a very small group of 12 articles, published since 1990, which have attracted more than 200 citations (Box 3). This Box does much to explain the ranking of the AAMRI institutes in Box 2. The Ludwig Institute for Cancer Research had only 135 publications satisfying our criteria of publication date and journal, yet three of these have attracted more than 200 citations. St Vincent's Institute of Medical Research had even fewer publications (130), but claimed authorship of the most highly cited publication for the period, with 551 citations, and another article with 256 citations. Seven of the listed articles, including the most highly cited publication, were "wholly" Australian; the other five articles involved international collaboration. Discussion Studying ISI journals in isolation does not permit conclusions to be drawn about quality. However, an analysis of citations can provide a guide to the source of Australia's most visible research, and there is a well established positive association8 between high visibility in ISI-indexed journals and research judged on other grounds, such as via peer evaluation and esteem measures, to be of high quality. The limitations of bibliometric analysis are well documented.9 Publications can attract large numbers of citations because they contain error, or because they report a new technique with wide application. Citation data are also highly skewed. Many publications attract no citations at all, and most of those that do receive only one or two. These and other problems are of little consequence when the focus is at the national or sectoral level, involving large numbers of publications.10 Our data provide only one approach to constructing a profile of Australian medical research. However, bibliometric or literature-based analysis cannot stand in isolation from historical and other kinds of evaluative judgements, and should not be used in a policy setting apart from those perspectives. That said, we believe that the information reviewed here does allow some interesting points to be made. The most encouraging inference we draw from our study is that, using the measure of Relative Citation Impact, Australian medical research stands relatively high in terms of international visibility. As Box 3 makes clear, Australian-based researchers publish in international journals and have well established links to collaborative projects in the major centres of work in the field.6 The bulk of Australia's basic research in the medical and health sciences comes from the universities and hospitals, but Australia's medical research institutes, the members of AAMRI, have the highest international profiles. Research from these institutions has had a major impact on the international community. However, high visibility is not confined to the AAMRI institutions, and, as we have shown, research achieving very high impact also comes from hospitals and universities. One of the most interesting policy issues which these data raise is the efficacy of block funding by comparison with direct project funding of research. Medical research in Australia is undertaken in a pluralist system, with major contributions from hospitals, universities, AAMRI and government institutions. While at first glance our data may appear to argue for block funding through the prominence of several AAMRI institutions funded in this way, the situation is more complex. Many of the AAMRI institutions are block-funded, but in some instances this accounts for as little as 35% of their total income. Any conclusions about funding await the completion of detailed bibliometric studies of the relative performance of medical research, in which we will attempt to identify the output of research supported by the varying modes of research funding. References Bourke P, Butler L. A Crisis for Australian science? Canberra: Performance Indicators Project, Australian National University, 1993. (Monograph Series No. 1.) < http://coombs.anu.edu.au/Depts/RSSS/REPP/repp.htm > Butler L, Bourke P, Biglia B. CSIRO: profile of basic research. Canberra: Research Evaluation and Policy Project, Australian National University, 1997. (Monograph Series No. 4.) National Board of Employment Education and Training (NBEET). Quantitative indicators of Australian academic research. Canberra: AGPS, 1994. (Commissioned Report No. 27.) Bourke P, Butler L. Monitoring research in the periphery. Canberra: Research Evaluation and Policy Project, Australian National University, 1996. (Monograph Series No. 3.) National Board of Employment Education and Training. International links in higher education research. Canberra: AGPS, 1995. (Commissioned Report No. 37.) Smith R. Top of the pile: the institutes. BMJ 1991; 302: 1006-1010. Narin F. Evaluative bibliometrics. Cherry Hill, NJ: Computer Horizons Inc, 1976. Van Raan AFJ, editor. Handbook of quantitative studies of science and technology. Amsterdam: Elsevier Science Publishers, 1988. Garfield E. In: Evered D, Harnett S, editors. Ciba Foundation Conference: the evaluation of scientific research. Chichester (UK): John Wiley & Sons, 1989. (Received 6 Jun, accepted 29 Sep, 1997) Authors' details Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, Canberra, ACT. Paul F Bourke, PhD, FASSA, Head of Research Evaluation and Policy Project; and Professor of History. Linda Butler, BEcon, Research Officer. Reprints: Professor P F Bourke, Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, ACT 0200. E-mail: paulb AT coombs.anu.edu.au - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul F Bourke · Linda Butler

Driving and dementia: a cause for concern Peter S Lipski Until we have better evidence about what is safe, we should not allow people with dementia to drive motor vehicles MJA 1997; 167: 453-454 For editorial comment, see Fox & Bashford Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - Road safety and dementia - Identifying impaired drivers - Identifying dementia - Implications - Conclusion - References - Author's details - - ©MJA1997 Introduction With the ageing of the Australian population, an increasing proportion of elderly drivers may not be medically fit to drive motor vehicles, particularly people with dementia of the Alzheimer's type. Many people with dementia, particularly men, refuse to give up driving, and families frequently have great difficulty convincing them to stop.1,2 Also, in my experience, drivers with dementia -- particularly those who live alone -- frequently continue to drive even when they have been advised not to and their driving licences have been cancelled. Road safety and dementia There is now strong evidence that the risk of motor vehicle accidents for drivers with dementia is significantly greater than that for aged-matched, cognitively normal drivers.1,2 This is not surprising, as important cognitive functions such as switching of visual selective attention, visuospatial orientation and judgement are impaired even in the early stages of Alzheimer's disease. Risks for car accidents are related to speed of information processing and efficient switching of selective attention, both of which are impaired in the early stages of Alzheimer's disease.2 When traffic conditions become complex and stressful (e.g., at intersections and roundabouts), demands on drivers with dementia may exceed their driving capabilities.3 Visuospatial orientation is important for selecting the correct side of the road and for making appropriate and safe turns. Impaired judgement would reduce a driver's ability to make appropriate decisions in traffic and to interpret traffic signs. Drivers with dementia would also have difficulty with aspects of driving that rely heavily on recent memory (such as remembering warnings about changed traffic conditions), and may not cope with sudden changes or new environments. Further, a recent postmortem study of the brains of drivers aged 65 years and older who were killed in car accidents found that over 50% had the neuropathological changes of Alzheimer's disease.4 Despite such evidence, and the increased risk of crashes among drivers with Alzheimer's disease (4.7 times that of control subjects),1 there is still great controversy in the medical literature about the safety of driving for people with the early stages of the disease. Some studies suggest that it would be acceptable to allow a person with early Alzheimer's disease to continue to drive rather that subvert their autonomy and "right" to drive a motor vehicle.3,5 Medical practitioners in Australia are not obliged by law to report drivers with dementia (there are much more specific guidelines for conditions such as epilepsy or stroke). The current New South Wales Roads and Traffic Authority guidelines for medical practitioners do not specifically exclude all people with dementia from driving (rather, recommending that drivers with dementia should be referred for on-road assessment if their ability to drive is in doubt),6 and do not give specific direction about how to assess cognitive function and behaviour in relation to driving skills. The Federal Office of Road Safety does exclude any person with dementia from driving a commercial vehicle.7 Restricted licences are commonly issued for impaired drivers in Australia. The use of these licences to allow drivers with dementia to drive only short distances from home has not been proved effective or safe, and may give a false sense of security to drivers with dementia and their doctors based on the erroneous expectation that people with dementia will not have problems if they remain in familiar surroundings. The increased crash risk for drivers with dementia remains even though they may restrict their driving.2,3 In one study nearly 50% of drivers with dementia incurred at least one crash, compared with only 10% of control subjects, within a five-year period.1 Having someone act as a "copilot" to assist drivers with dementia has not yet been proved a safe practice and should not be encouraged.8 Identifying impaired drivers Routine medical examinations frequently fail to identify elderly drivers with poor driving habits or those at higher crash risk.9 Increased crash risk may be associated with a lower Mini-Mental State Examination score, but this is not always the case.10,11 Also, a spouse or other family mem ber cannot be relied upon to predict the safety of continued driving.12 A multidisciplinary team approach involving an occupational therapist and neuropsychologist can help identify unsafe drivers when there is still doubt after a medical assessment.2,13 The occupational therapist and neuropsychologist are skilled in assessing cognitive impairments such as attentional deficits, impaired concentration, visuospatial impairments, slowed reaction times and distractibility which correlate with impaired driving. The current criterion standard in assessing driving safety is probably the on-road driving assessment, with specific testing protocols for drivers with cognitive impairments.9,13 Unfortunately such programs are costly, often geographically difficult to access, can entail lengthy delays and are impractical in view of the enormous number of elderly drivers who require such assessments. Identifying dementia Over 18 months in my department of geriatric medicine, of 1129 patients referred by general practitioners or medical specialists for routine geriatric medicine consultations we identified at least 38 drivers who had moderately or very advanced Alzheimer's disease who were not only continuing to drive, but whose dementia had not even been diagnosed by their referring practitioners. I believe that medical practitioners are failing to detect drivers with dementia because they are not routinely carrying out cognitive screening tests. Together, the short version of the informant questionnaire on cognitive decline in the elderly and the abbreviated mental test are a sensitive tool for detecting dementia.14 The simple clock drawing test (in which patients are asked to draw the numbers on a round clock face, requiring visuospatial orientation, concentration and planning ability) may also prove to be a very simple and sensitive, but non-specific, screening test for dementia.15,16 Compulsory screening of all drivers over 70 years old would be the only way to ensure compliance in screening. Implications There are currently 799 443 licensed drivers in Australia over the age of 70 years (Roads and Traffic Authority, unpublished data). Epidemiological figures tell us that about 10% of the population at 70 years may have dementia. Even if we make the generous assumption that 50% of all licence holders aged over 70 years no longer drive because of disability or for other reasons, then there would still be at least 40 000 drivers with dementia on Australian roads. Driving a car is a privilege and not a right. The evidence is not yet available to support allowing people with dementia to continue to drive. Further, there are no guidelines as to when people with early dementia who have been permitted to continue driving should be reassessed and what sort of end-points should be used in deciding when to terminate their licences. There are many reasons why a medical practitioner may allow a person with dementia to continue to drive. These include a perceived breach of personal liberty if a licence is cancelled, restriction in lifestyle for the older patient, demands by the older patient to continue to drive, and threats to the doctor-patient relationship. However, failure to advise a patient with dementia not to drive, failure to document that advice and failure to notify the relevant driver licensing authority may result in injury or death of the patient or of other innocent people. Such failure of patient care and social duty may breach professional ethics and may expose the doctor to legal action. Conclusion Doctors should use a recognised form of cognitive screening to assess all their patients over 70 years who drive. Doctors also need better training in medical driving assessments and diagnosis of early Alzheimer's disease. More funding is needed for on-road assessment of cognitively impaired drivers. We need more research into the reliability of medical driver assessments, crash risks and cognitive screening measures, particularly for the very early stages of Alzheimer's disease. Future research may also involve interactive computer-based simulations to evaluate on-road driving skills. To encourage drivers with dementia to surrender their licences, alternative forms of transport need to be arranged, including "community transport schemes" and better public transport.2,13 Rural drivers with dementia who are forced to give up their licences may be particularly at risk of becoming socially isolated, disadvantaged and perhaps stranded. Still, this is still no excuse for allowing an impaired driver to continue driving. References Freidland RP, Kos E, Kumar A, et al. Motor vehicle crashes in dementia of the Alzheimer's type. Ann Neurol 1988; 24: 782-786. Parasuraman R, Nestor PG. Attention and driving skills in ageing and Alzheimer's disease. Human Factors 1991; 33: 539-557. Hunt L, Morris JC, Edwards D, et al. Driving performance in persons with mild senile dementia of the Alzheimer's type. J Am Geriatric Soc 1993; 41: 747-753. Johansson K, Bojdanovic N, Kalimo H, et al. Alzheimer's disease and apolipoprotein E 4 allele in older drivers who died in automobile accidents. Lancet 1997; 349: 1143-1144. Drachman DA, Swearer JM. Driving and Alzheimer's disease: the risk of crashes. Neurology 1993; 43: 2448-2456. Roads and Traffic Authority. Drivers and riders. Guidelines for medical practitioners. 3rd ed. Sydney: NSW Roads and Traffic Authority, 1993. Dementia and other cognitive impairments. In: Medical examination of commercial vehicle drivers. Melbourne: National Road Transport Commission, and Federal Office of Road Safety, 1994. Shua-Haim JR, Gross JS. The "co-pilot" driver syndrome. J Am Geriatric Soc 1996; 44: 815-817. Johansson K, Bronge L, Lundberg C, et al. Can a physician recognise an older driver with increased crash risk potential? J Am Geriatric Soc 1996; 44: 1198-1204. Odenheimer GL, Beaudet M, Jette AM, et al. Performance-based driving evaluation of the elderly driver: safety, reliability and validity. J Gerontol 1994; 49: M153-M159. Fitten LJ, Perryman KM, Wilkinson CJ, et al. Alzheimer and vascular dementias and driving. A prospective road and laboratory study. JAMA 1995; 273: 1360-1365. Kapust LR, Weintraub S. To drive or not to drive: preliminary results from road testing of patients with dementia. J Geriatr Psychiatry Neurol 1992; 5: 210-216. Fox GK, Withaar F, Bashford GM. Dementia and driving: a survey of clinical practice in aged care assessment teams. Aust J Ageing 1996; 15: 111-114. Harwood DMJ, Hope T, Jacoby R. Cognitive impairment in medical inpatients. 1: Screening for dementia -- is history better than mental-state? Age Ageing 1997; 26: 31-35. Watson YI, Arfken CL, Birge SJ. Clock completion: an objective screening test for dementia. J Am Geriatric Soc 1993; 41: 1235-1240. Death J, Douglas A, Kenny RA. Comparison of clock drawing with Mini-Mental State examination as a screening test in elderly acute hospital admissions. Postgrad Med J 1993; 69: 696-700. Author's details Central Coast Area Health Service, Gosford, NSW. Peter S Lipski, MD, FRACP, Staff Specialist Geriatrician. Reprints will not be available from the author. Correspondence: Dr P S Lipski, Department of Geriatric Medicine, Central Coast Area Health Service, Health Services Building Level 2, Gosford Hospital, Stephen Street, Gosford, NSW 2250. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter S Lipski

Public health and politics: the demise of the ACT heroin trial Where is the commitment to evidence-based medicine? MJA 1997; 167: 348-349 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 The communique issued by the Ministerial Council on Drug Strategy (MCDS) meeting on 31 July 1997 stated: "If a number of preconditions can be met, the ACT Government [will] undertake a small trial of the controlled availability of heroin involving 40 people". Yet on 19 August, Federal Cabinet stopped the trial on the doubtful grounds that the Commonwealth would be required to pass special legislation permitting importation of heroin -- a claim contested by both the Federal Attorney General and the Health Minister. The Prime Minister also claimed that a rigorous trial of medically prescribed heroin was tantamount to legalisation and would "send the wrong message".1 What messages of certainty did the Prime Minister and Cabinet send by extinguishing the heroin trial? Firstly, that the lucrative profits of illicit drug trafficking, the very engine of this problem, would not be threatened. Secondly, that this problem will continue to be dealt with predominantly by law enforcement, an approach now widely recognised to be prohibitively costly and hopelessly impractical.2 The decision also sends a powerful message to medical researchers throughout Australia. Six years of careful scientific work on a significant community problem, widespread consultation, publications in quality peer-reviewed journals, openness to scientific scrutiny,3 support by the Australian Medical Association, presidents of medical colleges, numerous leaders of the medical profession, police commissioners, directors of public prosecution and a royal commissioner are not enough. An important, but controversial, scientific research project will be brought down politically if opposed by 51% of respondents in a community opinion poll4 and if subjected to a relentless campaign of media vilification and misinformation (Media Watch, ABC Television, 9.30 pm, 1 September 1997). This makes a mockery of the present government's advocacy of evidence-based medicine. Federal Cabinet's decision follows a long-standing tradition of basing policy in the illicit drug area on politics rather than science. Federal Cabinet's decision follows a long-standing tradition of basing policy in the illicit drug area on politics rather than science. Pharmacological fundamentalism even prevents doctors from recommending the option of smoking cannabis for palliating the intractable symptoms of terminal illnesses.5 The frequency of major inquiries into illicit drug use in Australia (at least 25, including Royal Commissions, in the past 25 years)6 suggests both considerable community anxiety as well as doubt about the effectiveness of current policy. Between 1979 and 1995, heroin-related overdose deaths increased from 10.7 per million population to 67 per million.7 Other illicit drug outcomes have also deteriorated alarmingly, while illicit drug law enforcement cost an estimated $1.7 billion in 1992.8 A Parliamentary Committee concluded that "all the evidence shows, however, not only that our law enforcement agencies have not succeeded in preventing the supply of illicit drugs to Australian markets but that it is unrealistic to expect them to do so".9 While generous funding continues for illicit drug law enforcement in the absence of demonstrable benefit, funding for treatment remains limited despite generally impressive outcomes. Methadone maintenance treatment is supported by overwhelming evidence of safety, effectiveness in improving health outcomes, reducing deaths, reducing crime and improving social functioning.10 The total cost of all methadone programs in Australia was estimated recently to be $40 million per annum,11 met by Commonwealth, State and Territory governments and by patients. Pharmacological treatments, especially methadone, are far more effective at attracting and retaining heroin-dependent patients than non-pharmacological treatments. The median duration of stay in drug-free rehabilitation facilities is only three to four weeks12 compared with about two years for methadone.13 Methadone maintenance is not attractive to all seeking pharmacological treatment and is not effective for all prepared to try it. When it comes to pharmacological treatment for heroin dependence, one size certainly does not fit all. Hence the need to expand the range of pharmacotherapies. Heroin was only one of a number of pharmacological agents to be evaluated for the management of heroin dependence. The MCDS also supported the evaluation of a number of other agents, including the opioid antagonist naltrexone, the long-acting agonist l- a-acetylmethadol (LAAM), the agonist-antagonist buprenorphine, and sustained release oral morphine. These trials are to go ahead. An official decision to support a heroin trial became difficult to oppose on any logical grounds after the final results of the Swiss heroin trial were released recently.14 Health outcomes of this trial were extremely impressive. Among 1146 subjects treated for 18 months, there were no overdose deaths, only three new HIV infections, four new hepatitis B infections and five new hepatitis C infections. Reported income from illicit and semi-legal activities decreased from 69% to 10%, the number of offences dropped by 60%, court convictions declined significantly, employment increased from 14% to 32%, and there were net savings of approximately $A45 per patient per day. It is difficult to think of any new law enforcement, education or treatment approach in the illicit drug field in the past 30 years which can boast such promising results. Why have the health, social and economic outcomes from illicit drugs in Australia continued to deteriorate for so many years? Firstly, there has been a systematic failure to collect relevant evidence (such as would be obtained from a heroin trial). Secondly, policy (including funding) has been based on ideology rather than evidence. If we want to help drug users lead normal and useful lives and offer some hope to their families and their communities, the first step is an unswerving commitment to evidence-based policy and practice without political interference. Tragically, in this country illicit drug policy has become inviolable while politicans remain terrified of losing an election lest rationality be misinterpreted as "being soft on drugs". The 1997 MCDS support for a 40-participant pilot stage of the heroin trial undoubtedly marked a watershed for evidence-based policy -- not for legalisation. There is no reason to believe that a heroin trial would have led inevitably to drug legalisation. After all, Britain has permitted medically prescribed heroin for more than 70 years while retaining a similar illicit drug policy to the one in Australia. Legalisation, if it means indiscriminate provision of all classes and quantities of currently illicit drugs, defies common sense, will always remain a political impossibility and would contravene Australia's international treaty commitments. The arguments for a heroin trial are as compelling now as they were before the prime ministerial intervention. As Justice Wood pointed out, "Without such a trial . . . its efficacy or otherwise will never be known. Until attempted, it is very difficult to move forward or to consider alternative strategies".15 The heroin trial was needed, and is still needed, as a circuit-breaker to move Australia from policies based on arbitrary historical decisions to a firm foundation on evidence. As far as the heroin trial is concerned, "the fat lady has not yet sung". Alex D Wodak Director, Alcohol and Drug Service St Vincent's Hospital, Sydney, NSW Short J, Hawes R, Kerin J. Heroin trials not on says Howard. The Australian 1997 Aug 20: 1. Flynn SE. The transnational drug challenge and the new world order. Washington, DC: The Center for Strategic and International Studies, 1993. Bammer G, Douglas RM. The ACT heroin trial proposal: an overview. Med J Aust 1996; 164: 690-692. Cockburn M. Nation's voters divided over ACT drug trial. Sydney Morning Herald 1997 Aug 19: 6. Kassirer JP. Federal foolishness and marijuana. New Engl J Med 1997; 336: 366-367. Australian Parliamentary Group for Drug Law Reform. Australian Drug Law Reform Foundation. Drug lore: the questioning of our current drug law. Canberra: The Foundation, 1997. Hall W, Darke S. Trends in opiate overdose deaths in Australia, 1979-1995. National Drug and Alcohol Research Centre technical report No. 49. Sydney: The Centre, 1997. Collins DJ, Lapsley HM. Social costs of drug abuse in Australia. National Drug Strategy Research Monograph No. 30. Canberra: Commonwealth Department of Community Services and Health, 1991. Report by the Parliamentary Joint Committee on the National Crime Authority. "Drugs, crime and society". Canberra: AGPS, 1989. Review of methadone treatment in Australia. Final report. October 1995. Canberra: Commonwealth Department of Human Services and Health, 1995. Ward J, Mattick R, Hall W. Key issues in methadone maintenance treatment. Sydney: New South Wales University Press, 1992. Swift W, Darke S, Hall W, Popple G. Who's who? A report on the characteristics of clients seen at We Help Ourselves 1985-1991. National Drug and Alcohol Research Centre technical report No. 14. Sydney: The Centre, 1993. Drug and Alcohol Directorate. NSW methadone programme annual statistical report, 1995-1996. Sydney: NSW Health Department, 1997. Uchtenhagen A, Gutzwiller F, Dobler-Mikola A. Programme for a medical prescription of narcotics. Summary of the synthesis report. Berne: Swiss Federal Office of Public Health, 1997. Wood JRT. Royal commission into the New South Wales police service. Final report. Sydney: The Government of the State of New South Wales, 1997: 228. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alex D Wodak

The public health impact of dog attacks in a major Australian city Peter G Thompson Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - ©MJA1997 Abstract Objective: To examine the impact of dog attacks by determining the incidence and risk factors for dog attacks. Design: Injury surveillance data on dog attacks for a major metropolitan hospital were converted to incidence rates using 1991 census figures for the hospital catchment area and combined with data on community attitudes and experiences derived from a large community survey. Setting: Queen Elizabeth Hospital (tertiary referral hospital), Adelaide, South Australia, January 1990 to July 1993. Participants: 356 victims of dog attacks who presented to the emergency department and 3093 respondents to the 1992 South Australian Health Omnibus Survey. Main outcome measures: Rates of dog attack by age and sex of the victim, hospital presentation and admission; differences in the representation of various dog breeds in attacks. Results: About 6500 people are injured in Adelaide each year as a result of dog attacks and about 810 seek hospital treatment (7.3 per 10 000 people per year). Children aged 0-4 years were attacked and required hospital treatment twice as often as adults aged 21-59 years, and men aged over 76 years twice as often as men aged 36-75 years. Males were more at risk of attack than females for all age groups. Hospital admission rates were five times higher for the elderly (95% confidence interval [CI], 2.3%-10.2%) and seven times higher for children 12 years and under (95% CI, 3.4%-15.1%) compared with people aged 13-59 years; 90% of children were admitted because of head and facial bites. The risk of attack from german shepherds, bull terriers, blue/red heelers, dobermans and rottweilers was four to five times higher than for other common breeds. Conclusions: The public health implications of dog attacks are significant and there needs to be increased awareness of the risks to young children. Potential interventions to reduce the incidence of dog attacks vary from strict controls on high-risk breeds to mandatory leashing to a "user pays" liability insurance proposal. MJA 1997; 167: 129-132 Introduction Dog attacks are a major cause of human injury in Australia. In 1991, it was estimated that there could be up to 30 000 people presenting to hospital annually as the result of dog attacks in Australia.1 Injury records from the Women's and Children's Hospital in South Australia show that dog attacks are the fourth most common reason for children being taken to hospital, after accidents from playground equipment, bicycles and motor vehicles.2 Studies from other States3,4 also report a high level of childhood injuries related to dog attacks, and a recent South Australian report5 confirmed that dogs were a significant cause of injury at all ages, including the elderly. In the United States, there has been a 37% increase since 1986 in dog bites that required medical attention, and dog attacks eclipse measles, mumps and whooping cough combined as a health threat to American children.6 To determine the impact of dog attacks and identify possible interventions to reduce their frequency, we examined surveillance data from a major metropolitan hospital in Adelaide and data from a large community survey. We report the rates of hospital treatment and admission for dog attacks, the severity of injuries, the groups most at risk of attack, community concern about dog attacks and a comparison of the relative risk between dog breeds. Methods Two data sources were used in this study: the South Australian Health Commission's Injury Surveillance System, and the 1992 South Australian Health Omnibus Survey. In both data sources, a "dog attack" was defined as an intentional bite by the dog, or direct aggression causing injury to the victim. 1991 Census population statistics were also used to determine the age- and sex-specific rates of dog attack, as well as the age-specific rates of admission to hospital resulting from dog attacks. Ethics approval was provided by the University of Adelaide. Injury Surveillance System The South Australian Health Commission's Injury Surveillance System automatically receives information from victims who present to selected metropolitan public hospitals for treatment. For the purposes of this study, it provided information about all victims of dog attacks (e.g., age and sex of victim, type of injury, location and description of incident and treatment) who presented to Queen Elizabeth Hospital in Adelaide between January 1990 and July 1993. This system, which includes all age groups, has the advantage of documenting the information at the time of treatment (in the hospital), which reduces the possibility of subsequent recall bias. Queen Elizabeth Hospital was chosen for this study because it has a well-defined catchment area with natural geographic boundaries on two sides. The other boundaries were determined by selecting the midpoint between adjacent public hospitals. Approximately 13% of the victims of dog attacks in the Adelaide metropolitan area who required hospital treatment between January 1990 and July 1993 presented to Queen Elizabeth Hospital. From a total of 356 attacks, the mean number by age and sex per year was calculated. The Injury Surveillance System provided the breed of dog (when it was known). We were confident that the breed names were accurate because in at least half of the attacks the victim was the dog's owner, a family member or a person who knew the dog well and the breeds named were common and easily recognised. Breeds that were unknown could have been a source of bias if their breed distribution was different. However, a comparison of victims who named the dog breed with those who did not failed to show any appreciable differences with regard to age, sex, dog ownership, body part injured and injury severity. The breed distribution of known breeds also largely agreed with other investigations.4,7-10 An indicator of the health impact of the injury on the person's life was whether the victim was admitted to hospital after initial examination in the emergency department. Those who were admitted were expressed as a proportion of the total number of people presenting to the emergency department. As data for all admissions came from the same hospital, the selection criteria for admission were likely to be consistent. The distribution of injury by body part was also examined. Health Omnibus Survey The 1992 South Australian Health Omnibus Survey11 contains information obtained from interviews with 3093 randomly selected persons in Adelaide in 1992.11 The annual Omnibus Survey is a population health survey that provides a large representative sample of the attitudes towards health issues and experiences of people aged over 15 years. For our investigation, 13 questions concerning dog attacks were incorporated into the Omnibus Survey, including: Does anyone in this household own a dog? What is the breed of the dog? Have you been attacked by a dog in the past three years? Whose dog was it? Where did the attack occur? To what extent do you fear being attacked or threatened by a dog? Respondents were also asked about injuries sustained and treatment received. Therefore, the Omnibus Survey provided data not only about victims of dog attacks who presented to hospital, but also data on victims of dog attacks who may have consulted a general practitioner as well as those who may not have been injured at all. The Omnibus Survey also provided information on the distribution of the dog population by breed. The frequency of breeds involved in attacks was converted to a representation ratio to compare the relative risks between breeds. The ratio was calculated by dividing the percentage of attacks per breed by the percentage of the total dog population represented by the same breed. Representation ratios allow confirmation of whether certain breeds of dog attack more frequently because they are more commonly chosen as pets (e.g., german shepherds may cause 25% of all attacks simply because they comprise 25% of the dog population). Population statistics from the Omnibus Survey as well as the 1991 Census were used to examine the demographics of the catchment area of Queen Elizabeth Hospital in comparison with metropolitan Adelaide. From an examination of the data on age, ethnicity and socioeconomic status, it was concluded that the catchment was representative of metropolitan Adelaide. Statistical analysis Ninety-five per cent confidence intervals [CIs] for admission rates were attributed to Lilienfeld and Lilienfeld,12 and 95% CIs for admission rate relative risks attributed to Rothman's analysis of crude data.13 Results Frequency of dog attacks: presentation to hospital Box 1 shows the age- and sex-specific rates of dog attack calculated from victims who presented to the emergency department of Queen Elizabeth Hospital from January 1990 to July 1993. The 356 dog attacks for this period equate to 7.3 attacks per 10 000 people per year requiring hospital treatment. The rate of dog attack for men over the age of 76 was nearly double the rate for men aged 36 to 75, but this was not statistically significant, possibly because of the small sample size of older men. Notably, the rate for children aged 0 to 4 years was twice that for adults aged 21 to 59 years. This rate was likely to be conservative because some children in the catchment area of Queen Elizabeth Hospital may have been taken directly to the Adelaide Children's Hospital. There was also a marked difference between the rates for men and women. Men had, on average, a 50% higher risk of attack at all ages ( Figure 1). Frequency of dog attacks: community survey Of the 3093 respondents to the Omnibus Survey, one in 20 reported that they had been attacked by a dog at least once in the past three years, and a third had been attacked more than once in the past three years. More than half (51%) reported that they had been attacked in a street or public place. Of the 88 people who reported in the Omnibus Survey that they had been injured by dogs and had required treatment, 35 people (40%) had consulted a doctor and 11 people (12.5%) had sought hospital treatment per year. The Omnibus Survey reported that 37.2% of households in metropolitan Adelaide owned at least one dog. The 1992 Dog Control Review Report estimated that there were about 190 000 dogs in metropolitan Adelaide.14 Admission to hospital Box 2 (above) shows the number of victims of dog attacks who were admitted to Queen Elizabeth Hospital between January 1990 and July 1993. The rates of admission to hospital, as an indicator of the health impact of dog attack, were five times higher for elderly people (95% CI, 2.3-10.2) and seven times higher for children (95% CI, 3.4-15.1) than for people aged 13-59 years. Nearly two-thirds (66%) of children aged up to 12 years received head and facial bites ( Figure 2); these injuries were responsible for 90% of admissions in this age group ( Figure 3). Relative risk of dog attack, by breed Box 3 (below) shows the proportion of dog attacks by various breeds, the representation of particular breeds in the total dog population, and the relative risk of attack by those breeds (representation ratio). The Injury Surveillance System provided the breed of dog in 43% of attacks (154). It can be seen that the first five breeds were responsible for 73% of all hospital-treated attacks, yet they represented only 31% of the dog population. The relative risk of attack by a german shepherd was about five times greater than a collie (2.5/0.5 = 5). Bull terriers, red/blue heelers and rottweilers presented a four-times-higher risk. The relative risk of attack by a doberman was even higher. It is possible that more dangerous dogs existed (e.g., the prohibited American pit bull terrier), but they did not feature in the Injury Surveillance System data because they comprised a small proportion of the dog population. Fear of dog attacks Half of the respondents to the Omnibus Survey felt threatened or feared being attacked by dogs (95% CI, 48.4%- 51.9%). Of those who were afraid, 28.4% said their concern was minor in that it did not affect their behaviour, 18.7% felt moderate concern which had had an effect on their behaviour (such as planning safer routes away from known dogs), and the remaining 3.1% expressed major concern which had had more dire consequences (such as deciding not to leave the house to go shopping). Incidence of dog attacks The total number of attacks represented a rate of 2.85% per year, which corresponds to about 29 000 attacks in metropolitan Adelaide each year, based on the 1991 Census population of 1 023 278. The total number of people injured and requiring treatment represented a rate of 0.63% per year, which corresponds to about 6500 people being injured and requiring treatment following dog attacks in Adelaide each year, with 2600 persons consulting a doctor and 810 seeking treatment at a hospital. If the overall rate of presentation to Queen Elizabeth Hospital following a dog attack (i.e., 7.3 per 10 000 people per year) is applied to the population of Adelaide, it corresponds to 750 persons presenting to hospital each year. This figure is close to the rate of 810 reported in the Omnibus Survey. If Adelaide is considered similar to most other Australian metropolitan areas, it could be expected that around 100 000 Australians will be injured and require treatment each year as a result of dog attack and that about 13 000 will seek treatment at a hospital. Discussion In this study, three-quarters of all hospital-treated dog attacks were caused by just five of the 160 or so available breeds. Limiting the availability of these breeds would be one way of reducing injury. Alternatively, ownership could be restricted to certified owners who accept responsibility to place specific controls on these breeds. These controls include obedience training and dog behaviour assessment, ensuring that the dog is on a leash at all times in public, the home property is securely fenced and warning signs have been erected for visitors. Owners should also be encouraged to join dog clubs to raise awareness of the responsibilities involved in owning a dog. More than half the attacks reported in this study occurred in a street or public place by loose uncontrolled dogs. It is reasonable to assume that if the dogs had been restrained these attacks would not have occurred. The Australian Capital Territory, the Brisbane City Council, and a number of Victorian councils have adopted the strategy of requiring all dogs to be on a leash at all times in public. Councils in those States that still consider dogs need only be under the verbal control of their master in public places should consider this safer option. Brisbane City Council also requires mandatory fencing to contain dogs within their owner's property. Data from the Injury Surveillance System clearly show that dogs and very young children frequently do not mix.1 Parents of young children would be wise to postpone purchase of a dog until their children are older, preferably more than five years of age. A nationwide publicity campaign is recommended to alert parents to the dangers, especially in view of the high level of attacks to the head and face of children found in this study. Another option to reduce dog attacks could be to adopt a "user pays" element into dog ownership by introducing a third party insurance scheme. The issue of a registration permit could be conditional on the presentation of a suitable insurance agreement. In 1993, a South Australian court awarded $380 000 to a garbage collector for injuries sustained when attacked by an unrestrained dog -- the dog's owners were found responsible for the damages.15 For low-risk breeds, it is anticipated that there would be no additional premium to standard home insurance cover, but for high-risk breeds an increased premium would be likely. The premium would ultimately be determined by the extent of the claims relevant to each particular breed (i.e., the performance of the insured determines the cost). The paying of an additional premium would have the effect of deterring "spur-of-the-moment" buyers by encouraging them to think more carefully when choosing a breed and perhaps buy a lower-risk breed. Another benefit would result from insurance companies insisting on better ownership practices for particular breeds (as outlined at the beginning of the Discussion) before issuing policies. The rates of dog attack in Adelaide were projected to the nation as a whole because most Australians live in metropolitan areas and large regional centres (similar to Adelaide) and it was therefore considered that dog attacks were a widespread public health problem. The finding that half of the population surveyed were concerned about being attacked by dogs indicates that strengthening of dog-control policies will be more acceptable to the community than previously thought. In view of rising community concern and increasing media reports on dog attacks, owners must take more responsibility and put in place measures to reduce the incidence of dog attacks. References South Australian Health Commission. Dog attacks. Inj Surveill Monthly Bull January 1991; 29: 1-2. Williams N. Women's and Children's Hospital. The perils of being a kid . The Advertiser (Adelaide) August 1995. Ashby K. Dog bites. Victorian Injury Surveillance System. Hazard 1996; 26: 7-13. Podberscer AL, Blackshaw JK, Nixon JN. The incidence of dog attack in children treated at a city hospital. Aust Vet J 1990; 67: 79-80. Langley A, Dantalis N, Edwards-Bert P. Environmental health in the home. Adelaide: South Australian Health Commission, 1996: 10-32. Wulf S. Man's best friend? Time 1997; June 23: 68. Greenhalgh C, Cockington R, Raftos I. An epidemiological survey of dog bites presenting to the emergency department of a children's hospital . J Paediatr Child Health 1991; 27: 171-174. Thomas PR, Buntine JA. Man's best friend? A review of the Austin Hospital's experience with dog bites. Med J Aust 1987; 147: 536-540. Langley J. The incidence of dog bites in New Zealand. Injury Prevention Research Unit, Preventive and Social Medicine. N Z Med J 1992; 105: 33-35. Avner JR, Baker MD. Dog bites in urban children. Pediatrics 1991; 88: 55-57. Harrison R. 1992 Health Omnibus Survey -- A research report. Adelaide: Harrison Market Research Pty Ltd; 1993: 11-21. Lilienfeld AM, Lilienfeld DE. Foundations of epidemiology. 2nd ed. New York: Oxford University Press, 1980: 336-337. Rothman KJ. Modern epidemiology. Boston/Toronto: Little, Brown and Company, 1986: 155-175. KJ McCann. Dog Control Review Report. Adelaide: South Australian Department of Environment and Planning, 1992. Revalk J. Dog scare garbo gets $380 000 for injuries. South Australian Advertiser March 1993. (Received 20 Aug 1996; accepted 26 May 1997) Authors' details Injury Surveillance and Control Unit, South Australian Health Commission, Adelaide, SA. Peter G Thompson, MPH, Injury Epidemiologist. Reprints will not be available from the author. Correspondence: Mr P G Thompson, Public and Environmental Health Service, South Australian Health Commission, PO Box 6, Rundle Mall, SA 5000. E-mail: somers.ronald@health.sa.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter G Thompson

Hepatitis C: waiting for the Grim Reaper Encouraging drug users to adopt non-injecting routes of administration may be the most effective way of controlling the hepatitis C epidemic MJA 1997; 166: 284 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 Until the controversial Grim Reaper campaign alerted Australians to the seriousness of its newly recognised AIDS epidemic, citizens of the Lucky Country were complacent about infections. Fortunately, the HIV epidemic has been stabilised among injecting drug users (IDUs) in Australia by a harm reduction/public health approach to intravenous drug use. Now we have evidence of another important viral epidemic -- hepatitis C. Despite it being arguably the commonest life-threatening infection in Australia, alarm bells have not yet been rung for hepatitis C. We are beginning to recognise hepatitis C as a public health problem comparable in magnitude with HIV The incidence and prevalence of hepatitis C in Australia are far higher than those of HIV infection. An estimated 130 000 Australians have been infected with hepatitis C virus (HCV) over the last 20 years, with about 6000 new chronic infections a year through injecting drug use alone.1 In contrast, an estimated 15 450 people have been infected with HIV by all routes of transmission, with about 500 new infections a year between 1994 and 1996.2 Although a smaller proportion of individuals infected with HCV experience serious morbidity and mortality, and only after a longer delay (10%-20% are estimated -- conservatively -- to develop cirrhosis within 20 years and 5% of these develop hepato cellular carcinoma within five years),3 the far larger pool of infected people and longer duration of illness suggest that the total health and economic burden of hepatitis C in Australia is considerable and may well surpass HIV before too long. The task of bringing hepatitis C under control is daunting. While the pieces of the hepatitis C jigsaw puzzle are still being assembled, injecting drug use is undeniably the major mode of transmission in Australia and other developed countries. In this issue of the Journal, Sladden and colleagues found that 85% of hepatitis C notifications involved IDUs. Their epidemiological study analysed notifications of hepatitis C from a community sample and assigned risk factors for a high proportion of respondents. However, the high non-response rate of 53% and the statistically significant differences between respondents and non-respondents qualify their findings. In contrast to Sladden and colleagues' results, a United States study estimated a much lower proportion of IDUs among hepatitis C notifications, but could not assign risk factors for as high a proportion of respondents.4 As official policy in the US advocates "zero tolerance" for any illicit drug use, it is hardly surprising that many American IDUs were apparently intimidated from revealing their risk behaviour. Australian national surveillance data (of uncertain quality) accord with Sladden and colleagues' results -- about 85% of hepatitis C virus infections involve IDUs.1 Current hepatitis C incidence in IDUs is now estimated to be about 15 per 100 person-years.1 IDUs entering prison on more than one occasion are at even greater risk.5 These alarming figures are consistent with those for other countries.6 Hepatitis C seroprevalence in a large cohort of IDUs in the United States was 65% for those who had injected for one year or less and 85% when the cohort was followed up for 49-72 months.7 Indeed, a recent review1 of published studies of the epidemiology of hepatitis C among Australian IDUs traces the epidemic back to at least 1971, soon after injecting drug use became established in this nation. Clearly, the epidemic will be halted only if it is controlled among IDUs. Could a harm reduction/public health approach control hepatitis C among IDUs? Such an approach, which includes needle exchange and methadone treatment programs, has already been successful in stabilising the HIV epidemic among IDUs in Australia. In contrast, the US "War on Drugs", which has resulted from the official policy of "zero tolerance" for any illicit drug use, has had catastrophic public health consequences. In 1994, IDUs accounted for only 2.5% of AIDs cases in Australia,8 compared with 28% in the US in 1993.9 While the prevalence of AIDS (per million population) in the United States was 4.3 times that in Australia in 1988, by 1992 this ratio had increased to 6.4,10 fuelled by an uncontrolled epidemic among IDUs and a secondary epidemic among heterosexual contacts of HIV-positive IDUs in the US. Despite the success of the harm reduction/public health approach in controlling the HIV epidemic and slowing the spread of hepatitis B among IDUs in Australia, it appears not to have reduced the incidence of hepatitis C.1 There is a very real possibility that hepatitis C transmission among IDUs requires only minimal breaches of infection control guidelines.1 Hepatitis C virus is an order of magnitude more infective than HIV,11 and hepatitis C has a far higher baseline prevalence than HIV infection. Consequently, while expanding needle exchange and methadone treatment programs may reduce hepatitis C incidence, this is unlikely to control the epidemic. The approach of eliminating importation or global production of injectable drugs continues to enjoy some support, especially during long election campaigns, but it is increasingly apparent that this is an expensive fantasy. Even a major architect of Nixon's "War on Drugs", the former White House adviser John Erlichman, testified to a US Senate Subcommittee: "the people in the federal government . . . know darn well that the massive war they have mounted on narcotics is only going to be effective at the margins. If they don't know it, they ought to know it."12 Reducing drug supply or demand is seemingly a more realistic objective, but the evidence of past decades provides little grounds for optimism. While attempts to eliminate harm from illicit drugs almost universally fail, efforts to reduce harm generally succeed. Therefore, encouraging drug users to adopt non-injecting routes of administration (sniffing, smoking, snorting or swallowing) appears to offer our best hope for achieving hepatitis C control among IDUs. Smoking of heroin has overtaken injecting in popularity in many parts of the United States, the United Kingdom and the Netherlands.13 Reasons differ between these countries but are thought to include, in the US, the scarcity of sterile injecting equipment, coupled with drug users' fear of contracting HIV infection through needle sharing, and (most importantly) the recent drop in price and increase in purity of available heroin. In other countries, the increased availability of heroin base, which has a lower melting point than heroin hydrochloride and is thus more suitable for smoking, has played a part. A strategy of promoting non-injecting routes of administration also offers the hope of reducing the growing epidemic of drug overdoses, which claim about 500 young Australian lives each year. We are beginning to recognise hepatitis C as a public health problem comparable in magnitude with HIV. The recent inclusion of hepatitis C in the Third National HIV/AIDS Strategy means that it will at least be included in a national policymaking apparatus, which delivered splendid, internationally recognised results for HIV/AIDS. Only when there is a national commitment to raise levels of awareness about the seriousness of this epidemic will Australia stand a chance of controlling hepatitis C. Until Australia embarks on a major national awareness-raising exercise, such as a "Grim Reaper"-style public education campaign, the band will continue to play on for hepatitis C as it once did for HIV. Alex Wodak Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW. Crofts N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis C virus infection among injecting drug users in Australia. J Epi Comm Health. In press. National Centre in HIV Epidemiology And Clinical Research. An epidemiological assessment of the HIV epidemic in Australia. Technical Appendix 1. Evaluation of the HIV/AIDS Strategy 1993-4 to 1995-6. Canberra: AGPS, 1996: 9-16. Albertis A, Realdi G. Parenterally acquired non-A, non-B (type C) hepatitis. In: McIntyre N, Benhamou J-P, Bircher J, et al., editors. Oxford textbook of clinical hepatology. Oxford: Oxford University Press, 1991: 605-617. Alter MJ, Hadler SC, Judson FN et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990; 264: 2231-2235. Crofts N, Stewart T, Hearne P, et al. Spread of blood borne viruses among Australian prison entrants. BMJ 1995; 310: 285-288. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev. In press. Garfein RS, Vlahov D, Galai N, et al. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, B human immunodeficiency and human T-lymphotropic viruses. Am J Pub Health 1996; 86: 655-661. National Research Council and Institute of Medicine. Preventing HIV transmission. The role of sterile needles and bleach. Washington DC: National Academy Press. 1995. National Centre For Epidemiology And Clinical Research. Australian HIV surveillance report. 11: 14. April. 1995. Feachem RGA. Valuing the past -- investing in the future. Evaluation of the national HIV/AIDS strategy 1993-94 to 1995-96. Canberra: Commonwealth Department of Human Services and Health, AGPS, 1995. Gerberding JL. Management of occupational exposure to blood-borne viruses. N Engl J Med 1995; 332: 444-451. Baum D. Smoke and mirrors. The war on drugs and the politics of failure. Boston: Little Brown and Company, 1996. Wodak A, Crofts N. Once more unto the breach: controlling hepatitis C in injecting drug users. Addiction 1996; 91: 181-184. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alex Wodak

Hepatitis C transmission on the north coast of New South Wales: explaining the unexplained Tim J Sladden, Alan R Hickey, Therese M Dunn and John R Beard MJA 1997; 166: 290 For comment see Wodak Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Exposures - Transmission to sexual partners and offspring - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To determine the routes of hepatitis C virus (HCV) transmission in an Australian community. Design: Questionnaire-based, cross-sectional survey of notified HCV cases. Subjects and setting: All cases notified to the New South Wales North Coast Public Health Unit between 1 January 1993 and 30 September 1994. Outcome measures: Frequency of potential transmission exposures (parenteral and sexual); most likely primary exposure; HCV infection rates in sexual partners and offspring. Results: 467 subjects responded (47% of resident cases). Of these, all but one reported actual or potential blood exposures (injecting drug user [IDU], 85%; IDU with sharing of injection equipment, 76%; pre-1990 blood transfusions, 6%; other blood exposures, 8%). Most subjects reported multiple exposures and none reported sexual contact as the only potential exposure. Of 233 sexual partners tested for HCV, 83 were positive; 54 of these were questioned and all had other parenteral exposures. Only three children out of 91 children tested were positive for HCV (two expressing maternal antibodies). Conclusions: In contrast with previous studies, possible HCV transmission modes were identified for almost all respondents. Most respondents in this community were IDUs. Non-parenteral transmission appeared minimal. Novel approaches to preventing HCV transmission in IDUs are needed. MJA 1997: 166; 290-293 Introduction Few studies have investigated transmission of hepatitis C virus (HCV) in representative, population-based samples.1-3 Most previous studies have examined patient series,4-6 those at risk (e.g., transfusion recipients and injecting drug users [IDUs])7-9 or other particular groups (e.g., blood donors, pregnant women and prisoners).10-12 Previous studies have also failed to identify exposures in significant numbers of cases (up to 45% of respondents).1-5,8 HCV transmission is predominantly parenteral13 (via shared drug injection equipment, infected blood products [almost entirely before screening was introduced in February 1990], unsterile skin penetration practices [e.g., tattooing, ear/skin piercing, acupuncture], needlestick and "sharps" injuries and shared personal items, such as toothbrushes and razors14 ). However, patient-to-patient transmission (via contaminated anaesthetic circuitry)15 and surgeon-to-patient transmission (via percutaneous injury)16 have both been demonstrated. Sexual transmission without blood contact appears rare,5,6,8,13 but the risk of blood exposure may be increased by sexual contact during menstruation and anal intercourse. Vertical transmission also appears rare.8,13,17 Both sexual and vertical transmission appear viraemia-dependent,8,9,13,17 and may be facilitated by genital lesions.6,17 Nipple trauma may enable postnatal transmission.18 Household transmission is probably restricted to infected personal items.19 Arthropod vectors have not been identified. Despite evidence that there is no risk of transmission via casual contact, community concern about hepatitis C transmission remains evident in the discrimination reported anecdotally by people with HCV. Clarification of how HCV is transmitted is needed both to allay this concern and to allow the development of new prevention strategies.20 One focus of the current Australian hepatitis C epidemic is the north coast of New South Wales (NSW), where the notification rate (201/100 000 residents) is double the NSW rate (103/100 000 residents),21 and nearly three times the Australian average (74/100 000 residents).22 We investigated the mode of transmission in notified cases in residents on the NSW north coast over a 21-month period. Methods All people diagnosed with HCV infection (through duplicate second generation anti-HCV antibody tests) who were notified to the North Coast Public Health Unit between 1 January 1993 and 30 September 1994 were invited to participate. Subject name, diagnosis and contact address were verified with attending doctors. Questionnaires were mailed to subjects with covering letters, consent statements, and reply-paid return envelopes. Non-respondents were recontacted by mail six weeks later. Data, with identifying codes removed, were entered into a restricted-access database. We developed a questionnaire that included demographic questions, a checklist of possible ways the subject may have contracted hepatitis C (see Box 1) and questions about the HCV status of the subject's current sexual partner and, for women, of their children. The questionnaire was pilot-tested on clients of a local sexual health service. The study and questionnaire were approved by the North Coast Region Health Service Ethics Committee. For subjects with multiple potential exposures, exposures were ranked according to expected risk, and the exposure with the highest risk was considered the most likely primary exposure. Parenteral exposures were assumed to be higher risk than sexual exposure and ranked as: High risk -- (in descending order of risk) injecting drug use (IDU) (with and without reported sharing of injection equipment), receipt of pre-1990 blood products, dialysis and transplants; Medium risk -- needlestick injuries, tattooing, or blood splashes into a cut, eye or mouth (i.e., during an accident or fight); and Potential or low risk -- origin from countries where medical services have used inadequate infection control procedures in the past (such as reuse of needles) or where unsterile tattooing or scarification is common (including the Mediterranean area, Eastern Europe, Asia, South America, Africa and the Middle East),23 post-1989 blood transfusion, ear or skin piercing and other clinical procedures. Transmission between study subjects and their current sexual partners was investigated; a modified questionnaire which included only the checklist of potential transmission routes was mailed to all HCV-positive partners. Household and social contact were examined when no other exposure was reported. Subjects with only low-risk or no parenteral exposures were offered testing for HCV RNA by polymerase chain reaction (PCR) to confirm their hepatitis C status. Demographic characteristics of respondents and non-respondents were compared with chi-squared tests and t tests, and sharing of injection equipment by current and former IDUs was compared with chi-squared tests. Results Of 1487 notified cases, 487 were excluded (395, temporary residents or non-residents; 67, with address unknown; seven, aged under 18 years; 18, other reasons), leaving a study population of 1000. Questionnaires were returned by 467 (46.7%). Respondents differed significantly from non-respondents in sex and age distributions: respondents included a significantly higher proportion of women than non-respondents (respondents: 219/467 [47%]; non-respondents: 212/533 [40%]; chi-squared = 4.42, P = 0.035) and were significantly older (respondents: mean age, 37.4 years; 95% confidence interval [CI], 36.6-38.3; range, 18-86; non-respondents: mean age, 34.9 years; 95% CI, 34.4-35.5; range, 18-62); t [unequal variances] = 4.70; df = 852, P < 0.001). Exposures Potential HCV exposures are shown in Box 1. Almost all 467 respondents reported at least one potential transmission exposure and most reported multiple exposures. The potential exposure with the highest expected risk was classified as the most likely primary exposure. Most respondents (398 [85%]) were IDUs (222 men, 176 women), including 287 (72%) former IDUs (although 45 [11%] of these reported stopping during the survey period). None of the 19 subjects aged over 60 years were IDUs. Of the IDUs, 354 (89%) reported having shared injection equipment. Frequency of sharing injection equipment by IDU status is shown in Box 2 (below). Current IDUs reported sharing significantly less than former IDUs ( chi-squared = 5.82; df = 1; P= 0.016). Hepatitis B infection was reported by 184 subjects (39%); 175 of these (95%) were IDUs. All but 11 sharers of injection equipment and all non-sharer IDUs reported other parenteral exposures (Box 1). Among subjects who were not IDUs, the most likely primary exposure (Box 1) was pre-1990 blood transfusion for 30 (6%), dialysis for two (0.4%), needle-stick injuries for six (1%) (including three health care workers, one with a known exposure to hepatitis C virus, a garbage collector and the partner of an IDU), tattooing for four (0.9%), blood splashes for four (0.9%), origin in a "high-risk" country for three (0.6%), post-1989 blood transfusion for two (0.4%), skin piercing for 13 (3%) and medical procedures for four (0.8%). About a third of subjects (151 [ 32%]) reported past or current HCV-positive sexual partners. However, 147 (97%) also had potential blood exposures (141, IDU; three, blood transfusion; and one each, tattoos, needlestick injury and blood splash). The remaining four had low-risk potential blood exposures (pierced ears or skin for three and a clinical procedure for one). Thus, sexual contact did not occur without concurrent or potential blood exposure(s). Sharing of personal items (e.g., toothbrushes) also could not be excluded for subjects reporting sexual contact. For 15 subjects, no sexual exposure and only low-risk potential parenteral exposures were reported. Another subject reported no risk factors. Polymerase chain reaction (PCR) was offered to these 16 to confirm their anti-HCV antibody test results. Ten were lost to follow-up (including the subject with no risk factors), three were confirmed HCV-positive (all had had clinical procedures, two had pierced ears and the third had social contact with an HCV-positive person) and three were HCV-negative, indicating either resolved infections or false positive initial antibody results. Transmission to sexual partners and offspring Three-hundred-and-twenty subjects (69%) had current sexual partners. Of 233 partners who had been tested for HCV, 83 (36%) were positive, 138 negative and 12 had unknown results. Of the positive partners, 80 (96%) were partners of IDUs, with independent parenteral exposures determined for 54 (68%) and unknown for the rest. Of the negative partners, 70 (51%) practised "unsafe" sex (defined as unprotected oral, anal or vaginal sex) with study subjects. Among the 219 women subjects, 173 had had children; 56 had had one child tested for HCV and 35, a second child. Only three children were anti-HCV positive -- two infants expressing maternal anti-HCV antibodies, and a three-year old. Discussion Many studies have investigated HCV transmission in limited patient series or specific groups,4-12 and full identification of exposures has been difficult.1-5,8 Our study was a population-based survey, and we were able to identify potential blood exposures for 99% of respondents. However, the response rate was low (47%), reflecting the difficulties of community-based surveys and, possibly, community sensitivities about bloodborne viruses. In addition, there were small but statistically significant age and sex differences between respondents and non-respondents, with a higher proportion of women among respondents and most older subjects responding. However, none of the 19 subjects aged over 60 years were IDUs. We suggest that non-IDUs would be more likely to respond than IDUs, and that a higher response rate in non-IDUs accounted for the age difference between respondents and non-respondents. Questionnaire comprehension was not thought to be a problem as the north coast population is predominantly English-speaking (96%).24 The high proportion of subjects declaring use of illicit drugs in the 60 years and under age group (89%) implies they were reporting truthfully. Therefore, we postulate that the respondents were representative of those infected with HCV in this community. If more respondents had denied injecting drugs, selection bias due to non-response of IDU subjects might have been a legitimate concern. Our results suggest that, on the NSW north coast, injecting drug use with sharing of injection equipment accounted for transmission in 76% of all people with hepatitis C. Transmission during injecting drug use remained possible in a further 9% who denied sharing injection equipment, as unrecognised contamination of such equipment (e.g., spoons, filters, water or swabs), poor recall or denial of sharing may have occurred. Apart from IDU, other high- or medium-risk blood exposures appeared to be responsible for a further 10% of respondents, and all but one of the remaining 5% had low-risk or potential blood exposures, with 1% of these also having sexual contact. While rates of IDU (past or current) may be relatively high on the NSW north coast, we suggest that almost all HCV transmission is via blood exposure, with varying proportions of different types of blood exposure in different populations. Thus, there appeared to be minimal HCV transmission via sexual, perinatal, household, occupational or social contact, provided blood exposures were avoided. Supplemental testing identified some false positives among the few subjects without obvious blood exposures. While a third of subjects had had sexual contact with HCV-positive partners, all of these had additional blood exposures (high risk for 95%, medium risk for 2% and low risk for 3%). Our results should help allay community concern about HCV transmission via casual contact. Sexual transmission appears to be minimal, but the risk may increase with menstruation, anal sex, concurrent STDs that involve scratching, sores or blisters, and increasing viraemia (often observed in early, acute stages of HCV infection). Uninfected partners should also avoid oro-facial abrasions of infected sexual partners (e.g., from toothbrushing or razor cuts). People with hepatitis C who are contemplating having children would be advised to seek medical advice regarding their HCV-RNA PCR status, hepatic enzyme function, and clinical symptoms as markers of viral activity. The low frequency of unexplained transmission in this study (< 1%) was almost entirely attributable to the high rate of reporting of injecting drug use. Other studies have found much lower rates of injecting drug use in HCV-positive subjects, but have been unable to explain transmission in a much higher proportion (27%-45%),1,3-5 possibly because of reluctance to admit illicit drug use. In our study, the privacy afforded by the self-administered questionnaire may have encouraged more truthful reporting than may occur in an interview or clinic situation. Many IDUs were former users, suggesting not only reluctance of current IDUs to participate, but also that much HCV infection is due to past drug use. Current IDUs shared injection equipment significantly less often than former IDUs, indicating increased awareness of the dangers and the effectiveness of needle and syringe exchange programs. However, sharing of injection equipment remains the commonest route of transmission of HCV, responsible for an estimated 10 000 new infections each year in Australia.25 The proportion of cases due to IDU will increase with blood product screening. This emphasises the need for transmission prevention and harm-minimisation programs, especially targeting adolescents before any experimental drug-taking. Community development and peer education of IDUs to promote safer injecting practices should be strengthened.26 The impacts of improved access to needle and syringe exchange and methadone programs, campaigns to encourage non-injecting routes of drug administration, development of non-reusable syringes,25 supply of heroin to registered users27 and provision of "safe-house" injecting venues on HCV transmission all need to be investigated. Acknowledgements Kieran Mutimer and staff at the Lismore Sexual Health and AIDS Service assisted with piloting and circulating questionnaires. References Alter MJ, Hadler SC, Judson FN, et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990; 264: 2231-2235. Mistry SA. Hepatitis C notifications in the Australian Capital Territory, January to June 1993. Comm Dis Intell 1995; 19: 183-188. Curran M. Acute hepatitis C notifications and associated risk factors in Australia, 1995 first quarter report. Comm Dis Intell 1995; 19: 615-617. Strasser SI, Watson KJR, Lee CS, et al. Risk factors and predictors of outcome in an Australian cohort with hepatitis C virus infection. Med J Aust 1995; 162: 355-358. Weinstock HS, Bolan B, Reingold AL, Polish LB. Hepatitis C virus infection among patients attending a clinic for sexually transmitted diseases. JAMA 1993; 269: 392-394. Tor J, Llibre JM, Carbonell M, et al. Sexual transmission of hepatitis C virus and its relation with hepatitis B and HIV. BMJ 1990; 301: 1130-1133. Crofts N, Hopper JL, Bowden DS, et al. Hepatitis C virus infection among a cohort of Victorian injecting drug users. Med J Aust 1993; 159: 237-241. Meisel H, Reip A, Faltus B, et al. Transmission of hepatitis C virus to children and husbands by women infected with contaminated anti-D immunoglobulin. Lancet 1995; 345: 1209-1211. Bresters D, Mauser-Brunschoten EP, Reesink HW, et al. Sexual transmission of hepatitis C virus. Lancet 1993; 342: 210-211. Kaldor JM, Archer GT, Buring ML, et al. Risk factors for hepatitis C virus infection in blood donors: a case-control study. Med J Aust 1992; 157: 227-230. Fairley CK, Leslie DE, Nicholson S, Gust ID. Epidemiology and hepatitis C in Victoria. Med J Aust 1990; 153: 271-273. Anand CM, Fonseca K, Walle RP, et al. Antibody to hepatitis C virus in selected groups of a Canadian urban population. Int J Epidemiol 1992; 21: 142-145. van der Poel CL, Cuypers HT, Reesink HW. Hepatitis C virus six years on. Lancet 1994; 344: 1475-1479. Davis AR. Contaminated razor blades as a possible source of hepatitis C virus infection [letter]. Med J Aust 1995; 163: 275. Chant K, Kociuba K, Munro R, et al. Investigation of possible patient-to-patient transmission of hepatitis C in a hospital. NSW Public Health Bull 1994; 5: 47-51. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334: 555-560. Zanetti AR, Tanzi E, Paccagnini S, et al. Mother-to-infant transmission of hepatitis C virus. Lancet 1995; 345: 289-291. Grayson ML, Braniff KM, Bowden DS, Turnidge JD. Breastfeeding and the risk of vertical transmission of hepatitis C virus [letter]. Med J Aust 1995; 163: 107. Davis AR, Kowalik AM. Hepatitis C virus transmission to heterosexual partner: bedroom or bathroom hazard? [letter] Med J Aust 1996; 164: 126. Strasser SI. Hepatitis C: questions still to be answered [editorial]. Med J Aust 1996; 164: 132-133. Sladden TJ, Hickey AR, Beard JR. Hepatitis C on the North Coast of NSW [letter]. Med J Aust 1995; 162: 166. Longbottom H, Evans D, Myint H, Hargreaves J. Annual Report of the National Notifiable Diseases Surveillance System. Comm Dis Intell 1994; 18: 521, 533. National Health and Medical Research Council Hepatitis C Working Party. Draft report on a strategy for the detection and management of hepatitis C virus in Australia. Canberra: NHMRC, 1996. Census Applications. Socio-economic profile of the north coast of New South Wales. Lismore: North Coast Regional Co-ordination Pilot Program, NSW Premier's Department, 1996. Wodak A, Crofts N. HIV revisited: preventing the spread of blood-borne viruses among injecting drug users. Aust J Public Health 1994; 18: 239-240. Feachem RGA. Valuing the past. . .investing in the future. Evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96. Canberra: Commonwealth Department of Human Services and Health, 1995 (ISBN 0644356944). Bammer G, editor. Feasibility research into the controlled availability of opioids. Canberra: NCEPH/AIC, 1991 (ISBN 0731512359). (Received 8 Feb, accepted 20 Nov, 1996) Authors' details North Coast Public Health Unit, NSW Health Department, Lismore, NSW. Tim J Sladden, MSc, MPH, Epidemiologist; Alan R Hickey, RN, Research Assistant; Therese M Dunn, BAppSc(Comp), Research Assistant; John R Beard, MB BS, FAFPHM, Director. Reprints: Mr T J Sladden, North Coast Public Health Unit, NSW Health Department, PO Box 498, Lismore, NSW 2480. E-mail: tslad AT doh.health.nsw.gov.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Tim J Sladden · Alan R Hickey · Therese M Dunn · John R Beard

"Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment Anthony F Jorm, Ailsa E Korten, Patricia A Jacomb, Helen Christensen, Bryan Rodgers and Penelope Pollitt MJA 1997; 166: 182 Abstract - Introduction - Methods - Sample - Interview - Ethical approval - Results - Recognition - Choice and rating of available help - Prognosis - Discussion - References - Authors' details - ©MJA1997 Abstract Objectives: To assess the public's recognition of mental disorders and their beliefs about the effectiveness of various treatments ("mental health literacy"). Design: A cross-sectional survey, in 1995, with structured interviews using vignettes of a person with either depression or schizophrenia. Participants: A representative national sample of 2031 individuals aged 18 -74 years; 1010 participants were questioned about the depression vignette and 1021 about the schizophrenia vignette. Results: Most of the participants recognised the presence of some sort of mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%) and 84% for the schizophrenia vignette (correctly labelled by 27%). When various people were rated as likely to be helpful or harmful for the person described in the vignette for depression, general practitioners (83%) and counsellors (74%) were most often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so. Corresponding data for the schizophrenia vignette were: counsellors (81%), GPs (74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to a psychiatric ward) were more often rated as harmful than helpful, and some non-standard treatments were rated highly (increased physical or social activity, relaxation and stress management, reading about people with similar problems). Vitamins and special diets were more often rated as helpful than were antidepressants and antipsychotics. Conclusion: If mental disorders are to be recognised early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Further, public understanding of psychiatric treatments can be considerably improved. MJA 1997; 166: 182-186 Introduction "Health literacy" has been defined as the ability to gain access to, understand, and use information in ways which promote and maintain good health.1 By extension, we have coined the term "mental health literacy" to refer to knowledge and beliefs about mental disorders which aid their recognition, management or prevention. Mental health literacy includes the ability to recognise specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking. The lifetime risk of developing a mental disorder is so high (nearly 50%)2 that almost the whole population will at some time have direct experience of such a disorder, either in themselves or in someone close. A high public level of mental health literacy would make early recognition of and appropriate intervention in these disorders more likely. Previous information on this topic is limited and is derived from national surveys on depression alone,3-5 or on depression and schizophrenia.6 Although these surveys found that most people believed depression to be treatable,3-5 most respondents had negative views about the effectiveness of medication for mental disorders. In contrast, counselling and psychotherapy were generally viewed more favourably.3,4,6 To assess the mental health literacy of the Australian population, we surveyed a representative national sample of adults on their knowledge of and beliefs about schizophrenia and depression. We report our findings on the ability of this population to recognise these disorders and their beliefs about the effectiveness of various treatments. Methods Sample The survey was carried out by the Australian Bureau of Statistics in August 1995 as part of its Population Survey Monitor.7 This is a household survey covering all private dwellings in urban and rural areas (excluding the sparsely settled areas) across all States and Territories. Selected households were initially sent a letter explaining that their dwelling had been selected for the survey. The letters gave advance notice that an interviewer would call to make an appointment. Interviewers made at least three call-backs in rural areas and at least five in urban areas before a dwelling was classified as "non-contact". Contact was made with a sample of 2531 households, with one person randomly sampled per household for a personal interview; 2164 persons agreed to participate (85%). Because a pilot study showed that people aged more than 75 years often had trouble understanding the interview, this age group was excluded, leaving a sample of 2031 respondents, aged 18-74. Fifty-six per cent of the sample was female and 74% Australian-born. The age distribution was: 21% aged 18-29, 25% aged 30-39, 22% aged 40-49, 16% aged 50-59, 11% aged 60-69 and 5% aged 70-74. The highest educational qualification was: secondary school certificate (51%), trade certificate/apprenticeship (11%), other certificate (17%), associate or undergraduate diploma (7%), bachelor's degree or higher (13%), still at school (1%). Weights were provided for each respondent, based on complex ratio estimation procedures, to adjust for probabilities of selection and to reduce non-response bias.7 Weighted percentages, which represent estimates of the whole of the Australian population aged 18-74, are presented here. Interview The interview was based on a vignette of a person suffering from a mental disorder. Half the sample were shown a vignette describing a person who met ICD-108 and DSM-IV9 criteria for major depression ( Box 1) and the others were shown a vignette of a person who met ICD-108 and DSM-IV9 criteria for schizophrenia ( Box 2). The sex of the person described was randomly assigned to be male (John) or female (Mary). After being shown the vignette and having it read out to them, respondents were asked two open-ended questions: "What would you say, if anything, is wrong with John/Mary?" and "How do you think John/Mary could best be helped?" The rest of the interview consisted of questions to determine the respondents' knowledge of and views about: Various people who could help (whether each category of person was likely to be helpful, harmful, or neither, for the person described); A range of possible treatments (whether each treatment was likely to be helpful, harmful, or neither, for the person described); Knowledge of likely prognosis; Knowledge of risk factors; and Beliefs associated with stigma and discrimination. Ethical approval Approval was obtained from the Ethics in Human Experimentation Committee of the Australian National University. Statistical analysis Using the chi-squared test, all estimates were compared according to recognition of a mental health problem. Only differences significant at the 0.01 level (P < 0.01) are reported below. Results Of the 2031 persons interviewed, 1010 were shown the depression vignette (508, John and 502, Mary) and 1021 were shown the schizophrenia vignette (514, John and 507, Mary). Recognition Figure 1 summarises responses to the question "What would you say, if anything, is wrong with John/Mary?", and shows those categories mentioned by at least 5% of the respondents (all responses were later categorised by the researchers). Multiple responses were allowed, and 30% of respondents gave at least two answers. For the depression vignette, 39% correctly identified depression and 22% mentioned stress. In all, 72% mentioned a category that could be regarded as being within the sphere of mental health. Eleven per cent mentioned items that we categorised as physical disorders (e.g., viruses, nutritional deficiencies, cancer), and half of these respondents did not mention a mental problem. A further 17% gave only answers that were extremely variable, but which we grouped as "personal or employment-related problems", "problems with not being active or sociable enough", and "other". Seven per cent of the sample responded with "don't know". For the schizophrenia vignette, although 84% mentioned at least one category in the sphere of mental health, only 27% recognised schizophrenia and a further 26% mentioned depression. Physical disorders were the only suggestion from 2% of the respondents, while 13% gave responses that described neither physical nor mental disorders (e.g., "has a problem"). There was less uncertainty with the schizophrenia vignette, however, in that only 4% responded with "don't know". Choice and rating of available help For the second open-ended question -- "How do you think John/Mary could best be helped?" -- 34% of the respondents (across both vignettes) made more than one suggestion. For the depression vignette, the most frequent response was "see a doctor" (44%), followed by "see a counsellor" (23%) and "talk over with family or friends" (20%). A psychiatrist was mentioned by 8%, while 5% answered "don't know". Responses for the schizophrenia vignette were: counsellor (31%), psychiatrist (28%), doctor (27%), family or friends (20%) and "don't know" (4%). The respondents were given a list of people who might potentially provide help and were asked to rate the various helpers by saying whether each would be helpful or harmful (Figure 2a). For the depression vignette, most of the respondents regarded GPs (83%), counsellors (74%), close friends (73%) and close family (70%) as helpful; around half the population rated telephone counselling services (53%), psychiatrists (51%) and psychologists (49%) as helpful. Fewer than 10% felt that any of the above groups would be harmful, although 43% believed it would be harmful for someone with depression to deal with it on their own. For the schizo phrenia vignette, most respondents regarded counsellors (81%), GPs (74%) and psychiatrists (71%) as helpful; a larger proportion of the population than for the depression vignette believed it would be harmful to try and deal with such problems alone (55%). Rating of pharmacological treatments Respondents were given a list of pharmacological treatments (Figure 2b) to rate as helpful or harmful. For the depression vignette, more of the respondents regarded each of the medications as harmful than helpful. The exception was the category vitamins, minerals, tonics or herbal medicines, which were regarded as helpful by 57% of respondents, and as harmful by 3%. Antidepressant medication was recognised as helpful by 29% and as harmful by 42% of respondents. For the schizophrenia vignette, antidepressants were regarded as helpful by 38% of respondents, followed by vitamins and minerals (34%) and antipsychotics (23%). The greatest percentage of "don't know" responses was for antipsychotics (about one-fifth of the respondents for both vignettes). Rating of non-pharmacological treatments When respondents were asked to rate non-pharmacological treatments (Figure 2c), most (for both the depression and the schizophrenia vignettes) regarded non-standard interventions (more physical or social activity; learn relaxation [including stress management, meditation or yoga courses]; reading about people with similar problems) as helpful and not harmful. On the other hand, most regarded admission to a psychiatric ward as harmful (depression, 62%; schizophrenia, 51%) and most regarded having electroconvulsive therapy (ECT) as harmful (depression, 72%; schizophrenia, 66%). For the depression vignette, psychotherapy was seen as helpful by 34% and harmful by 13%, compared with 55% helpful and 7% harmful for the schizophrenia vignette. The highest number of "don't know" responses was elicited for psychotherapy (16% for depression, 15% for schizophrenia) and for ECT (10% for depression and 14% for schizophrenia) (data not shown). As opinions about treatment might vary according to whether or not the respondent thought the person in the vignette had a mental health problem, the respondents were divided accordingly. The major difference in findings was that those who did not perceive a mental health problem were more likely to rate treatments as "neither helpful nor harmful" or to respond "don't know" . However, the rank ordering of treatments in terms of helpfulness was generally similar. Spearman rank correlation coefficients for the depression vignette were 0.82 (people), 0.90 (medicines) and 0.98 (treatments), and for the schizophrenia vignette they were 0.87 (people), 0.71 (medicines) and 0.98 (treatments). Prognosis All respondents were asked to give their views on prognosis with and without the professional help they thought most appropriate. For the depression vignette, 80% thought that there would be full recovery with help. If there was no help, 56% believed the person would get worse, and 5% that there would be full recovery. For the schizophrenia vignette, 69% believed that help would result in full recovery; if there was no help, 75% believed that the person would get worse, and 3% that there would be full recovery. Discussion Recognition of the presence of a mental disorder was high in our population sample, although only a minority gave the correct psychiatric label to their vignette. While it is not known whether there is any benefit to the public in being able to apply the correct psychiatric label, misidentifying a mental disorder as a physical one or as a problem unrelated to health may lead to inappropriate use or avoidance of health services. The major limitation in recognition is therefore seen in the 28% who thought the person described in the depression vignette did not have a mental disorder and the 16% who had the same opinion about the person in the schizophrenia vignette. When respondents were asked about the helpfulness of various people, GPs were rated very highly for both vignettes. Only half the respondents thought that a psychiatrist or psychologist would be helpful for the person in the depression vignette, a proportion less than that cited for GPs, counsellors, close friends, family, and telephone counselling. While psychiatrists and psychologists were rated as relatively more helpful for the person in the schizophrenia vignette, they were nevertheless less likely to be rated as helpful than counsellors or GPs. This suggests that public perceptions of mental health specialists need to be changed. Ratings given for the helpfulness of various treatments for depression are not consistent with the evidence of controlled trials, which have indicated that both antidepressant medication and psychotherapy are effective treatments. 10,11 Antidepressants were rated as helpful by 29% of our sample and as harmful by 42%, while psychotherapy was rated as helpful by 34% and harmful by 13%. Both were regarded as less helpful than treatments such as vitamins and minerals and special diets. The treatment with the highest negative rating was ECT. Although the patient described to the respondents could not be regarded as severely depressed enough to warrant ECT, 11 there is clearly a public perception that this treatment is harmful. The treatments that the public rated most highly were all non-standard in nature. These views may not be entirely misguided; there is evidence (e.g., from controlled trials) that physical exercise may have a positive effect on depression. 12 The findings were similar for the schizophrenia vignette. Although controlled trials show that antipsychotic medication is an effective treatment, 13 this was rated as helpful by 23% of the respondents and harmful by 34%; 20% did not offer an opinion. Similarly, admission to a psychiatric ward, which can be useful in the management of schizophrenia, 13 was rated as harmful by half the respondents. As with depression, non-standard interventions were the most likely to be rated as helpful. Despite these negative opinions of, or ignorance about, the helpfulness of many standard treatments, the public clearly sees the conditions described in the vignettes as treatable. The predominant belief that mental disorders are treatable has also been found in overseas surveys, 3,4 although a United States survey found that most respondents believed it possible to get better through one's own efforts. 5 There were some marked differences in responses to the depression and schizophrenia vignettes in terms of recognition, perceived helpfulness of treatments and prognosis. These differences show that the respondents did not see all mental disorders as the same and recognised that the condition described in the schizophrenia vignette required more vigorous intervention. Our results also indicate that the views of many members of the public diverge from those of health professionals, particularly mental health specialists. Such differences may lead to unwillingness to accept help from mental health professionals, or to a lack of adherence to advice given. Clearly, if mental disorders are to be recognised early and appropriate action taken, the level of mental health literacy in the population should be raised. There has been considerable interest in trying to improve the recognition and management of mental disorders in primary care, 10,14 but this knowledge needs to reach the consumers of services so that they can play a more effective role in the management of their own mental health. References Nutbeam D, Wise M, Bauman A, et al. Goals and targets for Australia's health in the year 2000 and beyond. Canberra: Australian Government Publishing Service, 1993. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19. McKeon P, Carrick S. Public attitudes to depression: a national survey. Ir J Psychol Med 1991; 8: 116-21. Sims A. The scar that is more than skin deep: the stigma of depression. Br J Gen Pract 1993; 43: 30-31. Regier DA, Hirschfeld RM, Goodwin FK, et al. The NIMH depression awareness, recognition, and treatment program: structure, aims, and scientific basis. Am J Psychiatry 1988; 145: 1351-1357. Angermeyer MC, Matschinger H. Public attitude towards psychiatric treatment. Acta Psychiatr Scand 1996; 94: 326-336. Australian Bureau of Statistics. Population survey monitor, August 1995 (No. 4103.0). Adelaide: ABS, 1995. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva: WHO, 1993. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed) (DSM-IV). Washington DC: APA, 1994. Depression Guideline Panel. Depression in primary care: Volume 2. Treatment of major depression. Clinical practice guideline, number 5. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993. The Quality Assurance Project. A treatment outline for depressive disorders. Aust N Z J Psychiatry 1983; 17: 129-146. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993; 37: 565-574. The Quality Assurance Project. A treatment outline for the management of schizophrenia. Aust N Z J Psychiatry 1984; 18: 19-38. Ustun TB, Goldberg DP, Cooper JE, et al. A new classification for mental disorders with management guidelines for use in primary care: The ICD-10 PHC. Br J Gen Pract 1995; 45: 211-215. (Received 22 Feb 1996, accepted 4 Nov, 1996) Authors' details NHMRC Social Psychiatry Research Unit, The Australian National University, Canberra, ACT. Anthony F Jorm, PhD, DSc, Deputy Director; Ailsa E Korten, BSc, Research Officer; Patricia A Jacomb, MSc, Research Assistant; Helen Christensen, PhD, Fellow; Bryan Rodgers, PhD, Fellow; Penelope Pollitt, PhD, Research Fellow. No reprints will be available from the author. Correspondence: Dr A F Jorm, NHMRC Social Psychiatry Research Unit, The Australian National University, Canberra, ACT 0200. E-mail: Anthony. Jorm AT anu.edu.au - - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Anthony F Jorm · Ailsa E Korten · Patricia A Jacomb · Helen Christensen · Bryan Rodgers · Penelope Pollitt

Outbreak of cryptosporidiosis linked to an indoor swimming pool Jennifer M Lemmon, Jeremy M McAnulty and Jason Bawden-Smith MJA 1996; 165: 613 Subsequently cited in Sinclair I, Fairley CK, Hellard ME. Protozoa in drinking water: is legislation the best answer? MJA 1998; 169: 296-297. Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - Authors' details - ©MJA1996 Abstract Objective: To determine the extent and source of a community outbreak of cryptosporidiosis. Design: Questionnaire-based survey and matched case-control study. Setting: Sutherland area in southern Sydney, September 1994 to January 1995. Participants: 70 patients reported by pathology laboratories to have stool specimens positive for cryptosporidia, of whom 43 were surveyed; 35 were compared with age- and neighbourhood-matched controls. Main outcome measures: Demographic characteristics and potential risk factors in the two weeks before onset of illness. Results: Laboratories reported 70 cases of cryptosporidiosis between September 1994 and January 1995. We found no association between illness and foods consumed or contact with people with diarrhoea or sick animals in the two weeks before onset. Seventeen of the case group (49%) reported swimming in a particular indoor swimming pool, compared with only seven controls (20%) (odds ratio, 3.7; P = 0.015). Cryptosporidial oocysts were detected in water from the swimming pool in January 1995. Conclusions: The outbreak of cryptosporidiosis was probably associated with ingestion of water from the indoor swimming pool, presumably contaminated by infected bathers. Recommendations: As it is difficult to eradicate cryptosporidia from swimming pools by either disinfection or filtration, we recommend that:People with recent diarrhoea should avoid public swimming pools; and Non-toilet-trained and faecally incontinent swimmers should be provided with alternative swimming facilities with separate water and filtration systems. To enable appropriate public health responses:Doctors and pathology laboratories should consider cryptosporidiosis in patients with diarrhoea lasting longer than three days; and Laboratory reporting of cryptosporidia to local health departments should be mandatory in all States and Territories. MJA 1996; 165: 613-616 Introduction The protozoan Cryptosporidium parvum was first recognised as a cause of illness in humans in 1976. 1 In the 1980s, cryptosporidia were reported to cause life-threatening, cholera-like illness in the immunosuppressed. 2 Subsequently, cryptosporidia were reported to produce a spontaneously resolving illness in the immunocompetent, characterised by diarrhoea with profuse watery stools lasting days to months, abdominal pain, nausea, vomiting, malaise and low-grade fever. 3 There is no known effective treatment. 4 Cryptosporidia (Figure 1) are common in the environment and are excreted in the faeces of those infected. They can be transmitted through contact with infected cattle, sheep and other animals, 5-7 person-to-person contact, 8 contaminated water supplies 4,9 and swimming. 10-12 Cryptosporidial infection was not a notifiable disease in New South Wales at the time of the study, and many laboratories do not routinely screen stool specimens for crypto sporidia. 3 Thus, we do not know the incidence of this disease in the community, nor the relative importance of different modes of transmission. In January 1995, a general practitioner in the Sydney suburb of Sutherland reported to the Southern Sydney Public Health Unit increases in numbers of patients presenting with watery diarrhoea and of stool specimens positive for cryptosporidia at a local laboratory. We therefore investigated the extent and source of this outbreak of crypto sporidiosis. Figure 1: Cryptosporidium oocysts from a faecal specimen. Modified Ziehl-Neelson stain; original magnification x 1000 (slide courtesy of Dr Stephen A Neville). Methods Methods were similar to those used by McAnulty et al. 10 and included a case survey and investigation of likely sources of the cryptosporidia, by comparison of cases and matched controls and an environmental study. Case survey In January 1995, the five major pathology laboratories serving the Sutherland area (defined as the area bounded by the Pacific Ocean to the east, Georges River to the north and the Royal National Park to the south) were asked to report all stool specimens in which crypto sporidia had been detected since September 1994. Two of the pathology laboratories examined stool specimens microscopically for cryptosporidial oocysts with a modified Ziehl-Neelsen acid-fast stain (modified by decolorising with hydrochloric acid and ethanol and counterstaining with malachite green) if structures suggestive of protozoa were seen on wet-mount examination. 13 The other three laboratories did not screen for cryptosporidia unless requested by the referring medical practitioner. Case patients were defined as people with a stool specimen positive for cryptosporidia between 1 September 1994 and 20 January 1995. Because of the high rate of person-to-person spread, cases were classified as primary (first to report diarrhoea in a household) and secondary (subsequent household cases). All people diagnosed as case patients after 1 December 1994 (and reported before 20 January 1995) and aged over 18 years were interviewed by telephone in January 1995 with a 34-item structured questionnaire. Interview was with parents if the patient was less than 18 years old. The questionnaire asked about the illness and about potential risk factors in the two weeks before onset of illness, including travel outside Sydney; childcare attendance; contact with other people with diarrhoea, or with pets and domestic animals; swimming; and sources of drinking water. The period of two weeks was chosen to include the incubation period for cryptosporidiosis of 1-12 days (average, about seven days). 14,15 People diagnosed before 1 December 1994 were not interviewed in detail because of the potential for poor recall given the time since infection. Case-control study To identify likely sources of infection, we compared potential risk factors of case patients with those of matched control subjects who had had no gastrointestinal symptoms in the previous two weeks, selected from a computerised telephone directory. Each matched control subject lived in the same street as (or within two streets of) the case patient and was matched for age within three years (for case patients younger than eight years), five years (for case patients aged 8-25 years), or 10 years (for case patients older than 25 years). Control subjects were administered a 23-item questionnaire on potential risk factors, referring to the two weeks before Christmas 1994. We chose this period as it was relatively easily identified by subjects and the season was similar or identical to that during the outbreak, so that conditions for swimming (a potential risk factor) were comparable. Differences in characteristics and risk factors between primary and secondary cases were tested for significance with either the c 2 test or, if expected cell size was less than five, with a two-tailed Fisher exact test. Differences between matched pairs of cases and controls were tested for significance with the probability of the maximum likelihood estimate of the odds ratio. 16 Swimming pool investigation We investigated a community swimming pool visited by some case patients (pool A), examining filtration systems and maintenance and chlorination records for the period November 1994 to January 1995. In addition, samples of poolwater and filter backwash water (water passed backwards through the filter to clean it) from this pool were tested for Crypto sporidium oocysts and Giardia cysts. For testing, water was filtered through a polycarbonate membrane (pore size, 2 m m for Cryptosporidium oocysts, or 5 m m for Giardia cysts), which was washed clean; washings were mixed with fluorescent antibody specific for either cryptosporidia or giardia. Particles were sorted by size and fluorescence with a flow cytometer and their identity confirmed by microscopy. 17 Filtration systems used at local government-owned swimming pools in the inner, eastern and southern areas of Sydney were surveyed. Operators were asked over the telephone about the type of filtration system used and whether general-use pools shared their water and filtration systems with pools for infants. Results Case survey We identified 70 cases of cryptospori diosis diagnosed between 1 September 1994 and 20 January 1995. Fortnightly incidence is shown in Figure 2. Characteristics and potential risk factors of the 43 case patients reported between 1 December 1994 and 20 January 1995 are shown in Box 1. (Another five case patients were diagnosed in the week to 20 January but not reported until later and so were not surveyed.) Symptoms included diarrhoea (42 of the 43 patients, 98%), cramping abdominal pain (23, 53%), vomiting (21, 49%), nausea (16, 37%) and fever (16, 37%). None of the people affected reported being immunocompromised; more than half were children aged under 4.5 years. Twenty-eight cases were primary and 15 secondary. The only significant differences between the primary and secondary cases were that secondary-case patients were more likely to be male (80% of secondary cases versus 36% of the primary cases; P < 0.01) and, as expected, were more likely to have had contact with people with diarrhoea (100% of secondary cases versus 25% of primary cases; P < 0.001). Figure 2: Cases of cryptosporidiosis diagnosed by laboratories in the Sutherland area of Sydney, 1 September 1194 - 20 January 1995 (specimen date was unknown for two cases). Case-control study Of the 43 cases reported between 1 December 1994 and 20 January 1995, five were excluded from the case-control study as they lived outside the Sutherland area, and three were excluded as matched controls could not be identified. As primary- and secondary-case patients reported similar potential risk factors, both sets of patients were included in the case-control study. Potential risk factors in the case and control groups are compared in Box 2. There was no association between illness and attendance at childcare, contact with people with diarrhoea, and drinking bottled water or city water. Although more of the case group than the control group reported swimming in the two weeks surveyed, the difference was not significant. However, significantly more in the case group than in the control group reported swimming in pool A. There was no significant association between cryptosporidiosis and swimming in any other pool. Swimming pool investigation Pool A is an indoor heated swimming pool located in a popular community swimming complex that caters for all ages from infants to adults. Average daily attendance between 1 September and 1 December 1994 was 1269 people (range, 1092-1443). The complex includes three outdoor pools (none associated on epidemiological grounds with cryptosporidiosis), as well as the indoor pool. The indoor pool comprises a 25-metre swim area, a teaching and aquarobics area (used by infant and toddler learn-to-swim classes), and a "bubble" area (with air jets, and popular with children). It contains about 1.6 million L of water and has a rapid sand filtration system, separate from the filtration systems for the outdoor pools. Chlorine levels in pool A, documented every three hours between 6 am and 9 pm daily, ranged from 0.55 to 5.0 mg/L. The New South Wales Health Department recommends that chlorine levels for indoor pools be maintained at 1.5 mg/L for those heated to less than 26¡C, and at a minimum of 2.0 mg/L for warmer pools. 18 Pool A was heated to more than 26¡C, and chlorine levels were in the recommended range 28% of the time. Eleven Cryptosporidium oocysts and 57 Giardia cysts were detected in a 55-L sample of the pool water taken in January 1995, but none in a 500-mL sample of filter backwash water. Among the 20 local government-owned pools surveyed, filtration used sand at 19, and fine-grade diatomaceous earth (a porous form of silica, composed of the fossilised shells of a type of alga) was used in the other. At all these pool complexes, general purpose pools and infants' pools shared water and filtration systems. As a result of the investigation, management at pool A erected signs warning patrons of the possibility of pool-water contamination and instructing that people who were not toilet-trained, who were faecally incontinent or who had had diarrhoea in the previous week should not enter the pool. The public was warned through a press release of the possible connection between the pool and cryptosporidiosis. On 20 January 1995, to allay public concern, pool A operators decided to replace the water in the pool and the outbreak subsequently abated. Discussion This is the first report of an outbreak of cryptosporidiosis associated with swimming in Australia. The outbreak, which lasted several months, was also the largest reported point-source outbreak of crypto sporidiosis in Australia. As many laboratories do not routinely screen for cryptosporidia, and as doctors may not order examination of stool specimens and people with diarrhoea may not consult a doctor, 3,9 there were undoubtedly many more cases of cryptosporidiosis than those reported. This outbreak probably began when the water in indoor swimming pool A was contaminated with cryptosporidia from an infected bather. The likelihood of contamination was increased by the pool's use by infants and children too young to be faecally toilet trained (crypto sporidia are present in the faeces of those infected). The infective dose of C. parvum causing illness in humans remains unclear, but recent evidence suggests it is very low (e.g., a dose of 30 oocysts has been reported to cause infection in a healthy volunteer). 19 While chlorine levels in pool A were not optimal, higher levels would have been unlikely to have prevented the outbreak, as cryptosporidial oocysts are extremely resistant to chlorine and can survive many days in chlorinated water. 20 We do not know if protection from ultraviolet light in the indoor pool may have enhanced cryptosporidial survival. While swimming at pool A was strongly associated with crypto sporidiosis, it explained only 49% of cases. No other single pool was significantly associated with illness and, as the epidemic subsided with draining of pool A, others were not tested. However, it is possible that others in the case group were infected at pools other than pool A (although not identified in our survey), or by direct contact with people with the disease, given the small infective dose. The localised nature of the outbreak and the age distribution of those affected (i.e., children or parents) indicated that drinking Sydney water was not a likely source of the outbreak. Detection of cryptosporidial oocysts in water from pool A confirmed the epidemiological findings that C. parvum contaminated the pool. However, the viability of the organisms detected is unknown. Although Giardia cysts were also detected, they are relatively sensitive to chlorine and unlikely to be viable. 20 Furthermore, local laboratories reported no increase in detection of Giardia cysts in stool specimens. Sand filtration systems have been implicated in previous swimming pool-related outbreaks of cryptosporidiosis, 10 and almost all of the local government-operated pools surveyed relied on this type of filtration. An uneven sand surface in this type of filter -ay reduce its efficiency. 11 Alternative filtration systems, such as those with diatomaceous earth, may be more effective in removing oocysts. However, swimming pools with malfunctioning diatomaceous earth filters have also been implicated in outbreaks of crypto sporidiosis. 12 There is not enough information on the comparative effectiveness of different filtration systems to warrant recommending one form of filtration over another at present. Because of the difficulty of eradicating cryptosporidia from swimming pools by either disinfection or filtration, preventing similar outbreaks depends on reducing contamination through the cooperation of swimmers and pool operators. 11 Patrons who have had diarrhoea in the previous week, who are faecally incontinent or not toilet trained should be discouraged from using the pool by signs at the pool entrance and in the change rooms. Similar recommendations have been made for controlling swimming pool-associated crypto sporidiosis in the United States. 10 In addition, new swimming pool complexes should provide separate facilities with their own filtration systems for patrons who are not toilet trained or who are faecally incontinent. People using these facilities should avoid swallowing pool water. Screening swimming pools for crypto sporidia would be of little use at present, as current detection methods do not determine oocyst viability and consequent ability to cause disease. In 1995, a Centers for Disease Control and Prevention workshop concluded that current knowledge about cryptosporidia, and about waterborne cryptosporidiosis in particular, is minimal and does not provide a scientifically sound basis for many essential decisions about the public health risks associated with infection. 21 In Australia, we do not know the incidence of cryptosporidiosis in the community or the extent to which swimming pools contribute to transmission. A first step in obtaining this information is to make cryptosporidiosis a notifiable disease and to encourage doctors and laboratories to consider cryptosporidiosis as a diagnosis in patients with diarrhoea lasting longer than three days. In 1995, South Australia was the only Australian State to require routine reporting of cryptosporidial detection by laboratories and doctors to public health authorities. Since then, Victoria and Queensland have introduced the requirement and New South Wales followed suit on 1 December 1996. Introducing this requirement in all States and Territories would assist in early detection and control of future outbreaks of cryptosporidiosis. Acknowledgements We thank Dr Philip Lye (Sutherland Division of General Practice), Sugermans Pathology (Hurstville), Dr Gary Grohmann (Australian Water Technologies) and the staff of the former Southern Sydney Public Health Unit for their assistance. References Nime FA, Burek JD, Page DL, et al. Acute enterocolitis in a human being infected with the protozoan Crypto sporidium . Gastroenterology 1976; 70: 592-598. Current WL. Cryptosporidiosis parvum : household transmission [editorial]. Ann Intern Med 1994; 120: 518-519. Berkelman RL. Emerging infectious diseases in the United States, 1993. J Infect Dis 1994; 170: 272-277. Gallaher MM, Herndon JL, Nims LJ, et al. Crypto sporidiosis and surface water. Am J Public Health 1989; 79: 39-42. Miron D, Kenes J, Dagan R. Calves as a source of an outbreak of cryptosporidiosis among young children in an agricultural closed community. Pediatr Infect Dis J 1991; 10: 438-441. Casemore DP. Sheep as a source of human cryptosporidiosis. J Infect 1989; 19: 101-104. Reif JS, Wimmer L, Smith JA, Dargatz DA, Cheney JM. Human cryptosporidiosis associated with an epizootic in calves. Am J Public Health 1989; 79: 1528-1530. Newman RD, Zu SX, Wuhib T, et al. Household epidemiology of Cryptosporidium parvum infection in an urban community in northeast Brazil. Ann Intern Med 1994; 120: 500-505. MacKenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of Cryptosporidium infection transmitted through the public water supply. N Engl J Med 1994; 331: 161-167. McAnulty JM, Fleming DW, Gonzalez AH. A community-wide outbreak of cryptosporidiosis associated with swimming at a wave pool. JAMA 1994; 272: 1597-1600. Joce RE, Bruce J, Kiely D, et al. An outbreak of cryptosporidiosis associated with a swimming pool. Epidemiol Infect 1991; 107: 497-508. Sorvillo FJ, Fujioka K, Nahlen B, et al. Swimming- associated cryptosporidiosis. Am J Public Health 1992; 82: 742-744. Rusnak J, Hadfield TL, Rhodes MM, Gaines JK. Detection of Cryptosporidium oocysts in human fecal specimens by an indirect immunofluorescence assay with monoclonal antibodies. J Clin Microbiol 1989; 27: 1135-1136. Jokiph LJ, Jokiph DMM. Timing of symptoms and oocyst excretion in human cryptosporidiosis. N Engl J Med 1986; 315: 1643-1647. Benenson AS. Control of communicable diseases manual. 16th ed. Washington: American Public Health Association, 1995. Dean AG, Dean JA, Coulombier D. Epi Info Version 6. Atlanta (GA): Centers for Disease Control and Prevention, 1994. Vesey G, Narai J, Ashbolt N, et al. Detection of specific microorganisms in environmental samples using flow cytometry. Methods Cell Biol 1994; 42: Pt B: 489-522. Marsh C. Guidelines for disinfecting public swimming pools and spa pools. Sydney: New South Wales Health Department, 1991. DuPont HL, Chappell CL, Sterling CR, et al. The infectivity of Cryptosporidium parvum in healthy volunteers. N Engl J Med 1995; 332: 13: 885-859. Korich DG, Mead JR, Madore MS, et al. Effects of ozone, chlorine dioxide, chloride and monochloramine on Cryptosporidium parvum oocyst viability. Appl Environ Microbiol 1990; 56: 1423-1428. Centers for Disease Control and Prevention. Assessing the public health threat associated with waterborne cryptosporidiosis: report of a workshop. MMWR Morb Mortal Wkly Rep 1995; 44 (no. RR-6): 15. (Received 17 Apr, accepted 12 Aug 1996) Authors' details Southern (now South Eastern) Sydney Public Health Unit, Sydney, NSW. Jennifer M Lemmon, BNurs, ICC, RGN, Infectious Diseases Consultant; Jeremy M McAnulty, MB BS, MPH, Director; currently, Specialist Medical Adviser, New South Wales Department of Health; Jason Bawden-Smith, MEnvStudies, Environmental Health Officer. No reprints will be available. Correspondence: Ms J M Lemmon, South Eastern Sydney Public Health Unit, PO Box 482, Kogarah, NSW 2217. To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Jennifer M Lemmon · Jeremy M McAnulty · Jason Bawden-Smith

Viewpoint Caring for a vulnerable population Who will take responsibility for those getting a raw deal from the health care system? Helen P Beange MJA 1996; 164: 159-160 Introduction - References - Author's details - - More articles on General practice and primary care Introduction In Australia, there is a minority population of about 70 000 people. Their mortality rate is at least 10 times that of the general population. They attend doctors twice as often, are admitted to hospital at twice the average rate, and have many more operations. More than half take prescription drugs daily, a third are taking multiple drugs, and 5% take more than four drugs. As 30% of this group have epilepsy, the commonest medications are anticonvulsants. On physical examination, they have an average of five serious medical disorders, but, astonishingly, only half of these conditions have been detected or treated. Although people in this minority group attend general practitioners frequently, they rarely see specialists, despite the fact that most of their disorders need specialist care. Blindness affects 4.4% (20 times the usual rate in Australia) and deafness affects 25% (compared with the average 2%) of people in this group, yet there are no special services for those who are blind or deaf. Although 9% have a psychiatric disability (compared with 2% of the general population), there are no special psychiatric services for them. Dental disease is the most frequent problem, affecting 86% of this group, but there are few special dental services. With such a gross difference in health when compared with the general population, it would be very reasonable to ask whether there are any modifiable risk factors for these diseases. The answer is yes -- surveys show that, while people in the group smoke very little and drink less than the general population, this minority group is generally unfit, obese and often hypertensive. So at least with exercise and better nutrition, it is likely they could avoid developing some diseases. Exercise opportunities improve the quality of life for people with an intellectual disability. (Reproduced with permission of the Stockton Centre, Newcastle, NSW.) How can this apparently disgraceful situation exist? Is Australia a Third World country? Is this a neglected and persecuted ethnic minority? No, not at all -- but this minority group does have problems accessing health care when compared with their fellow citizens. They are poorer and nearly all are dependent on social security. They tend not to marry or have children, and live mainly in public housing. Educational levels are low and illiteracy is the rule rather than the exception. They do not drive cars and many do not have an occupation. They are less mobile; 10% either need assistance to walk or use a wheelchair. One of the greatest barriers to health care is that many cannot speak at all and only half can communicate in complete sentences. The non-ideal social conduct of some of the group is such that doctors are nervous about keeping them waiting and reluctant to expose them to their other patients for fear of losing customers. Another barrier is that members of this group usually have to negotiate health care through another person, which only works successfully if their agent is trained and empathic and does not underestimate their complaints. Unfortunately, Australia has few doctors specially trained to understand this minority group. Australian doctors, although a decent lot, are (as a group) a bit impatient, are seldom able to fathom the language or unique culture of this group, and may not even recognise the names of most of the rare conditions from which they suffer. These conditions include fragile X syndrome, Rett syndrome and Angelman's syndrome. Further, because many of these patients take at least twice as long in consultation as the average patient, the more minority patients a doctor sees, the less the doctor's income. By now, you will have realised that the minority population I am concerned about is composed of people with an intellectual disability, which is defined as an IQ below 70. The figures given above are from a population study of adults between the ages of 20 to 50 in the lower North Shore of Sydney.1 All intellectually disabled adults living in a population of about 200 000 were identified and a random sample of 202 adults was examined. The lower North Shore is regarded as an affluent area of Sydney with good health services; it is thus reasonable to assume that conditions elsewhere in Sydney (and Australia) were either similar or worse. Studies on mortality and morbidity in people with intellectual disabilities in other parts of the world show similar results to the Sydney study.2,3,4 How can we improve the medical care of people with intellectual disabilities? I believe it is simplistic to think we can solve the problem by changing medical undergraduate training alone. Doctors currently treat intellectually disabled patients fairly well, but they are mainly dealing with minor illnesses and injuries. Serious problems are rarely recognised because these patients are used to suffering and cannot articulate their symptoms, and thus seldom complain. The woman with a slowly developing breast tumour, the man with anaemia as a result of a bleeding peptic ulcer, the child with Down's syndrome who is going deaf, the disturbed person having fluphenazine injections who is developing parkinsonism all depend on someone else to take them to a doctor. Young disabled people living at home are in less danger because there is a greater chance that their parents will badger the health system until something is done to help the child. But when a grown child leaves home, who will arrange medical care? Most Australian adults can be responsible for their own health, but we can rarely expect this of people with an intellectual disability. In the heyday of mental institutions, the medical superintendent was responsible for the health of people with an intellectual disability. Now, there is a question mark over just who is responsible. Local general practitioners, group home managers, area health service managers, heads of the Departments of Health and Community Services, perhaps even the Ministers, all disclaim responsibility. After all, the person is intellectually disabled, not sick. People with disabilities need access to the health system (a system which is becoming exceedingly complex). Once within the system, they need interpreters and advocates, and more time and resources than the average patient. General practitioners should obtain additional remuneration for the extra time spent with each patient. The health system needs to follow guidelines for improving the medical care of people with intellectual disabilities (see Box). The medical care of people with an intellectual disability should be set up in the mainstream of hospital medicine, not in academic backwaters. We need additional information about special health risks among people with disabilities and management protocols for the commonest syndromes. Preventive health services and health promotion would save enough money to make other special services available, such as dental clinics, psychiatric and neurological services and eye clinics. In the meantime, we are neglecting the health of people with developmental disabilities and, as a result, they are dying earlier and spending more time with doctors and more time in hospital than is necessary. If we valued the health of people with disabilities their lives would be longer and happier. References Beange H, McElduff A, Baker W. Medical disorders in adults with intellectual disability: a population study. Am J Ment Retard 1995; 99(7): 595-604. Fryers T. Mortality and cause of death. In: The epidemiology of severe intellectual impairment. The dynamics of prevalence. London: Academic Press, 1984: 139-141. Asberg KH. The need for medical care among mentally retarded adults. A five year follow up and comparison with a general population of the same age. Br J Ment Subnormality 1989; 35: 50-57. Howells G. Are the medical needs of mentally handicapped adults being met? J R Coll Gen Pract 1986; 36: 449-453. This article is based on a paper presented at the conference of the Australian Society for the Study of Intellectual Disability (NSW), Sydney, 12 May 1995. Author's details Stockton Centre, Developmental Disability Service, Hunter Area Health Service, Newcastle, NSW. Helen P Beange, MPH, FAFPHM, Visiting Medical Officer. No reprints will be available. Correspondence: Dr H P Beange, 23 Alpha Road, Willoughby, NSW 2068. Guidelines for improving medical care of people with intellectual disabilities Each patient with an intellectual disability should receive comprehensive and continuous health care, with primary care shared between clinical nurse specialists and general practitioners. They should have access to medical specialists and receive adequate attention in hospital. Clinical nurse specialists should be attached to the local group homes that are replacing institutional care. (Group homes usually house four people and are staffed either part-time or full-time.) These nurses would be responsible for health maintenance, preventive health care, arranging vaccinations and checking drugs. They would also make appointments for patients with acute and chronic health problems and maintain the medical records. General practitioners should be encouraged to review their disabled patients' drugs every three months and perform annual physical examinations. Full medical and genetic histories should be made available to these doctors. Health promotion clinics for people with disabilities should be established at teaching hospitals to provide back-up for the general practitioners in the area. These clinics should have formal links with genetic, paediatric and psychiatric departments and provide access to specialists who have expertise and empathy with disabled people. Clinics should offer medical, dietary and exercise advice, and opportunities for exercise after fitness testing. Protocols for dealing with particular syndromes should be developed (e.g., regular hearing and thyroid function tests for people with Down's syndrome, and regular surveillance for hip dislocation and urinary tract infections in people with cerebral palsy). All residential staff should be trained in basic health care, first aid, pharmaceutical treatment and nutrition. Staff should know how to treat fits and choking episodes. Courses in developmental disability medicine for medical students and interested family practitioners should be provided, utilising the skills of doctors who have experience in the field. A medical specialty in developmental disability medicine should be developed, so that these specialists could act as generalists in the same way as geriatricians care for the elderly. Back to text

Helen P Beange

Vaccine-preventable childhood diseases in Australia Too much disease, not enough vaccination: what more can we do? MJA 1996; 164: 61 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 In 1994, there were 17 442 notifications of vaccine- preventable diseases in Australia.1 This disgraceful situation exists despite the ready availability of free, safe and effective vaccines. Particularly damning were the 8661 cases of pertussis, measles, mumps, rubella and Haemophilus influenzae type b notified in children up to school leaving age (19 years old) -- all diseases for which a national immunisation program has been in place for many years! Why do we still have so much disease despite good vaccines and good delivery systems? While there is a lack of uniform reliable data on vaccination coverage, it would seem our national childhood vaccination rates are inadequate. The Australian Bureau of Statistics' 1989-90 National Health Survey reported that, according to parental recall, 53% of children up to six years of age had been vaccinated in accord with the National Health and Medical Research Council (NHMRC) vaccination schedules.2 Unpublished data from State health departments include the report of a 1991 cluster survey in Victoria of 630 children aged 18 months to 3 years which found that 88% were fully vaccinated against diphtheria, pertussis, tetanus, polio and measles (John Carnie, Manager, Infectious Diseases Unit, Victorian Department of Health and Community Services, Melbourne, personal communication); a 1994 ACT report found that only 67% of 236 children at school entry (aged about five years) were fully vaccinated (Ms Ann Kempe, Immunisation Coordinator, ACT Department of Health and Community Care, Canberra, personal communication). Whatever the true vaccination coverage, continuing notifications (in the thousands) of cases of measles, with its well-known risks of encephalitis, bronchopneumonia and subacute sclerosing panencephalitis (SSPE), highlight how much still needs to be done. In the United Kingdom a recent national measles-rubella immunisation program has successfully terminated measles virus circulation in schools; in March and April 1995, there were four confirmed cases of measles in England and Wales; three cases had recently arrived in the country, and the other occurred in an unvaccinated 15-month-old child.3 In Australia there were 229 measles notifications for the same period (National Notifiable Diseases Surveillance System, personal communication). there is still a lack of awareness on the part of parents and even some health practitioners of the benefit-risk equation for vaccination On the other hand, notifications of invasive Haemophilus influenzae type b have decreased from at least 3.5 cases per 100 000 population in 19911 to 1 case per 100 000 in 1994.1 Within three years we may see less than a quarter the number of cases of childhood bacterial meningitis recorded in 1990 -- evidence of the benefit of effective vaccination. The National Childhood Immunisation Committee has implemented a number of initiatives over the past two years to increase vaccination coverage rates in line with the goals of the 1993 NHMRC National Childhood Immunisation Strategy.4 More than 30 000 copies of a kit, which included the fifth edition of the Australian immunisation procedures handbook,5 were distributed to general practitioners and other vaccination service providers. A parents' guide to immunisation, Understanding childhood immunisation,6 was also produced and widely distributed; a recent mass media awareness campaign offers this booklet free to enquirers through a toll-free telephone number (1800 671 811). Such initiatives have received broad professional and community support from organisations such as the Australian Medical Assocation, the Royal Australian College of General Practitioners, the Australian College of Paediatrics, the Australian Institute of Environmental Health, the Sudden Infant Death Association and the NHMRC. Technical considerations also play a role in ensuring the optimal efficacy of vaccines: guidelines and systems for cold-chain maintenance have been implemented (some local studies have suggested that some vaccine providers have difficulty maintaining vaccines at between 2-81/4C7,8 ); knowledge of the thermolability of reconstituted measles-mumps- rubella vaccines and of oral polio vaccine at room temp erature is another important consideration. The safety and efficacy of vaccines are apparent to all but a few. A scheme to record, follow-up and regularly publish significant adverse events following vaccination has been under way since March 1995 (general practitioners and other providers notifying respective State or Territory health authorities by telephone). The data are collated, reviewed and published monthly in Communicable Diseases Intelligence. Adverse event rates of less than 1% have been recorded, although the data are as yet incomplete. Nevertheless, there is still a lack of awareness on the part of parents and even some health practitioners of the benefit-risk equation for vaccination, at least for some vaccines. A few individuals who propagate tired myths of exaggerated vaccination harm, however sincerely, make it more difficult to provide concerned parents with balanced benefit-risk information. To address this problem Commonwealth funding of $24 million has been allocated towards childhood vaccination during 1995-96 and 1996-97. Most of this outlay is provided to the States and Territories to purchase NHMRC standard childhood immunisation schedule vaccines in return for their undertaking to provide a coordinated program. Some of this funding will be used to obtain better information about vaccination coverage via the Australian Childhood Immunisation Register, which commenced on 1 January 1996. Information from the Register will enable resources to be targeted effectively to assist areas with the lowest coverage rates. Combination 4-in-1 (tetravalent) and 5-in-1 (pentavalent) vaccines (e.g., against diphtheria, tetanus, polio, Haemophilus influenzae type b and hepatitis B), less reactogenic acellular pertussis vaccines, as well as a varicella vaccine, are soon to appear on local markets. On the eve of the third millennium, once again we as a nation will need to debate the cost-benefit of disease prevention. In this debate we must acknowledge how far we have come in the two hundred years since Jenner's successful inoculations against smallpox, and how far we have yet to go. Gavin W Frost Senior Medical Adviser, AIDS/Communicable Diseases Branch Commonwealth Department of Human Services and Health, Canberra, ACT Monica Johns Senior Project Officer, National Childhood Immunisation Program Commonwealth Department of Human Services and Health, Canberra, ACT Hargreaves J, Longbottom H, Myint H, et al. Annual Report of the National Notifiable Diseases Surveillance System 1994. Commun Dis Intell 1995; 19: 542-574. Australian Bureau of Statistics. 1989-90 National Health Survey Children's Immunisation Survey, Australia. Canberra: ABS, 1992. (Catalogue No. 4379.0.) Interruption of measles transmission in school schildren, 1995. Wkly Epidemiol Rec 1995; 70: 215-216. National Health and Medical Research Council. National Immunisation Strategy. Canberra: NHMRC/AGPS, 1993. National Health and Medical Research Council. The Australian immunisation procedures handbook. 5th ed. Canberra: AGPS, 1995. Herceg A, Shelley S. Understanding childhood immunisation. Canberra: Commonwealth Department of Human Services and Health, 1995. Liddle JL, Harris MF. How general practitioners store vaccines. A survey in south-western Sydney. Med J Aust 1995; 162: 366-368. Herceg A, Longbottom H. A national immunisation provider survey. Canberra: Commonwealth Department of Human Services and Health, 1995. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Gavin W Frost · Monica Johns