Occupational diseases

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Ching Jou Lim BPharm(Hons) · Megan W-L Kwong MB BS, BMedSci · Rhonda L Stuart MB BS, FRACP, PhD · Kirsty L Buising MPH, MD, FRACP · N Deborah Friedman FRACP, MD, MPH · Noleen J Bennett PhD, MPH · Allen C Cheng FRACP, MPH, PhD · Anton Y Peleg MB BS, PhD, FRACP · Caroline Marshall FRACP, PhD, GradDipClinEpi · David C M Kong BPharm, MPharm, PhD

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Brian J Maguire DPH, MSA, EMT-P · Peter F O’Meara BHA, MPP, PhD · Richard F Brightwell PhD, BSc(Hons), PGCertEd · Barbara J O’Neill BSN, RN-OCN, PGCertNursEd · Gerard J Fitzgerald MD, FACEM, FRACMA

Workplace aggression is a worldwide concern that has been linked to impaired physical and mental health. There is limited international research describing the extent and impact of workplace aggression in medicine, however, and the few Australian studies have primarily focused on general practitioner experiences of patient aggression ...

Danny J Hills BN, GradCertMgt, MN(Hons) · Catherine M Joyce BA(Hons), MPsych, PhD · John S Humphreys BA(Hons), DipEd, PhD

To the Editor: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2 The condition is caused by ...

Hannah M Soulsby · Saliya Hewagama · Stephen Brady

Brian McGuirk was born in Newcastle on 4 September 1939. He graduated in medicine from the University of Sydney in 1965. After a period in the United Kingdom at Guy’s Hospital, London, he returned to Australia in 1969 and took up general practice in Sydney. In 1977, Brian was awarded a special service medal for being the first medical officer to attend victims of the Granville train disaster. Brian developed an interest in occupational health, gaining a Diploma in Public Health from the University of Sydney in 1984, and becoming a founding Fellow of the Australian College of Occupational Medicine. After roles in the New South Wales public service, he was appointed Commissioner for Occupational Safety and Health in Western Australia in 1985 and wrote the occupational health and safety regulations for that state. In 1990, Brian returned to Newcastle to become Chief Medical Officer for the Newcastle division of Manufacturers’ Mutual Insurance. When the University of Newcastle was commissioned to conduct the National Musculoskeletal Medicine Initiative in 1997, he was appointed Deputy Director of the Initiative. In that role, he was the senior author of the first study to demonstrate the efficacy of evidence-based medicine (EBM) for low back pain. After the Initiative closed in 2001, Brian continued to apply EBM in the management of injured workers as a Staff Specialist in Staff Health at Hunter New England Health. In 2007, Brian was awarded the Spine Society of Australia prize for his landmark study showing that EBM virtually eliminated workers compensation claims for back injuries. He also recorded his knowledge and experience in textbooks on back pain and neck pain, and in chapters on acute and chronic low back pain in the 2009 edition of Bonica’s management of pain. In November 2009, Brian retired at the age of 70. On 3 March 2011, he passed away quietly. His legacy was to show that an insurance doctor could successfully treat patients, rather than contest workers compensation claims.

Nikolai Bogduk

To the Editor: A 44-year-old female nurse with a 4-year history of hand dermatitis was referred to an occupational dermatology clinic in Melbourne. In 2009, her hand dermatitis had worsened when she started working in a neonatal intensive care unit, where she used antimicrobial hand gel more frequently. Her hands improved when she spent time away from work but worsened again within 2 days of returning. Patch testing was conducted using our baseline patch test series as well as rubber accelerators (used in manufacturing rubber gloves), antiseptics and the patient’s own samples (eg, gloves, moisturiser, etc). She developed positive reactions to formaldehyde and the formaldehyde releasers quaternium 15, imidazolidinyl urea and diazolidinyl urea, as well as the hand gel she had been using — Microshield Antimicrobial Hand Gel (Johnson and Johnson Medical, Sydney, NSW) — a gel containing 30%–60% water, and diazolidinyl urea as a preservative. (Diazolidinyl urea is not listed on the safety data sheet for this product as it is in a concentration of < 1%.) A negative result for a radioallergosorbent test indicated it was unlikely the patient was allergic to latex. She was advised to use a waterless, alcohol-based hand cleaner without preservatives and was given advice about general skin care, especially use of moisturising cream.1 She complied with this advice, and her condition subsequently improved. Diazolidinyl urea is a preservative commonly used in cosmetic products. Once absorbed into the skin, it releases small amounts of formaldehyde. Individuals may become sensitised to diazolidinyl urea, formaldehyde, or both. This can occur at any stage, even if the individual has been exposed to the product for years. At our occupational dermatology clinic we have patch tested 2688 patients and diagnosed 1461 of these with allergic contact dermatitis (ACD) over the past 16 years. Nine health care workers have been diagnosed with ACD to diazolidinyl urea contained in products they used at work. Thirty other patients have had ACD caused by this preservative from other sources, usually their skin care products. Many workers will simply accept their hand dermatitis as part of the job, or begin treatment without patch testing. It is only with patch testing that an accurate diagnosis can be made. Waterless hand cleaners are an important part of hand hygiene in health care settings,2 and they minimise irritation caused by washing hands with soap and water and drying with paper towels.3 Alcohol-based liquid hand-disinfectant solutions are more efficacious than gels.4 Our report provides another reason to use these products as, generally, alcohol-based liquids do not contain preservatives such as diazolidinyl urea.

Jennifer L Cahill · Rosemary L Nixon

Objective: To determine the prevalence of patient-initiated aggression toward general practitioners in Australia.Design, setting and participants: A cross-sectional national survey, conducted during February – May 2010, of 3090 GPs in 19 Divisions of General Practice, purposively sampled to represent urban, rural and remote areas.Main outcome measure: Proportion of GPs experiencing patient-initiated aggression.Results: Eight-hundred and four GPs returned completed surveys (response rate, 26.3%). In the previous 12 months, 58% of GPs had experienced verbal abuse and 18% had experienced property damage or theft. Very few GPs had experienced physical abuse (6%), stalking (4%), sexual harassment (6%) or sexual assault (0.1%). After controlling for other demographic variables, GPs with fewer years of experience (P = 0.003), or who worked full-time or in larger practices (both P = 0.03) experienced significantly more verbal abuse than their counterparts, and GPs who worked full-time (P = 0.004) or in metropolitan areas (P = 0.01) experienced significantly more property damage or theft. Female GPs experienced significantly more sexual harassment than male GPs (P < 0.001).Conclusions: This is the first national evidence of the prevalence of patient aggression toward GPs in Australia, which could inform the development of policies and guidelines that aim to reduce the prevalence of patient aggression toward GPs.

Laura E Forrest BSc, GradDipGenCouns, PhD · Pushpani M Herath MB BS, MSc · Ian S McRae BSc(Hons), MSc, PhD · Rhian M Parker PhD

Objective: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists.Design, participants and setting: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia — Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training).Main outcome measures: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics.Results: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39–0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41–2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25–1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20–1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23–0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08–0.83]).Conclusion: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.

Catherine M Joyce BA(Hons), MPsych, PhD · Stefanie Schurer MSc, PhD · Anthony Scott BA, MSc, PhD · John Humphreys BA(Hons), DipEd, PhD · Guyonne Kalb MEc, PhD

Whether pilots with insulin-dependent diabetes should be allowed to fly has long been a controversial issue. Hypoglycaemia remains a significant threat to flight safety, and a barrier for pilots with insulin-dependent diabetes to overcome. Some countries allow recreational pilots to fly while treated with insulin under strict conditions. Recent changes in aeromedical certification in Australia will give pilots with diabetes more freedom to exercise the privileges of their licence, while adopting mechanisms to ensure the safety of air navigation.

David J P Fitzgerald MB BS(Hons), DipAvMed, FAFOEM(RACP) · Pooshan D Navathe MB BS, FAFOEM(RACP), PhD · A Michael Drane MB BS, MAvMed, FRNZCGP

Australia should support international bans on asbestos trade The adverse health effects of asbestos are well known, with all forms of asbestos recognised as human carcinogens, causing malignant mesothelioma, lung, laryngeal and ovarian cancers1 as well as the debilitating non-malignant diffuse lung disease, asbestosis, and pleural plaques. Although use, import and export of asbestos and asbestos-containing materials is banned in Australia and 51 other countries,2 an estimated 125 million people around the world are still exposed to asbestos in their home and work environments.3 Crocidolite (blue asbestos) and amosite (brown asbestos), two forms of asbestos that were heavily used in the past, are no longer in use. Chrysotile (white asbestos) accounts for 95% of the asbestos produced and used globally since 1990. There is no safe level of exposure to asbestos4 and no discernible threshold below which there is no risk of mesothelioma.5 Given the clear dangers, why are workers and their families in many parts of the world still being exposed to asbestos? Exposure comes from two main sources: residual asbestos-containing materials remaining in buildings constructed before the mid-1980s (when asbestos-containing cement sheet was removed from the market); and continuing mining and use of asbestos in some parts of the world. In Australia, the legacy of asbestos remains a problem. In most cases, asbestos is in a non-respirable form, and is not a hazard to human health if undisturbed. However, if damaged, it can become friable and change to a respirable form. The issues central to this global problem are education and research. Education about when asbestos exposure may occur, and how to avoid it, remains important. In this respect, the recent survey by Safe Work Australia6 is reassuring, with most tradespeople reporting awareness of asbestos-related health risks and demonstrating an understanding of how exposures occur. However, there was a general lack of understanding about which materials may contain asbestos, and there are no data on the level of awareness among people doing their own renovations. Asbestos will be with us for decades, so targeted and contextually appropriate education programs for at-risk populations are required. The effects of such programs should be monitored for their impact on risk, mortality and morbidity. As most of the people who will die from asbestos-related cancers in Australia already have asbestos in their lungs, research aimed at preventing or curing these cancers is also vital. Globally, the major problem is with continued mining and use of asbestos, with over 2 million tonnes produced in 2008.7 Developing countries, especially in Asia and Eastern Europe, are mining or importing asbestos for domestic use, and now account for the majority of the world’s exposure to asbestos. Thousands, if not millions, of people are likely to die in these countries as a result of continued asbestos exposure.8 Chrysotile is the only form of asbestos that is being traded in the 21st century; it is mostly used in the manufacture of asbestos cement sheets and pipes. There is a mistaken belief that this form of asbestos is less harmful than other forms, but overwhelming scientific evidence refutes this assertion.9 All forms of asbestos are classed as human carcinogens by the United States Environmental Protection Agency, and cancer is seen in workers who have only been exposed to chrysotile asbestos.9 There is also a mistaken view that chrysotile can be handled safely. Reports from the National Public Health Institute of Quebec show a failure to achieve “controlled use”, even in Quebec. In many developing countries, exposure is uncontrolled, and education of workers is, at best, minimal, and often non-existent. Tobacco smoking is also widespread in Asia, and is synergistic with chrysotile in increasing the risk of lung cancer. International organisations such as the World Health Organization and the International Labour Organization have called for a global ban of all forms of asbestos, with the goal of eliminating asbestos-related diseases.10 The Collegium Ramazzini, an international academic society independent of commercial interests that examines critical issues in occupational and environmental health, has just renewed its call for such a ban. This could, in part, be achieved via the Rotterdam Convention (http://www.pic.int), an international treaty intended to regulate global trade in chemicals that have been banned or severely restricted because of the hazards they pose to human health or the environment. The Convention was enacted in 2004, and 131 nations, including Australia, are current partners. The goal of the Convention is to protect the world’s most vulnerable countries from importing hazardous pesticides or regulated chemicals without prior knowledge or consent. Repeated efforts to include chrysotile asbestos under the Rotterdam Convention have failed, due to opposition from countries which mine and manufacture asbestos, including Canada. The Canadian Medical Association, Canadian Cancer Society and Canadian Public Health Association oppose exporting asbestos to developing countries, yet their government officially condones this activity. We, personally and on behalf of our respective professional affiliations, call for Australia and Australians to strongly support the latest international effort to ban the mining and manufacture of all forms of asbestos; to increase efforts, at home and abroad, in effective education of the dangers of asbestos both in the workplace and in the environment; and urge our legislators to redouble their efforts to rid the world of asbestos-related diseases.

Peter D Sly MB BS, FRACP, DSc · Robin Chase MB BS, DPH, FAFOEM · John Kolbe MB BS, FRACP · Philip Thompson MB BS, FRACP · Leena Gupta MB BS, MPH, FAFPHM · Mike Daube BA(Hons), HonDSci · Ian Olver MD, FRACP · Deborah Vallance BMedSci, MB BS, MPH

Objective: To determine whether there is an excess risk of breast cancer among female employees of the Australian Broadcasting Corporation (ABC), especially outside Queensland, compared with women in the general populations of the states and territories.Design, setting and participants: We used an occupational cohort design. Information from ABC staff records was linked with data from state and territory cancer registries to identify female employees of the ABC with an incident, histologically confirmed breast cancer. Data linkage was complemented by a self-report method. We included a cohort of ABC female employees who had developed breast cancer at any time between 1994 and 2005, during their employment or after cessation of employment with the ABC. The standardised incidence ratio (SIR) was calculated as the number of women at the ABC observed with breast cancer divided by the expected number based on population rates in each state and territory. Tests for heterogeneity were performed to examine the variation of breast cancer risk between states and territories.Results: Out of 5969 women who were permanently employed either part-time or full-time at the ABC between 1994 and 2005, 48 eligible women with breast cancer were identified. An excess risk of breast cancer among ABC female employees in Queensland (identified in an earlier study) was reconfirmed. No excess risk of breast cancer was observed among ABC staff diagnosed in states outside Queensland (SIR, 1.01 [95% CI, 0.72–1.38]), or in Australia as a whole (including Queensland) (SIR, 1.12 [95% CI, 0.83–1.49]). There was no significant heterogeneity in breast cancer risk among states and territories once Queensland was excluded from the analysis (P = 0.39).Conclusion: No statistically significant excess risk of breast cancer in ABC female employees was found across the Australian states and territories as a whole compared with their respective population incidences. A statistically significant increased risk of breast cancer was found among ABC female employees in Queensland, consistent with the findings in an earlier report.

Freddy Sitas MSc(Med), MSc(Epidemiol), DPhil · Dianne L O’Connell BMaths(Hons), PhD · Cathelijne H van Kemenade MSc, MPH · Mark W Short BSc(Hons), PhD · Kun Zhao BEcon, BPsych(Hons)

Assessment of medical fitness to drive can be a sensitive and difficult task, particularly when it involves a condition such as epilepsy, where impairment is intermittent. The patient, their doctor and the driver licensing authority (DLA) each have responsibilities, both to the patient and to the wider community of road users. DLAs in Australia have shifted most of the responsibility for determining fitness to drive to the treating doctor. This creates a conflict of interest and may lead to unsafe decisions, damage to the doctor–patient relationship, interference with medical management and legal vulnerability for the doctor. Australian neurologists have argued for a system in which the treating doctor provides objective information about the patient’s condition, rather than an opinion on fitness to drive, and the DLA uses that information to determine fitness. This must be supported by an expert review process. Although drivers are legally obliged to notify the DLA when they become unfit, most people are unaware of this law. However, passing this responsibility to doctors in the form of mandatory reporting is counterproductive to road safety.

Ernest R Somerville MB BS, FRACP, FRCP · Andrew B Black BMedSc, MB BS, FRACP · John W Dunne MB BS, FRACP

To the Editor: On behalf of the Australian Association of Musculoskeletal Medicine (AAMM) and the Australasian Faculty of Musculoskeletal Medicine (AFMM), we would thank Briggs and Buchbinder for raising the topic of back pain as a National Health Priority Area (NHPA) for debate.1 The AAMM and its teaching arm, the AFMM, have been arguing for years that higher priority should be given to the management of low back pain, and we certainly support the arguments for making back pain an NHPA. We agree that back pain is a major burden on society, and that coordinated action that includes all stakeholders is required. Currently, members of the AAMM and AFMM are involved in contributing to the Australian Core Competencies in Musculoskeletal Basic and Clinical Science project,2 which aims to standardise the undergraduate teaching in musculoskeletal medicine around Australia. As well as supporting undergraduate initiatives, the AAMM and AFMM have been the significant providers of postgraduate education for doctors around Australia over the past 20 years, being engaged in activities that include the development of evidence-based guidelines and university-based postgraduate diploma and masters programs.3 It is then very disappointing to read disparaging comments about doctors with a special interest in musculoskeletal medicine. Briggs and Buchbinder assert that one potential disadvantage of making back pain a health priority is that it may provide “justification for those with . . . vested interests to promote clinically ineffective interventions”. The example they cite is a questionnaire survey of Victorian doctors in 2004, highlighting that a self-reported interest in low back pain or musculoskeletal medicine, or both, was strongly associated with back pain management beliefs and practices that are contrary to the best available evidence.4 The title of the Spine journal article4 is mischievous and misleading. The article implies that members of the AAMM have poorer knowledge about low back pain than doctors with no special interest in back pain. The real facts are that no attempt was made by the authors to specify what training or continuing medical education doctors had received, or whether they were members of the AAMM.

Victor J Wilk · Michael J Yelland · Michael B Oei

To the Editor: In the recent article by Briggs and Buchbinder, the authors propose that one advantage of including back pain as a National Health Priority Area (NHPA) is that it will increasingly encourage the management of back pain in accordance with best-practice clinical care guidelines.1 The emergency department (ED) is a key point of presentation for people with back pain. Research suggests that optimal management of low back pain incorporates multidisciplinary input, ensuring the provision of adequate analgesia and rational use of further investigations.2,3 On the basis of such data, we devised an interactive decision-support tool for completion by ED staff. The “Low Back Pain Assessment and Treatment” (LBPAT) guidelines were designed by a multidisciplinary team of nursing, medical, physiotherapy and pharmacy staff, based on accepted evidence-based standards of practice already in use.4 Use of these guidelines enables rapid assessment of “red flags” that may require further investigation and treatment. The guidelines include a flow diagram divided into three pain-management options for patients with mild, moderate or severe pain, with prompts for referral to physiotherapy and neurosurgery. The LBPAT guidelines indicate which imaging studies and blood tests may be required and when, as directed by findings. Information to assist discharge planning, including follow-up by a physiotherapist and general practitioner, and provision of information, is included. Once they were developed, we evaluated the effectiveness of the LBPAT guidelines in improving ED clinical practice. A retrospective case-record study of patients presenting to the ED and identified from International classification of diseases, ninth revision (ICD-9) codes (for back pain or low back pain) was undertaken before implementation of the guidelines (October–December 2006; 87 patients), immediately after implementation (May–August 2007; 96 patients), and about a year later (July–August 2008; 28 patients). Uptake of the LBPAT guidelines was only 47%–50% in both postimplementation periods. However, adherence to pain management guidelines improved significantly after implementation (59% [57/96] compared with 46% [40/87]; P = 0.02), and was maintained a year later (57% [16/28]). Use of aperients in patients who were coprescribed opiates was much improved in the period immediately after implementation (40% [27/68] compared with 16% [11/69]; P < 0.001) and 1 year later (70% [14/20]). Postimplementation data suggested a reduction in unnecessary blood tests (ie, no red flags requiring further investigation). For patients discharged from the ED, discharge planning and continuity of care did not improve immediately after implementation, but were greatly improved 1 year later. If back pain is included as an NHPA, use of a clinical decision tool such as the LBPAT guidelines is one potential method of preserving resources and improving patient outcomes in cases of back pain in the ED setting.

Stephanie K Vaughan · Julie L Gawthorne · Andrew S Finckh · Susan A Welch

In reply: The two preceding letters highlight that there are many stakeholders with an interest in back pain in Australia. Many craft groups are involved with the provision of postgraduate education and have contributed to the musculoskeletal core competencies initiative. Vaughan and colleagues describe promising results from using a clinical decision tool for acute back pain in an emergency department. On a national scale, implementation of such a tool in all emergency departments may significantly improve outcomes and reduce costs. Making back pain a national priority would provide unique opportunities to rigorously study these types of approaches. A timely illustration of our concern about vested interests potentially promoting ineffective or unproven interventions1 is the lively debate centred on the recently published United Kingdom National Institute for Health and Clinical Excellence guidance for the early management of persistent non-specific low back pain.2 The recommendation that injections of therapeutic substances into the back for non-specific low back pain should not be offered, as the evidence of effectiveness is lacking, led to the forced resignation of the president of the British Pain Society because of his refusal to denounce the guidelines he helped to formulate.3 To suggest that the title of the Spine journal article is misleading and mischievous is patently incorrect, as the title, “Doctors with a special interest in back pain have poorer knowledge about how to treat back pain”, simply summarises the main study findings.4 Based on 3831 responses from general practitioners in New South Wales and Victoria, collected in 1997, 2000 and 2004, doctors who reported a special interest in low back pain were significantly more likely to believe that patients with acute low back pain should be prescribed complete bed rest until the pain goes away (relative risk [RR], 1.89; 95% CI, 1.53–2.33); that they should not return to work until they are almost pain-free (RR, 1.55; 95% CI, 1.31–1.83); and that lumbar spine x-rays are useful in their work-up (RR, 1.36; 95% CI, 1.21–1.52). We also reject the suggestion that we made disparaging remarks about doctors with a special interest in musculoskeletal medicine. After adjusting for the presence of special interests in back pain, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine. While we cited a survey that found that Australian Association of Musculoskeletal Medicine (AAMM) members see a high caseload of patients with back pain,5 we made no claims about the knowledge base of AAMM members.

Rachelle Buchbinder · Andrew M Briggs

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

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

Objectives: To describe rates of occurrence of falls, injuries and fatalities to horse-racing jockeys in Australia.Design and setting: Retrospective analysis of data on race-day falls from stewards’ reports provided by the Principal Racing Authority of each state and territory of Australia, August 2002 – July 2006.Main outcome measures: Fall, injury and fatality incidence rates; comparison with overseas rates.Results: There were 3360 jockey falls from 748 367 rides. Falls occurred at a rate of 0.42 per 100 rides in flat races and 5.26 per 100 rides in jumps races. In flat racing, 54.6% (1694/3101) of falls occurred before the start of the race and 11.1% (344/3101) of falls occurred post-race. The 34.3% (1063/3101) of falls that occurred during flat races resulted in 61.7% (516/836) of the injuries sustained. In jumps racing, most falls occurred at a jump and 9.7% (25/259) of jockeys who fell were transported to hospital and/or declared unfit to ride. There were five fatalities resulting from falls during the study period, all in flat racing. Fall and injury rates were comparable with those found in the United Kingdom, Ireland, France and Japan.Conclusions: Being a jockey carries a substantial risk of injury and death. Although rates of injury in Australia are not exceptional by international standards, there can be improvement to safety standards in the Australian racing industry.

Peta L Hitchens BAppSci(Equine), MVPHMgt · C Leigh Blizzard PhD · Graeme Jones MMedSc, MD, FRACP · Lesley M Day BSc(Hons), MPH, PhD · James Fell BEd, MPhil, PhD