Occupational diseases

Objective: To examine the association between long-term health conditions and being out of the labour force among older Australians.Design, setting and participants: Retrospective analysis of cross-sectional data from the Australian Bureau of Statistics 2003 Survey of Disability, Ageing and Carers for people aged 45–64 years.Main outcome measures: Rates of premature retirement associated with ill health; odds ratios of being out of the labour force associated with each long-term health condition and number of conditions; weighted population estimates; estimates of gross domestic product lost as a result.Results: 9198 people surveyed were aged 45–64 years, 3010 of whom were not in the labour force. Of these, 1373 (45.6%) had retired because of a chronic health condition, most commonly a back problem (10.4%), or arthritis and related disorders (8.6%). When adjusted for age and sex, all conditions studied except diseases of the ear and mastoid process, other endocrine/nutritional and metabolic disorders, noise-induced deafness or hearing loss, and high cholesterol were significantly associated with being out of the labour force. Extrapolating from these results, an estimated 663 235 older Australians were not working because of ill health, reducing Australia’s gross domestic product by around $14.7 billion per annum.Conclusion: Prevention of long-term health conditions may help older Australians remain in the labour force longer, thereby increasing revenue to fund health care for the ageing population.

Deborah J Schofield BSpPath, GradDipComp · Rupendra N Shrestha BSc, MSc(Statistics) · Megan E Passey BMed(Hons), MPH, MSc · Arul Earnest DLSHTM, MSc · Susan L Fletcher BAppSc(Psych), PGDipPsych

At the time of his death in Georgetown, in Queensland’s Channel Country, Cyril Swaine had enjoyed a successful medical career of over 50 years, spent within and outside Australia, remaining active and moving with the times in a profession that was undergoing unimagined expansion and specialisation. Cyril was born on 1 November 1919 in the Adelaide Hills, the eldest of six children, into times that were frequently hard. He was mentored at an early age by a local general practitioner, Carl Jungfer, a later icon for Australian general practice. On graduating in medicine at the University of Adelaide, Cyril entered the wartime Royal Australian Air Force, serving in Malaya and rising to the rank of Squadron Leader. In 1947, he joined the Repatriation Department in Adelaide, gaining expertise in the management and treatment of tuberculosis. After 9 years in the Repatriation Department, Cyril spent a year working as a Senior Medical Officer at the then-active Woomera Rocket Range, followed by 14 years in general practice at Woodville in Adelaide. The next 13 years were spent in Indonesia and Papua New Guinea working for a mining company, where his practice included occupational and industrial medicine and was enlivened by obstetrics and emergency surgery. In 1983, he returned with his family to Cairns in Queensland with plans to semi-retire. But for a person of his great intellect and altruistic spirit, this proved difficult, and his practice actually expanded to include younger partners and a second site. He became active in Rotary and was elected to the executive of the Cairns Division of General Practice. In 1999, Cyril sustained two accidents that finally forced him to retire. Cyril relocated to Georgetown, where his wife Pam took up a position as Director of Nursing at the hospital. Cyril died there on 14 August 2007 from ischaemic heart disease. His requiem mass in Georgetown was notable for the attendance of many colleagues who had been flown into the relatively remote town courtesy of the Royal Flying Doctor Service. It was suitable recognition for a man who was described during his eulogy as displaying tremendous integrity, loyalty and honesty, and who epitomised the Christian ethic in his professional and personal life. He is survived by his wife Pam and children Marie, Stephanie, Brook and Justin. A son David predeceased him.

Peter P Thomas

A cold never killed anyone ... did it? I went to work with a cold. My nasty sore throat woke me early, so I spent the time emailing our incoming clinical students: Get your influenza vaccinations before you start your clinical rotations — influenza kills people, vaccinating health care workers decreases mortality in nursing homes, and vaccination reduces other viral infections and days off work or school, and meets duty of care for oneself and others!1,2 Sincerely, your (vaccinated) Clinical Dean Sneezing and miserable, I considered staying home, abandoning the 20 complex, high-admission risk (general medicine) patients scheduled at the Aboriginal Health Centre and the hospital, many of whom had waited 2–3 months for an appointment. I thought of my mother — “Go to school, you’re not dying, you only have a cold!” Memories of my only previous sick day resurfaced: as an on-call intensive care unit senior registrar — feverish, achy, sneezing, nose running like a faucet, I had decided this wasn’t good for anyone. Caving at the prospect of working all night sick, I settled for guiltily calling in a fellow registrar. My “chief” had then rung — “How are you?” — Oh no, they think I’m skiving off! Peer pressure is strong stuff. So, this time, with patients waiting and my past lurking, I took some paracetamol, packed some tissues, and went to work. My first patient, recovering from a lung resection for bronchiectasis after last winter’s viruses almost killed him, is now surviving his first postoperative virus — not a drama. After warning him to stay far away and not shake my hand, I got through the rest of the day constantly apologising to my patients and colleagues, suppressing sneezes, washing my hands, and touching as few things as possible. After clinic, an email explained the coincidental absence of my medical students — “Sick with cough, unable to attend”. A colleague’s voice from the doorway wryly observed, “You’re sending the students mixed messages about getting vaccinated and duty of care while working with a cold yourself, potentially infecting everyone in sight”. I responded blithely, “I’m more dedicated to my work than the students are (different generation), and besides, a cold never killed anyone” ... but then, a moment of evidence-based-medicine horror hit me — That’s true, right? Although my work-despite-a-cold ethic hasn’t done me any harm (misery aside), I salved my skiving-off guilt with my greater desire to “do no harm”, collected kilos of paperwork and my laptop, and retreated home for a day in isolation. A hasty MEDLINE search for “common cold AND mortality” from 1997 to 2007 revealed 68 papers. Of these, the 13 highly relevant papers (gulp) fell into three categories: chronic obstructive pulmonary disease (COPD) or asthma complications (eight); childhood morbidity and deaths, largely related to cold medications (four); and HIV-related deaths (one). I quickly discovered that over 50% of COPD exacerbations are attributed to respiratory viruses — no big surprise.3 More concerningly, rhinoviruses are now well established culprits causing significant morbidity and even mortality.4-6 Indeed, only miniscule amounts of rhinovirus are needed to infect patients who then develop lung function changes typical of COPD exacerbations.7 If COPD causes 4% of all deaths per year in the United States (Australia should be similar)8 and viruses cause half of COPD exacerbations, then about 2% of mortality is potentially attributable to respiratory viruses. I began to worry about my patient with bronchiectasis. On the other hand, at least I hadn’t done any harm by prescribing over-the-counter cold medications with worrying potential for harm for any of my adult patients, let alone any children.9 Hmm ... non-steroidal anti-inflammatory medications seem to have evidence for relief (as long as I don’t have hypertension, stomach ulcer, heart failure, or kidney disease),6 so I think I’ll take some. What about vaccination? Reassuringly, at least for my reputation among my students and staff, several reviews supported influenza vaccination,10,11 especially since influenza viruses account for up to 10% of “common colds”.6 Distressingly, however, vaccination rates among health care workers are less than optimal — 82% of doctors and 40% of nurses had been vaccinated in one emergency department study (the best rates I could find).11 One dilemma remains. I, like 80% of doctors, worked with an illness for which I would have “sick-listed” my patients,12 but given that I care for under-served patients in a rural area with a shortage of doctors, is it worse to stay home and reschedule patients for appointments weeks to months later or to risk exposing them to my virus-laden self? Mortality rates for residents of rural and regional areas in Australia are 10% higher than for city-dwellers13 — largely due to health care access issues. My personal vaccination campaign should decrease the frequency of my own (and my students’ and staffs’) “colds” and, if I’m sick less often, this should increase access to me, thus decreasing my patients’ morbidity and mortality. Sadly, the evidence suggests that if I were working in an intensive care unit or a medical ward with high-risk COPD patients, I could justify staying home, but in my general medicine role and doctor-shortage situation, the mortality trade-offs suggest that I should probably go to work with a cold next time too (sigh). But as for you, dear health care providers: first, do what I say and what I do (get vaccinated against influenza); and second, do what I say and not what I did, and consider staying home with your own cold — because, you never know, it just might kill someone ...

Dawn E DeWitt MD, MSc, FRACP

Objective: To determine the prevalence of health problems in New South Wales train drivers and the impact of the new national health-assessment standard on train drivers’ fitness for work.Design, setting and participants: Retrospective audit of files of all RailCorp train drivers (743) and train driver recruits (283) who were assessed under the new national standard for health assessment of rail safety workers between February 2004 and February 2005.Main outcome measures: Smoking status; prevalence of hypertension, heart disease, diabetes and obstructive sleep apnoea; alcohol use disorders; body mass index (BMI); total cholesterol level; fasting blood glucose level; cardiac risk score; fitness status.Results: 25.2% of drivers and 27.9% of recruits were smokers; 43.8% of drivers and 21.9% of recruits were hypertensive; 34.6% of drivers and 31.4% of recruits had high total cholesterol levels (> 5.5 mmol/L). Median BMI values were 29 kg/m2 (range, 18–59 kg/m2) for drivers and 28 kg/m2 (range, 19–55 kg/m2) for recruits. The prevalence of obesity (BMI ≥ 30.0 kg/m2) was higher in both male drivers and recruits compared with the general male population. At initial assessment, 65.1% of drivers and 88.0% of recruits were certified as unconditionally fit for work; 12.4% of drivers and 7.1% of recruits were assessed as temporarily unfit; and 22.5% of drivers and 4.6% of recruits were considered fit subject to review (after periods ranging from 3 to 12 months). Two per cent of drivers and 2.5% of recruits were subsequently deemed to be permanently unfit, the most common reasons being heart conditions, psychiatric disorders, orthopaedic problems, colour vision impairment and sleep apnoea.Conclusions: Cardiovascular risk factors and cardiovascular disease are the most significant health issues affecting train drivers’ fitness for work. With the more stringent health assessment and regular review required by the new standard, most drivers can continue with their duties, with the added benefits of improved personal health and greater safety to the rail network and the public.

Reem Mina MB BS, GradDipOccEnvHealth, FAFOM · Armand Casolin MB BS, MSciTech(OccMed), FAFOM

During 1994–2006, 10 cases of invasive breast cancer were diagnosed among 550 women employed for some time at a broadcast media site in Brisbane, Queensland. These cases represented a more than sixfold increase in risk compared with the female population of Queensland. After an initial unsatisfactory inquiry, an independent assessment was successful when the investigation addressed environmental factors of concern to the employees, as well as agents that may have accounted for the cluster. The perceptions of the women affected were documented in the television program Australian Story. No specific cause of the cluster was identified, but staff concerns were allayed by relocation from the site. The outcome suggests a specific duty of care involving adequate attention being paid to community needs in such situations.

Bernard W Stewart PhD, FRACI, DipLaw

To the Editor: Obesity in adults presents significant issues for health care providers, including practical problems in transporting and accommodating large individuals, and in performing standard tests and investigations.1 However, this issue has been little addressed in the mortuary setting, although a recent media report detailed the need for larger crematorium furnaces to accommodate oversized coffins, as well as larger graves for burials.2 We reviewed the body mass index (BMI) of individuals who had undergone coronial autopsies in South Australia in the first 3 months of 2007. Weight and height of all bodies were measured using standardised equipment and were used to calculate BMI by the usual formula.3 A total of 255 individuals aged over 17 years were included in the study (male to female ratio, 2 : 1; age range, 17–97 years). A third of individuals were classified as obese (BMI ≥ 30 kg/m2), and 6% as morbidly obese (BMI ≥ 40 kg/m2). The highest BMIs were: 132.3 kg/m2 (175 kg, 115 cm); 109.0 kg/m2 (315 kg, 170 cm); 82.8 kg/m2 (220 kg, 163 cm); and 79.5 kg/m2 (201 kg, 159 cm). In comparison, over a similar time period at the same institution in 1986, 17% of individuals were obese, and 3% were morbidly obese, with the four highest BMIs being: 55.2 kg/m2 (137 kg, 157.5 cm); 48.3 kg/m2 (148 kg, 175 cm); 44.7 kg/m2 (137 kg, 175 cm); and 41.9 kg/m2 (104 kg, 157.5 cm). This study demonstrates that forensic facilities are now dealing with individuals of considerable body mass. Despite government and industry guidelines for manual handling practices,4 these bodies are difficult to lift, move and store, and present major logistical problems for pathologists and technicians attempting to perform standard examinations. Mechanical lifting hoists, x-ray tables and trolleys are often not designed to cope with such weights. Putrefaction is hastened in morbidly obese individuals, and associated skin slippage and purging makes the bodies even more difficult to handle. Given that autopsies are often required in such individuals to determine the cause of death, consideration must be given to the significant occupational health and safety issues they create for staff in facilities with substandard equipment (ie, designed for normal-sized bodies). The construction of specially designed mortuaries will be required if this trend continues, with larger storage and dissection rooms, and more robust equipment engineered to cope with increasing numbers of individuals with BMIs sometimes considerably greater than 30 kg/m2. Failure to provide these may compromise the postmortem evaluation of markedly obese individuals, in addition to potentially jeopardising the health of mortuary staff.

Roger W Byard · Maria Bellis

Two people employed for several years in the spawning shed of a mushroom farm developed mushroom worker’s lung. The first patient presented in respiratory failure, with radiological features characteristic of hypersensitivity pneumonitis. The condition of the second patient was subacute on presentation, with a computed tomography (CT) scan showing ground-glass opacities. With absence from the workplace and no steroid therapy, the symptoms of both patients subsided and the results of lung function tests and CT scans improved markedly. Clinical recordTwo employees of the same mushroom farm presented to our hospital within a 5-month period. The farm is a large commercial producer of Agaricus bisporus mushrooms. Both workers were employed in the spawning shed, where mushroom compost is tipped onto a conveyor belt for mushroom spawn (sterilised grain inoculated with mushroom mycelia) distribution. The process is associated with increased levels of ambient organic dust.1 The principal means of minimising organic dust in the shed was local exhaust ventilation. Neither worker recalled receiving instructions about respiratory protection or the specific hazard of organic dust exposure during their employee-induction process. Case 1A 36-year-old man, who was a non-smoker, had been employed at the mushroom farm for 8 years, and had worked in the spawning shed for 3 years. He described a 4-month history of non-productive cough that was noticeably worse in the afternoons at work and improved on weekends. Two weeks before presenting, he developed daily chills, sweats, myalgia, chest tightness and exertional dyspnoea. His symptoms consistently commenced 5 hours after arriving at work and persisted into the evening at home. They abated sufficiently by morning and over the weekend to allow him to return to work. He had lost 7 kg in weight over 4 weeks. He presented to the emergency department with worsening dyspnoea after a day at work. He was pyretic (38.1°C) and had bilateral basal inspiratory crackles. Measurement of arterial blood gases confirmed hypoxaemia (Pao2, 57 mmHg; reference range [RR], 80–100 mmHg). Inflammatory markers were elevated: C-reactive protein level, 92 mg/L (RR, < 8 mg/L); and erythrocyte sedimentation rate, 17 mm/h (RR, 8–12 mm/h). Results of a full blood examination were within normal limits. Chest x-ray showed a diffuse bilateral reticulonodular infiltrate, and a high resolution computed tomography (HRCT) scan showed changes consistent with hypersensitivity pneumonitis (Box 1). Mushroom worker’s lung was diagnosed and the patient was admitted for observation and oxygen administration. Corticosteroid treatment was not administered. Respiratory function tests showed a borderline restrictive ventilatory defect, with moderately impaired transfer factor for carbon monoxide diffusion (TLco) (Box 2). During 4 days of observation, there was an improvement in oxygenation, his fever abated, and C-reactive protein levels fell to 15 mg/L. He was discharged home and advised not to return to work. Over the next 4 months, with ongoing avoidance of workplace exposure, ventilatory function, gas transfer and vital capacity improved significantly, and the abnormalities seen on HRCT scan partly resolved, with persistence of tiny centrilobular nodules (Box 1). Precipitin testing for antibodies to A. bisporus was not available. Precipitin testing for antibodies to Micropolyspora faeni (a fungus of compost, hay and grain), done at the 1-month review, gave negative results. Case 2A 40-year-old man, an ex-smoker, who had worked in the spawning shed for 6 years, had experienced 3 months of non-productive cough, fatigue, exertional dyspnoea and weight loss. His working day in the spawning shed started at 6 am, with onset of symptoms usually occurring around midday. He presented on two occasions to another hospital after a full day’s work complaining of dyspnoea, cough, chest tightness, myalgias and fever. At the first of these two presentations, resting Spo2 (oxygen saturation measured by pulse oximetry) was mildly reduced at 93%. Results of a full blood examination showed neutrophilia (9.4 × 109/L; RR, 2.0–8.0 × 109/L), and the C-reactive protein level was 13.5 mg/L. No abnormalities were seen on chest x-ray. He was diagnosed with a respiratory tract infection, prescribed antibiotics and discharged. His symptoms abated during a period of sick leave, but recurred 2 hours after returning to work in the spawning shed. On presenting to our outpatient clinic, 9 days after his last work exposure, he reported that his cough and fever had abated, but exertional dyspnoea persisted. Spirometry tests showed no abnormality, but TLco was impaired at 22.8 mL·min-1·mmHg-1 (58% predicted). Serum precipitin testing for M. faeni gave negative results. HRCT scan of the chest showed subsegmental air-trapping on expiratory scans and subtle patchy ground-glass opacities in both lower lobes (Box 3). After 4 months of avoiding further exposure, he noted no recurrence of symptoms, slow improvement in exercise tolerance, and improved gas transfer. DiscussionMushroom cultivation in Australia is a large agricultural industry, employing over 2500 people,2 yet mushroom worker’s lung has not previously been reported in the Australian medical literature, nor to an occupational lung disease notification scheme.3 It is likely that there is considerable under-recognition of this condition, as it is estimated that 5%–15% of those exposed to the causative antigens may develop hypersensitivity pneumonitis.4 In the largest cross-sectional study of workers at an Agaricus mushroom farm, 20% of those heavily exposed to organic dust reported experiencing symptoms consistent with mushroom worker’s lung.5 Unfortunately, with no thorough epidemiological studies, specifically cohort studies, it is not possible to estimate the true incidence of respiratory disease in mushroom farm workers. Several outbreaks of mushroom worker’s lung have been reported in the international literature since the 1950s. Workers with high exposure to organic dust from mushroom compost, such as spawners and compost handlers, are commonly affected and hence the more specific term “mushroom compost worker’s lung” is occasionally used.1,6 In this form of mushroom worker’s lung, M. faeni (currently known as Saccharopolyspora rectivirgula of the class Thermoactinomycetes), which is present in mushroom compost, is the most commonly implicated allergen.1,5,7 Organic dust from mushroom compost consists of a vast array of microorganisms and organic antigens; failure to demonstrate precipitins to M. faeni, as in the patients reported here, does not exclude the diagnosis of mushroom worker’s lung.1,4,8 Japanese mushroom farm workers have been reported to suffer an alarmingly high incidence of allergic respiratory disease.9,10 In a 3-year follow-up study by Tanaka et al, 40% of workers left the industry due to intolerable respiratory symptoms.10 Japanese mushroom varieties such as Hypsizygus marmoreus (Bunashimeji) are grown on wet wood dust rather than compost and release billions of spores 4–6 μm in diameter before being harvested.10,11 The inhaled mushroom spore (rather than Thermoactinomycetes) is the causative allergen in this setting, with the term “mushroom picker’s lung” used to more accurately describe the group of workers at risk of this form of mushroom worker’s lung.11 Although commercial cultivation of “exotic” mushrooms in Australia is small (1000 tonnes per year compared with 52 250 tonnes of Agaricus mushrooms), as demand for and cultivation of these mushrooms increases, employers must be aware of the significant hazard posed by these varieties when developing safe work practices.2 The most important component of identifying hypersensitivity pneumonitis is recognition of exposure to a causative antigen, reinforcing the importance of a thorough occupational history, and identification of workplace hazards (Box 4).7,12 A temporal relationship between the development of symptoms (cough, fever, chills, dyspnoea, chest tightness and malaise) 4–8 hours after the start of exposure, and an improvement during weekends or vacations, is quite indicative of this condition.4,8 Organic dust toxic syndrome, a form of inhalation fever, may be difficult to differentiate from acute hypersensitivity pneumonitis and is estimated to be 30–50 times more common.12 Organic dust toxic syndrome may result from a single heavy exposure to organic dust, and is self-limiting, with symptoms rarely exceeding 36 hours.8 Optimal management of hypersensitivity pneumonitis requires early recognition and complete avoidance of further exposure to the causative antigen;8,7,12 a change of occupation may be necessary. Although corticosteroid therapy has been shown to result in more rapid improvement in lung function and may be warranted in severely unwell patients, it has not been shown to improve long-term outcomes.9 Recurrence of acute hypersensitivity pneumonitis is more common in patients treated with steroids; this may be due to their improved sense of wellbeing and less stringent adherence to antigen avoidance.8,13 The natural history of hypersensitivity pneumonitis has been poorly described, primarily due to a lack of longitudinal studies.8 With repeated acute or chronic low-level exposure in farmer’s lung, permanent lung damage caused by pulmonary fibrosis and emphysema has been shown to occur, with associated chronic dyspnoea and permanent impairment.8,9 Even patients who remain asymptomatic may have long-term physiological sequelae.8 Australian occupational health and safety legislation describes in broad terms employers’ responsibilities to ensure every reasonable action is taken to preserve the health and safety of workers. Obligations to control hazardous non-organic substances, such as isocyanates and silica, are further described by subordinate Occupational Health and Safety (Hazardous Substances) Regulations (Vic) and the accompanying Hazardous Substances Code of Practice. Despite organic dust clearly having the potential to harm human health, the requirement to control organic dust falls outside the domain of hazardous substance legislation in Australia. Therefore, for their duty of care to be discharged, employers in the agricultural sector must demonstrate due diligence in their identification and control of all workplace hazards, including organic dust. The National Occupational Health and Safety Commission (now known as the Australian Safety and Compensation Council) has established limits for some organic dusts, such as cotton.14 However, organic dust in most agricultural settings is a complex and variable mixture of constituents, impairing the ability to set useful standards.8 Episodic high concentrations of dust exposure, rather than static ambient levels, may precipitate respiratory diseases, further increasing the difficulty of determining “safe” exposure standards. These factors impair our ability to advise employers how best to control this hazard. It is also difficult to determine what can reasonably be expected of employers as far as monitoring is concerned. Urgent research has been called for in this area by the American Thoracic Society.8 Employers in agricultural industries should demonstrate awareness of the hazard of organic dust, and aim to reduce exposure levels using the “as low as reasonably practicable” (ALARP) principle. Mushroom farm workers specifically should be educated about the risk of developing hypersensitivity pneumonitis and be advised of the symptoms and warning signs.5 1 Lung imaging — Patient 1 A: High resolution computed tomography (HRCT) scan of the chest of Patient 1 at presentation showing small, ill-defined centrilobular ground-glass nodules < 5 mm in diameter. Scans of the lower zones (not shown) revealed more confluent areas of ground-glass opacity, without discrete nodules. B: Repeat HRCT scan performed 1 month later (1 month without workplace exposure) showing significant improvement, but with persistence of tiny centrilobular nodules, particularly in the upper zones. 2 Respiratory function tests — Patient 1 Normal range Time since exposure (percentage of mean predicted value) Tests Presentation 1 month 4 months FEV1 (L) > 3.34 3.24 (76%) 4.50 (107%) 4.54 (108%) FVC (L) > 4.27 4.11 (78%) 5.17 (99%) 5.51 (105%) FEV1/FVC (%) > 72% 79% 87% 82% TLco (mL·min-1·mmHg-1) > 30.3 19.8 (53%) 26.8 (72%) 32.7 (88%) VA (L) > 5.8 5.3 (78%) 6.4 (95%) 6.9 (104%) FEV1 = forced expiratory volume in 1 second. FVC = forced vital capacity. TLco = transfer factor for carbon monoxide diffusion. VA = alveolar volume. 3 Lung imaging — Patient 2 High resolution computed tomography scan of Patient 2 at presentation, showing normal upper lobes (A) and patchy, centrilobular ground-glass opacities, with expiratory subsegmental air- trapping at the lung bases (B, C). This is a non-specific pattern, compatible with hypersensitivity pneumonitis. 4 Occupational causes of hypersensitivity pneumonitis — disease and source of exposure9,12 Farmer’s lung: mouldy hay, grain; compost Bagassosis: mouldy sugarcane Mushroom worker’s lung: mushroom compost, mushroom spores Ventilation pneumonitis: humidifier, air conditioner Machine operator’s lung: contaminated metal working fluids Humidifier lung: ultrasonic cool-mist humidifiers Floor finisher’s lung: mouldy wood floors Malt worker’s lung: mouldy malt dust (brewing) Compost lung: compost Tobacco worker’s lung: mouldy tobacco Sequoiosis: contaminated red-wood dust Wood worker’s lung: mouldy wood dust Wood trimmer’s disease: mouldy wood trimmings Wine grower’s lung: mouldy grapes Suberosis: mouldy cork dust Cheese worker/washer’s lung: cheese mould Salami worker’s lung: salami seasoning Saxophonist’s lung: mouldy saxophone reed Bird fancier/breeder/handler’s lung: pigeon, duck, chicken, turkey, parrot Furrier’s lung: cat hair, fur dust Laboratory worker’s lung: laboratory rat or gerbil urine Oyster shell lung: shell dust Tobacco grower’s lung: tobacco dust Coffee worker’s lung: coffee bean dust Tea grower’s/worker’s lung: tea leaves Streptomyces hypersensitivity pneumonitis: contaminated fertiliser Detergent worker’s disease: detergent

Ryan F Hoy MB BS · Jeffrey J Pretto BAppSc, GDBI, CRFS · David van Gelderen MB BCh, FRANZCR · Christine F McDonald MB BS, PhD, FRACP

Nanomaterials — a wide variety of materials with a diameter of less than 100 nm — have unique properties. Nanotechnology is being promoted as the technology that will drive the next industrial revolution. Nanomaterials may have unique biological activities, but little research has been undertaken to investigate their potential effects on human health and the environment. Many seminal reports have identified gaps in our knowledge, and a large multidisciplinary effort will be required to undertake the necessary research to assist the framing of regulatory models to deal with any novel risks.

Brian G Priestly MPharm, PhD · Andrew J Harford BAppSc, PhD · Malcolm R Sim PhD, FFOM

Napping at night may benefit both health professionals and their patients Delivering medical care is a 24-hour business that inevitably involves working the night shift. However, night shift requires the health professional to work when the body’s clock (circadian system) demands sleep. Added to this is the problem of “sleep debt”, arising from both prolonged prior wakefulness on the first night shift and cumulative sleep debt after several nights’ work and repeated unsatisfactory daytime sleeps. A further aggravation, particularly for trainee medical staff in teaching hospitals, has been the demand for excessive work hours across the working week. As has been dramatically shown in recent well controlled studies, the net result of this assault on the sleep of health professionals can be impaired patient safety,1 and the health and safety of health professionals themselves.2 The good news is that health organisations and regulators are beginning to treat the matter seriously. In Australia, the United States and Europe, work hours of medical staff have recently been shortened by government regulation, and bodies such as the Australian Medical Association and professional colleges are advising their members on strategies to improve their sleep health and thus work safety. A recent publication prepared by the Royal College of Physicians (London) (RCP), Working the night shift: preparation, survival and recovery. A guide for junior doctors, is an excellent example.3 One proposed countermeasure for excessive sleepiness is the use of strategically placed naps both before and during the night shift. But does napping either before or during the night shift reduce sleepiness and improve performance, and, if so, how practical is it? There are two important, independent mechanisms of sleep and sleepiness that hold the key to these questions.4 Probably the more potent mechanism impairing night-shift alertness is the circadian system. For most individuals, even those working permanent night shift, the circadian system is in sleep mode during the night. This causes slowed reactions, increased feelings of fatigue, impaired concentration, and increased sleep propensity. The second important mechanism affecting night-time alertness is homeostatic sleep drive. This increases in intensity the longer we are awake and, like appetite which is sated by eating, homeostatic sleep drive is reduced by sleeping. If the first night shift starts at midnight following a normal wake time at about 8 am, about 16 hours of wake sleep debt has already been accrued and the rest of the night shift will be performed under intense homeostatic, in addition to circadian, sleep drive. Performance decrements during this night period can be similar to those measured in the daytime with a blood alcohol concentration of 0.05%–0.10%.5 Day sleep in the home environment is likely to be shorter and less effective than night sleep so, even though second and subsequent night shifts may follow fewer wakeful hours (8–10 hours), homeostatic sleep drive is likely to remain elevated during night shifts because of incomplete repayment of the previous sleep debt. To a limited extent, it is possible to “bank” sleep (or pay off residual sleep debt) before the first night shift, potentially reducing subsequent night-time homeostatic sleep drive and improving alertness and work safety. A long (1–2 hours) nap in the afternoon, as recommended in the RCP report, is best. Afternoon sleep is more efficient than early evening sleep as it uses the natural afternoon “dip” in circadian physiology6 and avoids the risk of post-sleep grogginess or sleep inertia impinging on the start of night duty. Between subsequent night shifts, the aim should be to maximise daytime sleep length (at least 7 hours) and efficiency by including the afternoon sleepy period (1–4 pm). What about napping during a night shift to improve alertness and reduce errors and accidents? Brief afternoon naps of 10–30 minutes (so-called power naps) improve alertness and performance. We compared afternoon naps of 5, 10, 20, and 30 minutes of total sleep.7 The 10 minute sleep (about a 15 minute nap opportunity) produced improvements over the 3 hour post-nap period in all eight alertness and performance measures, without any of the post-nap impairment of sleep inertia that followed the 20 and 30 minute naps. Whether these results would be replicated at, say, 3 am in a night-shift environment, with considerably greater homeostatic and circadian sleep drive, is now being tested. Only a few studies have measured the effects of night-shift napping. Long naps of about 2 hours appear as effective at about 3 am as at 3 pm.8 However, 1–2 hour naps were followed by sleep inertia, during which alertness was impaired for up to an hour.9 Longer naps, although beneficial once sleep inertia has been dissipated, may be used reluctantly by medical staff wishing to maintain continuity of patient care.10 Briefer naps (18–26 minutes) have also improved performance in night-shift environments.11 Therefore, the picture emerging from night-shift napping studies is similar to that from the afternoon studies. Very brief naps (10–15 minutes of sleep) may improve alertness immediately without the negative effects of sleep inertia. How long this improvement lasts and what is the optimal nap length on the night shift remains to be determined. In the meantime, as recommended in the recent RCP guide, health professionals who work night shift should, for the sake of their own health and safety and that of their patients, consider the benefits of night-shift napping. Optimal benefit and a higher take-up rate are likely for sleep lengths of 10–15 minutes.

R Doug McEvoy MD, FRACP, BMedSc · Leon L Lack BA, PhD

The implications arising from the Inquiry into the Waterfall train crash for medical examinations of safety-critical workers are discussed. Examinations need to be appropriate for the level of risk in the job and apply current medical thinking. A careful balance is required between the various legal obligations, including duty of care, disability discrimination and privacy. The frequency of examinations depends on a combination of medical, economic and logistical factors. Health professionals who conduct examinations should be familiar with the occupation of the person being examined. Ethical relationships with the worker’s general practitioner or specialist(s) must be observed. The procedures associated with the examinations are as important in achieving safety as the actual examinations. These include complying with relevant standards; providing all relevant documentation with a referral for an examination; acting on the doctor’s report appropriately; and auditing the process.

Bruce Hocking FAFOM, FAFPHM, FRACGP

Noelene S O'Keefe,* Kristina A Heinrich-Morrison,† Bruce McLaren‡ * Project Officer, Legionella Program, Environmental Health, † Public Health Nurse, ‡ Medical Officer, Communicable Diseases Section, Department of Human Services, 17/120 Spencer Street, Melbourne, VIC 3000. bruce.mclarenATdhs.vic.gov.au To the Editor: A 23-year-old man presented to a Victorian hospital with a 4-day history of fever, rigors, confusion and malaise. A chest x-ray showed left lower-lobe pneumonia, and Legionella pneumophila serogroup 1 antigen was detected in his urine. No respiratory specimens were obtained. He recovered completely after treatment for community-acquired pneumonia, including intravenous ampicillin and oral roxithromycin, and returned to work 16 days after onset. Investigations for the source of the infection included environmental review and sampling of cooling towers near his workplace, home, and other sites visited during the incubation period. Active workplace surveillance prompted testing for and detection of L. pneumophila serogroup 1 urinary antigen in a second employee, a 53-year-old man who had presented 2 days earlier than the patient above to another Victorian hospital with fever, abdominal pain and diarrhoea. Legionellosis was not suspected on presentation. He had no symptoms, signs or radiological evidence of pneumonia. Treatment, including intravenous ampicillin and oral roxithromycin, began when the antigen result was obtained, and he was discharged after 10 days in hospital, although he felt unwell for 2 or 3 weeks after discharge. The two men worked near each other in a welding area. A water tank was placed at the entrance to the area, with the cover left open. This acted as a heat exchange for the welding cooling system. A high count of L. pneumophila serogroup 1 (1300 colony-forming units/mL) was grown from a sample of this water. It was common on hot days to cool the work place with an industrial fan. The open water tank was between the fan and the two employees during the incubation period. No L. pneumophila isolates were found in any linked cooling towers. Remedial action included commencing a disinfection program for the water reservoir, and a request to fit the cover correctly and move the fan. No further cases were detected. Because no clinical isolates were obtained, a direct subtype match between clinical and environmental specimens was not possible. Urine antigens are considered definitive laboratory tests given a compat-ible illness (fever or cough or pneumonia).1 Outbreaks of Legionnaire’s disease and Pontiac fever (legionellosis without pneumonia) with industrial sources other than cooling towers have been reported.2,3 This outbreak demonstrates that a simple change in the environment (adding a fan) and an apparently low-risk source (a warm water bath) have the potential to give rise to significant disease. It also shows the value of active workplace surveillance after a single case.

Noelene S O'Keefe · Kristina A Heinrich-Morrison · Bruce McLaren

The challenge for health authorities is to implement effective preventive strategies and a zero-tolerance policy Although in Australia the risk of death or serious physical injury from a violent workplace incident is quite remote, each year about one Australian health worker is murdered at work1 and large numbers are either verbally abused, bullied or assaulted.2 Claire Mayhew and Duncan Chappell have been involved with research and public policy development related to workplace violence for over a decade. They both worked at the Australian Institute of Criminology (Canberra); they were involved in the NSW Health “Taskforce on prevention and management of violence in the health workforce”; they conducted the most extensive study on violence in the health industry in Australia to date and have collaborated in the development of publications for the International Labour Office in Geneva. Workplace violence has been defined in various ways, and behaviours ranging from verbal abuse and threats to sexual harassment, physical assaults and homicide may be included. The precise definition adopted will affect incidence and severity rates of workplace violence. An inclusive definition developed specifically for the health sector is: Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.3 There are two core risk factors for violence in any workplace: face-to-face contact with clients or customers; and cash or high-value goods on site which may attract perpetrators of instrumental violence.4 Marked variations in risk exist between different occupational groups, reflecting the relative presence or absence of these two core risk factors.5 These patterns generally hold across different countries so that high-risk jobs in one country tend to also be high-risk jobs in others. For example, throughout the industrialised world there is a very high rate of homicide of taxi drivers, who also experience high levels of verbal abuse and assault. Conversely, white collar workers, with little face-to-face contact with members of the public, generally have very low incidence and severity rate. Fast-food outlet workers tend to experience high levels of verbal abuse but homicide is rare (apart from those located in suburbs with a high risk of hold-ups). Other occupational groups have diverse experiences essentially determined by levels of exposure to known risk factors. In health care settings, one of the two core risk factors — face-to-face contact with patients and visitors — is particularly common. The Box gives workplace verbal abuse, bullying and assault rates for various Australian industry sectors. These estimates were collated after separate face-to-face surveys conducted with representative samples of employees. In each case, interviewees were requested to state precisely what, if any, form of workplace violence they had experienced over the previous 12-month period. While space prohibits an exposé of these different studies here, it is clear that health care ranks fairly highly compared with many of the groups.6 Almost all the cited “bullying” events were from one staff member to another (Box). A similar pattern of variable risk across industry sectors and occupational groups is also evident in Britain.4 In 2001–02, representatives from the International Labour Office, International Council of Nurses, World Health Organization and Public Services International initiated an international collaborative program to develop policies and approaches to prevent and eliminate violence in the health sector. Outcomes included: a series of country-specific research studies (Brazil, Bulgaria, Lebanon, Portugal, South Africa, and Thailand and a linked Australian study; see <http://www.icn.ch/sewworkplace.htm>); a Synthesis report of the commissioned country reports;3 and finally the drafting of Framework guidelines for addressing workplace violence in the health sector.7 Across the various country-specific research studies, more than 50% of health workers reported experiencing one or other form of workplace violence in the previous 12 months; ambulance officers were at greatest risk, followed by nurses. The linked Australian health study involved face-to-face interviews with a representative sample of 400 public health employees, including medical officers, nurses, allied health, ancillary and ambulance workers.2,6 About two-thirds (67%) of all interviewees said they had been verbally abused in the previous 12-month period, 10.5% had been bullied, and 12% assaulted, rarely resulting in physical injury. As in other countries, incidence rates varied between and within health occupations, with ambulance officers most at risk, followed by nurses. Among medical officers interviewed, 62% had been verbally abused, 15% bullied and 17% assaulted over this period. The perpetrators of verbal abuse and assaults were predominantly clients and visitors, however, other staff members were responsible for almost all bullying events. Nevertheless, only a small proportion (between 8% and 10%) of these events had been formally reported — providing health authorities with limited evidence on which to base preventive planning. Similar incidence rates have been reported in general medical practice,8 including the study by Magin et al in this issue of the Journal (page 352).9 Comprehensive workplace violence prevention strategies have been developed and are available.4,10-12 However, in our experience, there is a tendency among health workers to favour preventive strategies that have only been trialled at other health sites. We would encourage health workers to consider the full range of prevention strategies, many of which have been well documented and evaluated in other industry sectors — including, in particular, those published in the scientific literature for criminology and occupational health and safety (OHS). All workplace violence prevention strategies — regardless of the setting, health care or otherwise — should be multifaceted and organisation-wide, and involve widespread consultation with all workers (including casuals and those off-site) in their development and implementation. In health care settings, this may involve nursing agencies, ambulance officers, and workers in the community and remote locations. In the OHS “hierarchy of control” approach to violence, designing out risk is the preferred action in all workplace environments, and should include health care settings such as hospitals, clinics, general practices, and ambulances and other vehicles. For example, to remove or minimise risk, careful attention can be paid to the design of buildings (eg, placement of windows) and their fittings (eg, counter height and width, and choosing chairs for waiting areas that cannot be easily lifted and thrown).2,10,13 The least preferred action is sole reliance on staff training, as the causes of workplace violence are multifactorial and hence simplistic solutions are unlikely to be effective in prevention. Chief executive officers (CEOs) should demonstrate commitment to zero tolerance of workplace violence. They should encourage cultural change and show enhanced concern for workers’ safety. Strong encouragement should be given to formal reporting of workplace violence, including the removal of covert penalties and the excessive filling in of forms. Regular violence vulnerability audits should be conducted by independent OHS professionals. The files of serial perpetrator patients should be “flagged” to forewarn other staff (the best predictor of violence is past aggression), and, ultimately, such patients should be sanctioned, which, although difficult, is an essential component of a comprehensive workplace violence prevention strategy.14 Particularly in the UK National Health Service, the sanctioning of perpetrators of violence has become increasingly common; however, the deterrent reach of penalties can be limited by the lack of capacity of certain patients to control their behaviour, including those suffering from mental illness and dementia. Under the OHS legislative framework in each Australian state and territory, primary responsibility rests with employers and CEOs to provide a safe place and a safe process of work for their employees, including those who work off-site. OHS obligations are not diminished by the rights of patients to confidentiality or to treatment. Employers (including public health departments) and CEOs may be prosecuted for a breach of this “duty of care” with respect to their employees, as well as being liable under common law.15 The core challenges for health authorities will be to: implement a zero-tolerance policy with effective prevention strategies encompassing all health occupational groups, and especially those working off-site and in general medical practice; adopt preventive strategies which have been successful in other industry sectors; and develop and implement a deterrent sanctioning policy for perpetrators. The group of articles in this issue of the Journal will further assist the health industry to recognise the potential benefits from involvement with the Australian Patient Safety Foundation (APSF) database (Benveniste et al, page 348);16 identify verbal cues of imminent overt aggression in mental health settings (Forster et al, page 357);17 understand possible causes of under-reporting of violence against emergency department staff (Kennedy, page 362),18 and to also recognise the particular vulnerabilities faced by those working in general medical practice.9 Workplace violence experiences of 1362 workers over a 12-month period (% of respondents) in Australia6 Workplace Verbal abuse Bullying Physical assault Juvenile justice 68% 12% 17% Tertiary education 50% 65% 1% Health care 67% 10.5% 12% Seafaring 19% — 1% Long-haul transport 33% — 1% Fast-food 48% — 1% Taxis 81% — 10%

Claire Mayhew BAdmin(Hons), PhD · Duncan Chappell LLB, PhD

Frustration and anger arising out of illness and pain, psychiatric disorders, alcohol and substance abuse, can affect behaviour and make people verbally or physically violent. The incidence of violence faced by workers in contact with people in distress is so common that it is often considered an inevitable part of the job. Health care workers are at the forefront of this situation.1 In 1996, the World Health Organization declared violence a leading worldwide public health problem.2 Its subsequent publication World report on violence and health confirmed that violence had become a global phenomenon of epidemic proportions in all societies.3 In the European Union, for example, an estimated three million workers, or 2% of the labour force, have been subjected to physical aggression and violence at work.3 We already know from a number of studies conducted among health professionals that Australian health care workers frequently experience violence (Box 1). However, collection and aggregation of incident data reported by health professionals from multiple hospitals can reveal information not available from single hospital or single study reports. The purpose of such a patient safety reporting system is “to ferret out and correct vulnerabilities, not to count them”.11 The Australian Patient Safety Foundation (APSF), a non-profit research organisation, has played an important role in developing systems to collect, aggregate, monitor and analyse incidents related to patient safety since its formation in 1988, when it received its first reports of anaesthetic-related events for the Australian Incident Monitoring Study in anaesthesia. In 1998, to re-analyse data from the Quality in Australian Health Care Study,12 the APSF created a taxonomy and software which became the Australian Incident Monitoring System (AIMS). This involved developing a classification of health care incidents — both adverse events and near misses — an incident being “any event or circumstance which could have led, or did lead, to damage, loss or harm”.13 Incident reporting to AIMS has always been voluntary. Reports have been made by all types of health care professionals from a varying number of participating hospitals and other health facilities within Australia and New Zealand. Data are de-identified before aggregation and analysis, and thus cannot be used to determine incidence rates. However, their value lies in understanding the contributing, minimising and preventive factors involved, which can then be used in devising corrective strategies and action plans for incidents affecting patient safety. Violence is one major category of incident classified within AIMS. Because of growing concern about violence in health care in Australia, we reviewed the relevant data collected using AIMS.14 Here, we present and discuss some of the summary data relating to reported incidents of violence. What has been reported? The complete AIMS collection of patient-safety-related incidents from January 1998 to June 2002 contains nearly 80 000 coded reports. The data include contributing factors, action taken and outcome, when available. Among 42 338 incidents reported from 1 July 2000 to 30 June 2002, 3621 (9% of all incidents) involved patients and physical violence (for example, assaults or throwing objects) or violent verbal exchange (abuse or threats) occurred.14 Staff injury was reported in 5% of cases. Box 2 summarises the key findings. Although 9% of reported incidents in all health units involved violence, the proportion was higher in emergency departments (16%) and higher still in mental health units (28%). Incidents in these two areas have their own characteristic patterns of contributing and precipitating factors. In reports from 12 emergency departments, 16% of all reported incidents (190 of 1214 incidents) involved violence. Mental health problems were patient-related contributing factors for over half of the violent incidents, with alcohol or drug intoxication contributing to more than 25%. The most common staff-related contributing factors were “communication problems” and “insufficient or inadequate [numbers of] staff”. Precipitating factors included dissatisfaction with staff decisions to admit or discharge a patient from hospital, lack of support on discharge, or non-prescription of a patient-requested medication. Weapons used in incidents included hospital equipment, razor blades, scissors and blood-filled syringes. In reports from 10 mental health services, 28% of all incidents reported (1467 of 5326 reports) involved violence. In violent incidents in which the patient’s status (voluntary or involuntary admission) was known, 79% involved patients who were legally detained. There was often a precipitating factor, such as refusal of privileges. What are the issues? Health services are provided in a changing environment where new policies and programs are often needed in response to changing patient demand — such as varying demographic characteristics of patients and the nature of their presenting symptoms — but these policy changes have to be balanced against the obligation to provide a safe environment for both health professionals and patients. Mental health services The violence seen in our health services reflects changes in our society, including changes in mental health service provision. Over the past decade, deinstitutionalisation of patients with mental illness has had an impact on public hospital emergency departments. Between 1998–99 and 2002–03, mental-health-related separations (that is, deaths and discharges) from public acute hospitals increased by 11%, whereas those from public psychiatric hospitals decreased by 24%.15 Secure rooms have been built in general hospitals to seclude violent patients presenting to public hospital emergency departments. However, psychiatric patients, including prisoners with mental illness, have been detained in public hospital wards that did not have appropriate resources to cope with them, posing a potential risk to other patients.16 In one incident, an entire ward of a NSW district hospital was closed when an elderly woman inpatient died after being attacked in her bed by a patient with mental illness.17 In South Australia, the potential risk to emergency staff may increase as the last public psychiatric hospital is scheduled for closure in 2007, and patients with acute psychiatric conditions are to be directed to general hospitals.18 Such health system changes have major implications for risk management and injury litigation in all acute health services. Staff protection Medical practitioners working in psychiatry, emergency medicine, general practice or rural and remote health need to develop protective behaviours, both for their own safety and that of their patients. Since 1992, in South Australia alone, there have been two workplace deaths of psychiatrists associated with patient violence.19,20 These and other incidents of violence indicate the importance of staff access to duress alarms, escape routes and back-up support, as illustrated in the incident described in Box 3. Preventive strategies AIMS analysis highlights the importance of understanding the contributing and precipitating factors in violent incidents to determine the vulnerability of a health facility. Our review supports a variety of initiatives that are being developed and adopted to reduce violent incidents. These include: de-escalation training for staff, and introduction of violence management plans;21 improved design of buildings to enhance safety of staff and patients;22 initiatives for emergency department fast-tracking of patients with mental health problems;23 and initiatives to improve waiting times in public hospital emergency services using a clinical initiatives nurse (whose priority will be emergency department patients waiting for care, and their families/carers).21 Some hospitals have developed comprehensive aggression management programs to integrate strategies involving environmental design, staff training and team response.24 An Aggression Risk Assessment tool has been developed by Consultation and Liaison Psychiatry at Austin Health in Victoria for use in initial assessment of patients in a variety of inpatient settings (see Forster et al, page 357).25 The National Health and Medical Research Council has developed a resource manual for rural and remote practitioners.26 Further, the Australian National Institute of Clinical Studies has a program to assist emergency department staff to improve care of patients with mental health conditions — the Mental Health Emergency Care Interface Project.27 Incident analysis: the way forward AIMS has continued to evolve since an early version was evaluated in November 2002.28 It is now capable of analysing incidents from all sources in health care including investigative analyses, coroners’ reports, and mortality and morbidity reviews as well as incident reports. Importantly, it now also allows for consumer complaints. AIMS is now used on a state-wide basis by the health departments of New South Wales, Western Australia, South Australia and the Australian Capital Territory, as well as by some health facilities in the Northern Territory, Victoria and Queensland. States collect and analyse their own data to aid state-based decision-making. Incident monitoring also has the potential to enable health services to collect local data on patient, staffing and system factors that contribute to incidents, and to develop and evaluate local management plans. However, there is currently no national system to aggregate incident monitoring data. We recommend that a national system be developed to share and compare incident monitoring data, to monitor trends, and to facilitate learning and thinking at all levels — ward, department, hospital, state and national. At all levels, intelligent interrogation of data and imaginative initiatives will be needed to improve care. 1 Experience of violence by Australian health professionals4-10 A survey conducted in 1999 of 266 emergency department nurses in metropolitan and regional hospitals in New South Wales revealed that all had experienced some form of violence at work at least weekly, but over 70% of incidents were not reported to authorities.4 In a 2002 survey of all Tasmanian nurses, 64% of over 2400 respondents had experienced violence in the past 4 weeks.5 In another survey conducted in 2001–2002 of 400 Australian health care workers interviewed to provide baseline data for the “Taskforce on the prevention and management of violence in the health workplace”, three-quarters of the 200 nurses involved had experienced some form of violence in the past 12 months; the highest rate of events per worker was among ambulance officers.6 Exposure to violence is particularly high for nurses in inpatient psychiatric facilities7 and remote area nursing.8 Situations of increased risk for medical practitioners include working in emergency departments, treating clients affected by drugs or alcohol, and dealing with high-stress situations in delivery suites, intensive care or coronary care units.6 Violence towards medical practitioners is not confined to hospital services; 73% of rural general practitioners in Western Australia, New South Wales and Victoria reported experiencing some form of aggressive behaviour from patients and 20% had been subjected to physical abuse during their careers as rural doctors.9 Urban GPs have reported that providing after-hours care now puts them at increased risk of assault, and some have restricted provision of after-hours care as a result.10 2 Key findings in 3621 incidents involving patients becoming violent in Australian hospitals and health services, 1 July 2000 – 30 June 2002 Any health care setting Number of incidents 3621 incidents, 9% of all health care incidents (n = 42 338) Most common contributing factors Patient-related — mental health conditions, 40% of incidents; dementia, 15%; pathophysiological factors, 13%; confusion, 9%; alcohol or drug intoxication, 6% Staff-related — “insufficient or inadequate [numbers of] staff”; “communication problems”; “inadequate knowledge or inexperience” System-related — “security problems” Most common outcomes Change of treatment, over 40%; informing a medical practitioner, 25%; patient transfer, 16%; restraint team called, 15%; police or security called, 15%; staff injury, 5% Accident and emergency services (reports from 12 services) Number of incidents 190 incidents, 16% of all incidents in this setting (n = 1214) Most common contributing factors Patient-related — mental health conditions, more than 50% of incidents; alcohol or drug intoxication, more than 25% of incidents Staff-related — “insufficient staffing”; “communication problems” Most common precipitating factor Dissatisfaction with staff decisions Mental health services (reports from 10 services) Number of incidents 1467 incidents, 28% of all incidents in this setting (n = 5326) Most common contributing factors Patient-related — mental health conditions; where admission status was specified, 79% were involuntary admissions Most common precipitating factor Refusal of privileges 3 Incident reported to the Australian Incident Monitoring System (AIMS) A doctor was interviewing a patient with a psychiatric condition in an interview room of an emergency department. The patient was in a psychotic state and became agitated and violent. The doctor tried unsuccessfully to press the duress alarm, but managed to escape from the room. The patient followed the doctor into the triage section, lunging and pinning the doctor against the wall and tearing clothing. The patient was eventually calmed by other staff and urgent restraint was requested. Security personnel arrived after the patient had been calmed by another doctor.

Klee A Benveniste PhD, MAPS · Peter D Hibbert BAppSc(Physio), GradDipComp, CertHlthProgEval · William B Runciman MB BCh, PhD, FJFICM

Strategies to prevent and manage violence and aggression in the health care setting have become a primary health and safety issue. A series of vignettes are provided to highlight key elements in developing a program for preventing behavioural violence and aggression in a tertiary hospital. Key components of the program include staff education and training, risk assessment and management practices, the use of patient contracts and policy development. The program aims to integrate and balance occupational health and safety obligations to staff with the duty of care owed to patients.

John A Forster RN, RPN, GradDipPsychNurs · Mark T Petty RN, BAppSci(Nurs Admin), GradDipCompSci, MHA, FRCNA · Colin Schleiger GradDipOccupHazMan, DipPublHealth · Helen C Walters CPN, BPN, GradDipPsychNurs

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude — to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known “system blockers” to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence — the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.

Marcus P Kennedy FACEM, FRACGP, DA(UK)

Objective: To examine the effects of asbestos exposure and tobacco smoking on the level and rate of change of the diffusing capacity of the lung for carbon monoxide (Dlco).Design and participants: A cohort study of 934 people (including both mine workers and town residents) exposed to crocidolite (blue asbestos) at the asbestos mines and in the town of Wittenoom, Western Australia, between 1943 and 1966. Dlco measurements were taken during a follow-up period from 1992 to 2002.Main outcome measures: Baseline levels of Dlco and change in levels over time.Results: 2980 Dlco measurements were done on 934 people (of whom 818 were men and 724 were workers) who underwent a median of 2 (range, 1–17) measurements during the follow-up period. Radiographic asbestosis at baseline and asbestos exposure at a younger age were associated with lower Dlco values. The average rate of decline in Dlco was 0.33 (95% CI, 0.31–0.35) units per year, plus an additional decrement of 0.22 (95% CI, 0.12–0.32) units per year if the participant had radiographic asbestosis at the beginning of the follow-up period. Compared with never-smokers, current smokers and ex-smokers had lower Dlco at baseline, but smoking status did not affect the change in Dlco during the follow-up period.Conclusions: Our results confirm a continuous deleterious effect of crocidolite on Dlco, especially on people with asbestosis. Smoking was associated with lower Dlco levels, but was not a significant predictor of rate of change in Dlco. Smoking status did not affect the relationships between crocidolite exposure and the level or rate of change of Dlco in this population.

Helman S Alfonso PhD · Lin Fritschi PhD · Nicholas H de Klerk PhD · Nola Olsen MSc · Jan Sleith MSc · Arthur (Bill) W Musk PhD, FRACP

To the Editor: Osteonecrosis of the jaw, recently reported in patients treated with bisphosphonates, may be analogous to the historic occupational disease “phossy jaw”.1,2 Phossy jaw was osteonecrosis of the jaw caused by exposure to white phosphorus during the manufacture of matches. “Lucifer” strike-anywhere matches were first produced in 1833. They were made by dipping the match ends into a mixture containing white phosphorus.3 Workers were exposed to fumes from the white phosphorus during mixing and spreading of the dip material, and dipping, drying and boxing of the matches.3,4 The first case series, comprising 22 cases, was reported in Vienna in 1845.5 About 11% of those exposed developed the disease.5 The average period from first exposure to diagnosis was 5 years.4,5 Occasionally, this period was as short as a few months.5 The mandible and maxilla could be affected, the mandible in 60% of cases (Box).3 Dental decay was considered a prerequisite, and preventive measures included dental surveillance and treatment within the factories.4 In that pre-antibiotic era, phossy jaw was fatal in about 20% of cases, usually because of septicaemia or meningitis.5 Donald Hunter, British doyen of occupational medicine, commented: “It was the most distressing of all the occupational diseases because it was very painful and was accompanied by a foul fetid discharge that made its victims almost unendurable to others. It was obstinate and chronic, the treatment was agonising and the final result was a distressing disfigurement. It was this disfiguring effect plain to every observer that made phosphorus poisoning so notorious and led to determined efforts for its abolition in every civilised land.”5 In 1906, several European countries banned the manufacture and importation of white phosphorus matches at the Berne Convention.4,5 A safe substitute, sesquisulfide, had been discovered by a French chemist and successfully used for manufacture of strike-anywhere matches in 1898.4,6 In the United States, John Andrews published a report in 1910 of 150 cases of phossy jaw from 15 of 16 match factories then in operation.4,6 The Diamond Match Company, which held the American patent rights for sesquisulfide, waived their rights, thereby allowing the entire US match industry to use this alternative.6 Congress then passed the Esch law, which imposed a prohibitive tax on white phosphorus matches and banned their import and export.4,6 Eventually safety matches were developed that used amorphous red phosphorus, which did not have the toxic properties of white phosphorus.5 Phosphorus necrosis of the jaw A Deformity resulting from excision of entire lower jaw in a case of phosphorus necrosis. (Case of Dr John P. Andrews, The Occupational Diseases, W Gilman Thompson, D Appleton & Co, New York, 1914). B Phosphorus necrosis of entire lower jaw excised by Mr McCarthy in 1884 (London Hospital Medical College Museum).

A Michael Donoghue

Accidents, such as the Exxon Valdez grounding, show how long work hours and fatigue can affect health and performance — pharmacological, behavioural, technological and legal countermeasures are available Thanks to Edison and other 19th century inventors, we now live in a 24/7 society. Electric lighting keeps factories, supermarkets and airports operating around the clock. Planes fly across multiple time zones. Trucks are driven all night. Health care delivery is a 24-hour business. The price we pay is that lack of sleep and circadian disruption are contributing to work, parenting, social and family pressures, sleep and other medical disorders, and voluntary sleep curtailment. The second annual Sleep Loss Symposium, held in Sydney on 17 November 2004, was organised by the Woolcock Institute of Medical Research, University of Sydney. The symposium focused on the risks associated with working and sleeping around the clock, with presentations from internationally recognised experts from the United States, Sweden and Australia. Health effectsTorbjörn Åkerstedt (Professor of Behavioral Physiology, Karolinska Institute, Stockholm) reviewed evidence in shiftworkers of the increased risk of cardiovascular disease (50% higher incidence of coronary heart disease and increased risk of myocardial infarction), gastrointestinal complaints (50% greater risk of developing peptic ulcers) and breast cancer.1,2 He highlighted recent studies showing that shortened sleep leads to reduced insulin responses to high glucose levels, decreased leptin and increased ghrelin levels, increased triglyceride levels, higher cortisol levels, reduced thyroid axis activity and altered timing of melatonin secretion. The term “shift work sleep disorder” is used to describe insomnia or excessive sleepiness in relation to work schedules that occur during the habitual sleep phase. Shiftworkers have higher risk of peptic ulcer, fatigue-related accidents and depression than those without the disorder. Åkerstedt’s work has recently focused on an increasingly common result of sleep disturbance and chronic exposure to stress —“burnout” — a major burden on the Swedish social security system and common in health care workers. The clinical symptoms of burnout include overpowering fatigue with a lack of restitution from sleep, impairment of memory function, depressive symptoms, poor work performance and lack of empathy; it is distinct from chronic fatigue syndrome. Åkerstedt highlighted the impact of disturbed sleep in more severe cases of burnout, and described positive responses to individual sessions of cognitive behaviour therapy during about a 12-month period. Neurobehavioural effectsNaomi Rogers (Senior Research Fellow, Woolcock Institute, Sydney) presented data illustrating the effects of chronic sleep loss with and without circadian disruption. People with sleep restricted to 3–7 hours in each 24 hours for up to 2 weeks had performance decrements comparable to those of people kept awake continuously for 3 days and nights. Importantly, individuals fail to recognise their level of impairment, highlighting the ineffectiveness of self-monitoring sleepiness and accident risk. Many speakers highlighted the importance of individual differences in susceptibility to sleep loss, with some individuals being particularly sensitive to sleep loss, while others remain relatively resistant.3 Evidence for individual differences in tolerance to shift work, ability to sleep and subsequent sleepiness were also described by Åkerstedt. David Dinges (Professor of Psychology in Psychiatry, University of Pennsylvania) gave examples of real-world effects of sleep loss, including the grounding of the Exxon Valdez on Bligh Reef in Alaska and air crashes (eg, American Airlines crash in Little Rock, Arkanas in 1999). The Exxon Valdez grounding on Bligh Reef just after midnight on 24 March 1989 was found to be directly contributed to by fatigue due to sleep loss. The captain, first mate and second mate had all been awake and working excessive hours loading the vessel and had gone below deck to sleep. The third mate was also sleep-deprived and in violation of the federal statute governing hours of duty in ship mates, but was left to guide the vessel out of Prince William Sound. On leaving the Sound, the third mate failed to correctly manoeuvre the vessel, and it ran aground. As a result of this accident, eight cargo tanks were ruptured and about 250 000 barrels of crude oil emptied into the ocean, causing a serious environmental catastrophe. The Exxon company was ordered to pay $US5.25 billion in damages — a decision it is still appealing. In June 1999, an American Airlines flight (AA1420) from Dallas to Little Rock, Arkansas, overran the end of the runway and crashed into lighting towers, killing 11 (including the captain). At the time of the crash, the captain had been working for at least 16 consecutive hours, and was attempting to land the plane at a time that was 2 hours after his normal bedtime. As well, in the United States, the National Transportation Safety Board (NTSB) estimates that at least 100 000 crashes, 71 000 injuries and 1500 deaths in motor vehicle accidents are a result of the driver falling asleep. Serious accidents resulting from fatigue and sleep loss are not restricted to the transportation area. Dinges also presented recently published data about serious medical errors in hospitals. In one report, it was found that when nurses worked more than 12.5 hours in one shift (which was the case in nearly 40% of their shifts) the chance of a near error was nearly double, and there was a threefold greater incidence of there being one or more serious errors during that shift.4 A recent study of sleep and errors among first-year and second-year medical residents reported that 66% of residents slept for an average of 6 hours or less per night, and 22% of residents slept for an average of 5 hours or less per night. In those averaging 5 hours or less of sleep, there was an increased likelihood of serious accidents or injury, conflicts with other professional staff members, use of medications to maintain wakefulness, working in an impaired condition, significant medical errors, and being named in a malpractice suit.5 Reducing the work hours of intensive care unit residents from an average 85 hours to 65 hours per week resulted in increased sleep duration and a reduction in errors and performance failures.6,7 On 85-hour work weeks, residents had 50% more attentional lapses during the day and more than twice the attentional lapses at night compared with the 65-hour work week schedule. In addition, during the 85-hour work week, residents made 35.9% more serious medical errors, including 56.6% more non-intercepted serious medical errors, 20.8% more serious medication errors and 5.6 times more serious diagnostic errors. CountermeasuresDinges described the use of various countermeasures including pharmacological, behavioural and technological. He spoke about the need to reduce the use of illegal and dangerous pharmacological wake-promoting substances (such as amphetamines), and discussed safer alternatives (such as caffeine and modafinil), and behavioural countermeasures such as naps. Technological countermeasures, such as fitness-for-duty devices and automated fatigue-detection devices (eg, those that monitor the rate and number of eye closures), were reviewed. However, to date there is no validated and accurate device for predicting when someone is likely to fall asleep. Dinges also provided a critique on one of the controversial areas in sleep and circadian research, as industries try to manage their fatigue-related problems — biomathematical models to predict fatigue and performance. He discussed the currently available models (widely used in Australian rail and other transport industries) that were recently objectively tested using a variety of sleep loss and circadian disruption scenarios, with the results published in a special edition of the journal Aviation, Space and Environmental Medicine.8 While all models were able to accurately predict fatigue during total sleep deprivation, none could accurately predict fatigue and performance during different chronic sleep restriction or circadian disruption scenarios. This presentation highlighted the need to validate these models before they are ready to be used in the real world, despite the fact that some models have been adopted into industry settings already. MedicolegalRon Grunstein (Clinical Associate Professor, Woolcock Institute, Sydney) provided an overview of the current medicolegal situation when an accident or injury is related to fatigue induced by sleep loss and long work hours. Examples included the Selby train crash in the United Kingdom, in which the driver of a motor vehicle caused two trains to crash, killing 10 people and injuring more than 70 others. The driver had not slept the previous night and was sentenced to 5 years in prison. In a recent case in Australia, it was deemed that a commercial truck may be considered a part of the work place, and an employer was held liable for the death of the driver, who had not slept for 2 days before the crash because of work demands. In another case, a medical officer at a Queensland hospital made a diagnostic error resulting in the death of a young patient; fatigue due to extended work hours and lack of sleep was deemed to be the underlying cause of his misdiagnosis. The doctor’s work hours were restricted by the Medical Board, and professional bodies called on Queensland Health to change its work practices. Grunstein highlighted how occupational health laws and work hours may potentially affect hospital administrators and supervising consultants, who may be liable for fatigue-related errors by junior doctors working extended hours under their supervision. Panel discussionThe symposium concluded with a wide-ranging, interactive panel discussion with all the speakers. Many delegates expressed frustration at the lack of action in some industries, where work hours and excessive shiftwork place not only individuals, but large sections of the community, in danger. Some panelists identified specific areas for attention by occupational health practitioners, including screening for sleep disorders and ensuring that work hours were a health, and not just an industrial, issue. The conclusion was that 24/7 operations were here to stay — health researchers will need to develop ways to maximise the health and safety of workers, patients and the community at large.

Naomi L Rogers BSc, PhD · Ronald R Grunstein MD, PhD, FRACP

Sharps injuries experienced by surgeons are common, but are under-recognised and under-reported. The overall risks of transmission of blood-borne viruses to surgeons are low, with hepatitis C posing the greatest transmission risk. Recent trials show that early treatment of acute hepatitis C results in a cure rate approaching 100%. Surgeons and theatre staff should be encouraged to report and follow up sharps injuries to allow early detection and treatment. Additionally, because exposures to blood-borne viruses may be unrecognised, surgeons should have regular tests for blood-borne viruses. There should be no restriction of practice in the “window period” between potential exposure and obtaining results of testing, because of the overall low risk of transmission.

Katrina J R Watson MB BS, FRACP, MPH

Studies of doctors’ health have emphasised psychological health, and limited data have been collected on their physical health status. Doctors often fail to follow current preventive health guidelines for their physical health. About half of doctors do not have an established relationship with an independent general practitioner. This would enhance their health and provide a means of ready access to the healthcare system should a problem arise.

Margaret P Kay FRACGP, DipRACOG · Geoffrey K Mitchell MB BS, FRACGP · Christopher B Del Mar MD, FRACGP, FAFPHM

Arc welding produces the full spectrum of ultraviolet radiation (UVR). It is possible that welders are at greater risk of developing skin cancer than the general population, but there is a dearth of well designed studies in this area. The only major study of the relationship between arc welding and skin cancer risk did not reveal an increased incidence of skin cancer in welders. As the welders examined were all well protected and the length-of-exposure period was limited, the findings cannot be generalised to all welders. Studies have demonstrated that welding increases the risk of ocular melanoma. Just as we urge the public to protect themselves from UVR, we need to consider similar advice for arc welders.

Anthony J Dixon FACRRM · Brian F Dixon PhD

Constructing RSI: Belief and desire. Yolande Lucire. Sydney: UNSW Press, 2003 (xvi + 216 pp). ISBN 0 86840 778 X. It is with some interest that this reviewer, a clinical and investigative rheumatologist who is too young to have experienced the height of the repetitive strain injury (RSI) epidemic, finds himself being asked by the Medical Journal of Australia to report on independent medical examiner and forensic psychiatrist Yolande Lucire’s popularisation of her 1996 PhD thesis. Dr Lucire was a significant critic during the 1980s epidemic and still believes that the Medical Journal of Australia should have withdrawn several of the articles it published, and through which it irresponsibly contributed to the epidemic. It is clear that attitudes remain acrimonious and polarised on these matters. Dr Lucire continues in her view, even in the “endemic” period of recent years, that RSI is entirely a psychogenic disorder due to somatisation of psychosocial distress. As evidence, she relates the results of her PhD. This was a retrospective case study review of 100 (out of 319) randomly selected RSI patients who had been referred to her for an opinion between 1984 and 1991. She used census statistics for controls, and found that virtually all the patients had one or more personal problems or disruptive life events close to the time of seeking compensation. She also impressively reviews the historical forces of the time, highlighting the lack of correlation between workload and symptoms, and the persistent absence of objective abnormalities. Hers may have indeed been the most robust investigation of the RSI phenomenon possible for the epidemic, but it is tragic that no serious follow-up study of RSI sufferers has ever been performed. Moreover, a diligent Medline search will reveal more recent contrary epidemiological data and growing evidence for peripheral and central neural changes, at least some of which might not be reversible. The jury remains out as to whether RSI is just somatisation. Richard A KwiatekRheumatologist Queen Elizabeth HospitalAdelaide, SA

Richard A Kwiatek

Andie S Lee,* John R Dyer† * Registrar, † Senior Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. John.dyerATfmc.sa.gov.au A 79-year-old man presented with 5 days of right-leg pain, high fever, severe headache and deteriorating conscious state. He was previously fit and healthy and took no medications. The patient appeared unwell, had a temperature of 39.5°C, moderate irritability and depressed conscious state. There was marked neck stiffness and his left wrist and right knee joints appeared swollen and inflamed. There was a cardiac systolic murmur, but no stigmata of bacterial endocarditis. Aspirates of the left wrist and right knee yielded purulent fluid containing numerous gram-positive cocci. The patient was admitted to the intensive care unit and treated with high dose benzylpenicillin plus vancomycin. A cerebral computed tomography scan was normal; lumbar puncture was not performed. The affected joints were washed out within 24 hours. All cultures of blood and synovial fluid yielded a Lancefield Group C β-haemolytic streptococcus, identified further using the ID 32 Strep strip (BioMerieux, Marcy l’Etoile, France) as Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) based on its ability to ferment sorbitol and not trehalose. This isolate was shown to be sensitive to penicillin (minimum inhibitory concentration, < 0.1 mg/L). Intravenous penicillin therapy was continued. Transoesophageal echocardiography showed echodensities close to the aortic valve which suggested vegetations. The patient’s condition improved steadily, and he ultimately received intravenous antibiotics for 6 weeks. Further history revealed that the patient collected fresh horse manure for his garden daily from a local paddock. He reported no direct contact with animals or ingestion of unpasteurised dairy products. S. zooepidemicus could not be cultured from a single specimen of horse manure collected from the paddock, and it was not possible to collect clinical specimens directly from any of the horses that used the paddock. Human infection with S. zooepidemicus can usually be traced to an animal source.1 Outbreaks associated with ingestion of unpasteurised milk and cheese have also been described.2,3 Likely entry routes include the respiratory or gastrointestinal tract and skin.1 Severe sequelae of S. zooepidemicus infection include endovascular infection, meningitis, septic arthritis, and epidemic post-infectious glomerulonephritis. Our patient’s clinical picture indicated multifocal sepsis, with polyarthritis, endocarditis, and probable meningitis. In a recently reported case of S. zooepidemicus meningitis, pulsed-field gel electrophoresis showed molecular identity between patient isolates and a throat swab isolate from a horse with which the patient had been in close contact.4 Our patient was most likely infected via the respiratory or cutaneous routes, or by ingestion after contact with respiratory secretions of horses deposited in the environment. Exposures in the garden can lead to a variety of severe infections.5 This is the first reported case where S. zooepidemicus infection appears to have been acquired through gardening. Severe disease with this organism can be a particular hazard in elderly gardeners with comorbid conditions.1

Andie S Lee · John R Dyer

Targets for the prevalence of smoking in 2010 are embarrassingly modest The Risk Factor Prevalence Survey conducted by the National Heart Foundation in Australian capital cities in 1989 revealed that, for the first time ever, there were more ex-smokers than current smokers among Australian adults of working age. This major landmark in public health went unnoticed, and, well over a decade later, has still not been achieved in Britain. How can it be that the cradle of epidemiology and the home of the British Doctors Study (and all that it has taught us about the harm done by smoking) is itself doing so poorly in tobacco control? The UK has undeniably made a huge contribution to the science behind effective tobacco control When a survey of over 9000 Londoners in 2002 revealed that 29% were smokers and 27% were ex-smokers, it comes as no surprise that one of the first comments regularly made by visitors from “Down Under” concerns the high ambient levels of tobacco smoke — from the halls of Heathrow onwards. Smoke-free policies are in place on London buses and the Underground, but there are still some smoking carriages on long-distance trains, and many shopping centres permit smoking. Waiting in a crowd for a commuter train at peak-hour is decidedly unpleasant for non-smokers, while pubs and restaurants can comply fully with the “Public Places Charter on Smoking” simply by displaying a sign saying “Smoking permitted throughout”. Despite the recommendation of the International Union Against Cancer (UICC) that tobacco control should combine legislation, education and cessation activities, the Blair Government has until very recently put all of its eggs in the “cessation” basket. Having nicotine replacement therapies and bupropion available on the National Health Service is undeniably important in removing economic barriers to effective aids to quitting smoking, and supporting this with publicly funded smoking-cessation clinics is unprecedented. However, the “ring-fence” around funding for these clinics is not necessarily permanent, and the overall approach remains decidedly unbalanced when judged against the UICC’s recommendation. The UK government has conspicuously failed to take a strong lead, either nationally or within Europe, in adopting the regulatory strategies on smoking and the tobacco industry that are now taken for granted in Australia and New Zealand. UK newspapers and billboards continued to carry advertisements for cigarettes until February 2003, a decade after they disappeared in Australia. Sophisticated, community-wide health promotion using prime-time electronic media, now an export industry for Australia, remains virtually unknown as a tobacco-control activity here, with embryonic campaigns only just beginning to emerge. Evidence that the major tobacco manufacturers are well aware of diversion of significant fractions of their outputs into smuggling operations has not prompted effective official action. Consequently, tax has not been paid on perhaps a third of cigarettes sold in London, significantly undermining the use of price as a disincentive to smoking. The minimum age at which children can purchase cigarettes is stuck at 16 years, and packets of 10, known to appeal especially to school-age smokers because of their low price and greater ease of concealment, are still on the market. Warnings on cigarette packets have been enlarged in size and range, but this is a small advance in an environment that, by standards now well established in Australia, remains otherwise remarkably permissive of smoking. The UK has undeniably made a huge contribution to the science behind effective tobacco control and, beginning with the first report on smoking from the Royal College of Physicians in 1962, has been a pioneer in collating and publishing authoritative, independent expert reviews of the accumulating epidemiological and clinical data as a stimulus to official public health action. It also gave the world the prototypic advocacy organisation Action on Smoking and Health (ASH). Seen through “colonial” eyes, however, it doesn’t have the teeth that have regularly been bared by its Australian counterpart (ASH Australia), the Cancer Council of Victoria, or the Australian Council on Smoking and Health. Meanwhile, the UK Department of Health apparently feels no pressing need to adopt international best practice in tobacco control. A further consequence of the dearth of effective advocacy is the tolerant attitude of the media, up to and including the BBC. For example, the opinions of vested interests that the wider introduction of smoke-free policies would bring an end to commercial and civilised life as we know it are reported uncritically, and seemingly without any effort to find examples that disprove such assertions. Radio audiences are much more likely to be treated to an aside that smoke-free policies in bars in France have been an abject failure than to one that reminds listeners that active smoking accounts for 30% of avoidable cancers, or that passive smoking measurably increases the risk of lung cancer and heart attack, for example among non-smoking staff in bars. The coverage of smoking issues is truly meagre — it takes 4444 deaths from smoking to generate a newspaper story, but only 0.375 deaths from measles, 1.5 from variant Creutzfeldt–Jakob disease, and 22.5 from HIV/AIDS.1 It feels like a time-warp — the British media now are where the Australian media were a generation ago — which is what the overall figures for the prevalence of smoking show, too. But, it also demonstrates an interesting point — the apparent gullibility of the media here is not so much a case of “who pays the piper, calls the tune” (since advertisements for cigarettes have disappeared from newspapers), but the failure of government and health interests to generate and maintain vigorous discussion about the hazards of smoking, active and passive. While no less an expert than Professor Sir Richard Peto argues, with good foundation, that smoking-cessation activities will save lives much faster than waiting to create a whole new generation of non-smokers, this view has allowed the UK government to avoid facing up to the need for a comprehensive tobacco control policy. Its targets for the prevalence of smoking in 2010 are embarrassingly modest. They concentrate on short-term indicators for smoking-cessation services without a population focus, and these are likely to be reached simply as an extension of the background downwards trend of an absolute reduction of around 0.25% per annum. Meanwhile, Britons continue to die from smoking at the rate of one every 5 minutes. Roll on 1989!

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

Stacey L Emmett,* Adam J O’Brien,† Joseph E Ibrahim† * Research Officer, † Consultant Physician, Clinical Liaison Service, Victorian Institute of Forensic Medicine and the State Coroner’s Office, 57-83 Kavanagh St, Southbank, VIC 3006. staceyeATvifm.org To the Editor: Root-cause analysis is an established, retrospective, structured investigative technique1 that was first introduced into wide clinical practice in public hospitals in Victoria in 2001.2 It is usually reserved for investigating infrequent and significant adverse events and explores the nature and causes of organisational systems failures.1 It is important for all healthcare professionals to understand this technique, as it is used increasingly by healthcare organisations. Cooper and Blamey’s Lesson from Practice described the outcome of an investigation using root-cause analysis of an occupational exposure to HIV from a needlestick injury.3 We commend the analyses that identified multiple failures of the system for reporting and responding to occupational exposures to hazardous material. The practice changes that ensued at Southern Health demonstrate the value of root-cause analysis. However, more information and analysis is required about the mistaken use of the stored serum samples. As the authors explain, the initial information was that the source patient tested negative for HIV antibodies. Some time later, it was discovered that the specimen tested was not from the source patient but from a patient of the same surname in the same ward. This caused a 3-day delay between the initial test and the Infectious Diseases Unit being notified that the source patient had twice tested positive for HIV antibodies. We contend this is an important and common systems failure that usually makes headlines of the form “Wrong site, wrong procedure, wrong person surgery”. The Joint Commission on Accreditation of Healthcare Organisations developed a universal protocol with the intention of highlighting the causative systems failures and minimising the frequency of recurrences of wrong-site surgery.4 The information given by Cooper and Blamey does not clearly explain why (ie, the root cause) the incorrect specimen was tested initially. The pathology department’s review identified the presence of unacceptable “informal norms” in the practice of blood collection and labelling. The suggested remedy that “all serum should be collected with strict adherence to blood collection and labelling protocols” is unlikely to prevent a recurrence. Exhortation to do better rarely solves the underlying problem. It is therefore important to understand why health professionals violate procedures and protocols.5 The experiences of Cooper and Blamey demonstrate that some of the limitations and benefits of root-cause analysis depend on the depth of the investigation. The early and unquestioning acceptance that strict adherence to an existing protocol will prevent another “wrong person” error is not convincing. This contrasts with the well-conducted inquiry and subsequent management of occupational exposure to needlestick injuries.

Stacey L Emmett · Adam J O’Brien · Joseph E Ibrahim