We need more than just new antibiotics to fight superbugs

By 2050, drug resistant diseases could be killing more people than cancer, an extra 10m deaths per year. They could also cause a loss to the global output of US$100 trillion dollars – equivalent to a sum greater than the size of the current global economy.

A potential future catastrophe in healthcare, where even routine surgical procedures and easily treated infections become significantly more hazardous, is commonly attributed to the appearance of new strains of antibiotic-resistant bacteria. It is often argued that the answer is more funding for the development of new antibiotics.

What is less commonly recognised is the possibility of a future catastrophe in food production. Modern practice means the extensive use of antibiotics in the farming of fish, poultry and meat. In the US, 70% of all antibiotics enter the food chain.

An arms race against natural selection

Antibiotics are effective against bacteria, just one class of microbe, while the term antimicrobial resistance (AMR) covers the development of resistance in a wider group of bacteria, fungi, viruses and protozoa (such as malaria) to the various measures used to combat them.

The development of new antimicrobial drugs is an arms race against natural selection that cannot be won: when antimicrobials (not just antibiotics) are applied, microbes of all types (not just bacteria) have proven to be adept at developing resistant strains from the survivors. If the drug kills 99.99% of a population of microbes, it is the genetic makeup of the survivors that goes forward to the next generation. To mitigate against potential catastrophes in healthcare and food production, measures over and above the development of new antibiotics have to be undertaken.

These include two key elements. One is infection prevention. If a dangerous microbe never enters the body, no antimicrobial is required. The development of new microbe-resistant materials and products, as well as the development of minimally invasive procedures in hospitals and clinics, improvements in waste disposal and a revolution in cleaning, are some of the measures already being researched.

However, this does not just involve scientists and clinicians. To take just one example, despite all efforts, many in the UK and the US persist in washing their hands lamentably short of the 20 seconds in warm soapy water that experts recommend. We need better leadership to rectify this by implementing advice from those who understand behaviours in workplaces and homes, and we need to invest in science and engineering that makes proper handwashing easy for the public to adopt.

The second element to reducing the use of antimicrobials is the removal of environments that encourage resistant strains to develop, for example in the body of the patient or farm animal, with simple measures such as ensuring a full prescription is taken rather than stopping early when symptoms disappear – a practice that encourages the survival of resistant microbes. Other measures include the invention of sensors to detect infection early and identify the specific microbe present, so that targeted antimicrobials can be used in place of broad-spectrum agents, one example of responsible antimicrobial stewardship.

We must understand how society, climate, land and water resources interact to alter the risk of microbes moving from one host to another. It is a realistic scenario that a resistant strain in a UK hospital might have emerged because of livestock practices half way across the world, where increased flooding, cultural practices, conflict, the movement of money and populations, and the accepted patterns of behaviour, create an environment very different to our own. Conversely, we could find that resistant strains in far-off countries might have their roots in the use of antibiotics in intensive farming in the UK.

The way to do it

The figure below illustrates how the problem extends geographically, and across the workforce and society. The patient in the hospital bed has a reduced risk of infection if the surgeons use a minimally invasive procedure illuminated with lights that deter microbes, and if the surgical instruments, the trays, the rooms, and the tubes that enter the patient (the catheters, nasal drips, endoscopes and so on) are made of materials on which microbes do not readily adhere, and are properly and promptly cleaned (weekend closure of sterile services departments might appear to save costs in the short term but must avoid allowing Friday’s contamination to dry on before washing on Monday).

The anti-resistance movement. University of Southampton., Author provided

For the patient shown in the figure, wounds can be cleaned and dressed with materials that deter microbes. If infection does occur, it can be promptly targeted with a specific (as opposed to broadspectrum) antimicrobial if it is detected early and rapidly identified (with instruments that feed into a communications hub that alerts the doctor’s phone, which is already becoming equipped with apps containing guidance informed by local susceptibility data).

Treatment of the waste from this patient (solid, fluids and materials contaminated with them) alters the possibility of AMR spreading. Achieving the right hospital environment requires far more than the development of new drugs, and their use by healthcare workers. It goes into the management and maintenance of the hospital, and in to the practices of the people who implement these. New technologies and practices must be designed to ensure that their use will be adopted, which requires understanding design and understanding people.

Indeed, the world outside of the hospital (in the lower half of the figure above) provides an enormous reservoir in which AMR can develop. Analysis and, if necessary, change of our processes and technologies are required in water and waste treatment, and in the production, transport, packaging and retail practices in the food industry.

In many parts of the world, climate change and flooding, war, corruption, politics, received wisdom, traditions and religious practices, and the supply of fuel and money, play a far greater role in food, water, waste treatment, healthcare and the transport of microbes from one host to another, than do the outputs of the drug companies.

The twin potential catastrophes are global, and so are the causes. The solutions lie with scientists and engineers to develop new technologies and embed new practices in the public and workforce; they lie with farmers, plumbers, office workers, water and sewage workers, medical practitioners, food retailers, innovators in business … indeed most of us. And they lie with those who are responsible for shaping behaviour across the world – not just the pharmaceutical companies.

Tim Leighton is Professor of Ultrasonics and Underwater Acoustics at University of Southampton.

This article was originally published on The Conversation.
Read the original article.

[Comment] The sustainable development agenda and the end of AIDS

2015 marks a pivotal turn in development debate and practice. In September, UN member states are expected to endorse a bold agenda that will guide social, economic, and environmental action over the next 15 years. The agenda, built around 17 Sustainable Development Goals (SDGs), signals a transformational shift towards society-wide, people-centred approaches. The universality and breadth of the sustainable development agenda will demand an overhaul in how countries, sectors, and issue-specific groups work together.

Indigenous Health Services – DHS Education Resources

The Department of Human Services has five new online guides, tailored for health professionals to better manage and improve health outcomes for Aboriginal and Torres Strait Islander patients, which complement its eLearning programme, Indigenous Health Services.

The five education guides include:

Aboriginal and Torres Strait Islander health assessments and follow-up services
Chronic Disease Management services to support Indigenous health
Closing the Gap – PBS Co-payment Measure
Mental health services – supporting Indigenous health
Telehealth – supporting Indigenous health

The guides and eLearning programme are recommended for general practitioners and the Aboriginal and Torres Strait Islander Community Controlled health sector, and are available on the Department of Human Services Indigenous health education page.

Other DHS online educational services to assist health professionals in understanding Medicare and the Pharmaceutical Benefits Scheme can be found here.

This was originally published in GP Network News

Medical Devices Safety Update, Volume 3, Number 4, July 2015

In this issue: Action after registry data analysis; Environmental extremes; Button battery dangers; Infant sleep positioners reviewed

Tackling climate biggest ‘global health opportunity in 100 years’

The effects of climate change are already being felt and it presents a “potentially catastrophic” threat to human health unless urgent action is taken to rein in carbon dioxide emissions, according to a report by the respected Lancet Commission on Health and Climate Change.

In findings that reinforce AMA warnings about the need for governments to prepare for the inevitable health effects of climate change and extreme weather events, the Lancet Commission said that the world was at risk of undoing half a century of gains in global health and development.

The Commission’s report, Health and climate change: policy responses to protect public health, warned that unless there was a change of course, the world was on track to exceed 2900 billion tonnes of carbon dioxide emissions within the next 15 to 30 years, forcing global average temperatures up by between 2.6 and 4.8 degrees Celsius by the end of the century.

But the Commission said that, rather than being viewed as a burden, addressing climate change should be seen as “the greatest global health opportunity of this century”.

“Many mitigation and adaptation responses to climate change are ‘no regret’ options which lead to direct reductions in the burden of ill health, enhance community resilience, alleviate poverty, and address global inequity,” the report said.

AMA President Professor Brian Owler said the Lancet report, prepared by a collaboration of European and Chinese climate scientists, geographers, social and environmental scientists, engineers, health professionals, energy policy experts and political scientists, provided further evidence on the need for global action to combat and mitigate the effects of climate change on human health.

“It is the AMA’s view that climate change is a significant worldwide threat to human health that requires urgent action, and we recognise that human activity has contributed to climate change,” Professor Owler said. “There is considerable evidence to encourage governments around the world to plan for the major impacts of climate change, which include extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.”

Earlier this year, Professor Owler helped launch an Australian Academy of Science report, Climate change challenges to health: Risks and opportunities, that detailed the likely health effects of climate change, including increasingly deadly heatwaves, the spread of food and water borne illnesses and diseases like malaria, and the death and damage caused by more frequent and extreme storms, droughts and floods.

Governments around the world are preparing to attend the United Nations’ Paris Climate Change Conference in November, and the AMA President said there was an urgent need for action.

“The evidence is clear – we cannot sit back and do nothing,” Professor Owler said. “Governments must prepare for the inevitable health and social effects of climate change and extreme weather events.”

The Lancet Commission has called for the framework for an international carbon pricing mechanism to be established in the next five years, along with a rapid expansion in the use of renewables and the speedy phase out of coal-fired power.

In a rallying call for the medical community, the Commission said that until now health effects had been largely ignored in the international debate over climate change, but doctors needed to help lead a change in focus that would bring the consequences of rising global temperatures into sharp relief.

“Health professionals have worked to protect against health threats such as tobacco, HIV/AIDS and polio, and have often confronted powerful entrenched interests in doing so,” it said. “Likewise, they must be leaders in responding to the health threat of climate change. A public health perspective has the potential to unite all actors behind a common cause – the health and wellbeing of our families, communities and countries.”

Professor Owler said the Abbott Government should use the Lancet Commission report and the Australian Academy of Science study as key references in the development of the action plan it takes to the Paris Climate Change Conference.

Adrian Rollins

MERS: worst may be past

The World Health Organisation has indicated that the Middle East Respiratory Syndrome (MERS) outbreak that has so far claimed 24 lives in South Korea may have passed its peak.

While warning that it was critical health authorities closely monitor the situation, the WHO’s Emergency Committee has nonetheless declared that South Korean efforts to track and quarantine infected people had “coincided with a decline in the incidence of cases”.

Since the first case was reported in South Korea last month, 166 people in the North Asian country are confirmed to have been infected with MERS, including 30 currently receiving treatment, while a further 5930 are in quarantine at home or in medical facilities.

Fears that the disease might spread further in the region were fuelled earlier this week when Thai officials reported a visiting businessman from Oman had fallen ill with the disease, and 59 people who had been in contact with have been placed in quarantine.

But the WHO praised South Korean health authorities for rapidly alerting their Chinese counterparts about an infected traveller, who was quickly located and isolated.

The World Health Organisation’s Emergency Committee, which met earlier this week to discuss the outbreak, said it was not yet serious enough to warrant the declaration of a public health emergency, and advised that travel restrictions and airport screening were not necessary.

Nonetheless, the Committee warned the outbreak was “a wake-up call” for governments about the speed with which serious infectious diseases could spread “in a highly mobile world”.

“All countries should always be prepared for the unanticipated possibility of outbreaks of this and other serious infectious diseases,” it said. “The situation highlights the need to strengthen collaboration between health and other key sectors, such as aviation, and to enhance communication processes.”

No cases have been reported in Australia, and a Federal Health Department spokeswoman said the risk of MERS arriving in Australia was considered to be low, at least for the time being.

But health and border protection authorities are on alert for the disease, and the Federal Government is planning to warn Australians travelling overseas, particularly to the Middle East as part of the Hajj pilgrimage, about MERS and what precautions they need to take to minimise the chances of infection.

Though Korean authorities have been praised for the strength of recent actions to control the spread of MERS, serious shortcomings in their initial response have been blamed for helping the outbreak gain momentum.

The WHO Emergency Committee detailed a number of factors that helped the disease spread, including ignorance of MERS among health workers and the broader public; “suboptimal” infection prevention and control measures in hospitals; keeping patients infected with MERS in crowded emergency departments and wards for extended periods; the behaviour of patients in going to several different doctors and hospitals for treatment; and the custom of family and friends staying with their infected loved ones in hospital.

“There are still many gaps in knowledge regarding the transmission of this virus between people, including the potential role of environmental contamination, poor ventilation and other factors,” the Committee said, though adding that there was no evidence of sustained transmission in the community.

Adrian Rollins

Smoke-free homes and workplaces of a national sample of Aboriginal and Torres Strait Islander people

Second-hand smoke was estimated to cause more than 600 000 deaths globally in 2004, mainly from ischaemic heart disease, respiratory infections, asthma and lung cancer.1 Protecting people from the dangers of second-hand smoke by banning smoking in indoor and other public places is an essential element of effective tobacco control programs.2

Smoking is banned in virtually all enclosed public places in Australia.3 More than 92% of Australian smokers and ex-smokers reported that smoking was not allowed in any indoor area at their workplace in 2010–2011, slightly less than in similar surveys in the United Kingdom and Canada but more than in the United States and European and middle- and low-income countries surveyed.4 In Australia5 and all countries with available trend data, the proportion of the population living in smoke-free homes is increasing; this is not just due to falling smoking prevalence.6

Forty-two per cent of Aboriginal and Torres Strait Islander people aged 15 years or older were daily smokers in 2012–2013, 2.6 times the age-standardised prevalence among other Australians.7 This is a decrease from 45% in 2008 and 49% in 2002, a similar rate of decline as among other Australians.7 In 2008, Aboriginal and Torres Strait Islanders who smoked daily were less likely than other Australians to live in homes where no one usually smoked inside (56% v 68%).5 Aboriginal and Torres Strait Islander smokers with lower household incomes were significantly more likely to live in homes where someone usually smoked inside.5

Here, we provide the first national picture of smoking bans in the workplaces of Aboriginal and Torres Strait Islander people. We also describe whether home smoking bans were always followed and assess the associations between smoke-free workplaces and homes and quitting.

Methods

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people using a quota sampling design in the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait, and has been described elsewhere.8,9 Briefly, the 35 sites were selected based on the geographic distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or ex-smokers who had quit ≤ 12 months before, and 25 non-smokers, with equal numbers of women and men and in each of two age groups (18–34 and ≥ 35 years). In four major-city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged less than 18 years, not usual residents of the area, staff of the ACCHS, or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). There were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.8 A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed at each site.

The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.

As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), interview questions were closely based on those in other ITC Project studies, especially the Australian ITC surveys.10 We asked questions about whether smoking was allowed inside the home, and whether people smoked inside even if it was not allowed. For those with either an incomplete smoking ban or a complete ban where people still smoked inside the house, we asked if participants were uncomfortable telling elders or community leaders, other visitors or other household members to smoke outside. For participants who were employed, we asked about smoking rules in indoor areas at work. The questions used in this article are listed in Appendix 1.

Results were compared with those from the Australian ITC Project surveys conducted in September 2011 to February 2012 (Wave 8.5, n = 1504) or July 2010 to May 2011 (Wave 8, n = 1513). These surveys were completed by random digit telephone dialling or on the internet, and included those contacted for the first time and those who were recontacted after completing surveys in previous waves. Only smokers were recruited, so these samples only included smokers and ex-smokers who had quit since previous waves. Slightly different definitions of smokers between the TATS project and ITC Project surveys meant that only daily and weekly smoker categories were directly comparable. We focused our comparisons on daily smokers.

Statistical analyses

We calculated the percentages and frequencies of responses to the TATS project questions, but did not include confidence intervals for these as it is not considered statistically acceptable to estimate sampling error in non-probabilistic samples. We compared results for daily smokers with those from Australian ITC Project surveys, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

Associations between the outcome variables and sociodemographic and smoking variables were assessed using logistic regression to generate odds ratios (ORs) and P values based on Wald tests. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, using 35 site clusters, and the age–sex quotas as strata.11

Reported percentages and frequencies exclude participants who refused to answer, answered “don’t know”, or for whom the question was not applicable (eg, not employed or no indoor area at work). Less than 1% answered “don’t know” or refused to answer each of the questions analysed in this report, except for questions about being uncomfortable telling others to smoke outside, being treated unfairly, quit attempts and wanting to quit. However, even the least completely answered of these questions, about wanting to quit, had only 79 participants (4.8%) who answered “don’t know” and 11 (0.7%) who refused to answer.

Results

Smoke-free homes

More than half of smokers (56%, 908/1628) and 80% (701/876) of non-smokers reported that smoking was never allowed anywhere in their home. Non-daily smokers (69%; OR, 1.94; 95% CI, 1.45–2.58), ex-smokers (79%; OR 3.36; 95% CI, 2.50–4.51) and never-smokers (80%; OR, 3.58; 95% CI, 2.84–4.52) were significantly more likely to report such bans than were daily smokers (53%) (Box 1). A similar age–sex-standardised percentage of Australian daily smokers (53.4%) reported total home smoking bans in Wave 8.5 of the Australian ITC Project study.

Of the smokers who reported that smoking was never allowed inside, 10% (91/903) said that some people still smoked inside regardless. So, 50% (812/1623) reported an effective total ban, and 28% (450/1623) a partial ban (including a total ban that was not fully effective), while 22% (361/1623) reported that smoking was allowed anywhere inside. Of those with a partial ban, 51% (225/442) reported being uncomfortable telling elders or community leaders (190/439; 43%), visitors (154/443; 35%) or other householders (125/442; 28%) to smoke outside. Of the respondents with no ban, 59% (213/363) reported it would be possible to stop people smoking inside, but 53% of these (114/215) reported that they would have to make some exceptions.

Smokers who were significantly more likely to report an effective total home smoking ban included non-daily smokers, employed people, Torres Strait Islanders and people who were both Torres Strait Islander and Aboriginal (v Aboriginal people), people aged 18–24 years (v those aged 45 years or over), people with children in their home, those who had finished Year 12 or had post-secondary educational qualifications (v those with less than Year 12), and those who did not feel they had been treated unfairly in the past year because they were Aboriginal or Torres Strait Islander (Box 2). There was no significant association between sex, remoteness or area-level disadvantage and having an effective ban.

Smoke-free workplaces

Most employed Aboriginal and Torres Strait Islander daily smokers (406; 88%) reported that smoking was not allowed in any indoor area at work, similar to the standardised estimate in Wave 8 of the Australian ITC Project study (88.5%) (Box 1).

Remoteness and area-level disadvantage were significantly associated with non-smokers not being protected by a workplace indoor smoking ban (Box 3). Smokers working in smoke-free workplaces were more likely to have effective smoking bans at home than those in workplaces where smoking was allowed in some or all indoor areas (287/484, 59% v 22/65, 34%; OR, 2.85; 95% CI, 1.67–4.87).

Association with quit attempts and wanting to quit

Smokers who lived in homes with an effective total smoking ban were significantly more likely than other smokers to have made a quit attempt in the past year, to want to quit and (among smokers who had attempted to quit in the past 5 years) to have made a quit attempt of 1 month or longer (Box 4). In contrast, there were no such significant associations with working in a smoke-free workplace.

Discussion

Smoke-free homes

Previous research has shown that the proportion of smokers who reported living in smoke-free homes was increasing faster among Aboriginal and Torres Strait Islanders than among other Australians, but that a gap remained in 2008.5 Our study demonstrates that this gap now appears to have been closed, reflecting a significant change in behaviour by Aboriginal and Torres Strait Islander smokers.

This does not mean that there is no gap in the proportion of households that are smoke-free or in the proportion of children who live in smoke-free households. Changes to these will probably require smoking prevalence to fall further, along with more smokers choosing to smoke outside. We found that the presence of infants, children and adult non-smokers in the household was associated with having a smoke-free home, consistent with earlier ITC Project research, including Australian surveys.12 Longitudinal research in Darwin also showed that Aboriginal households implemented smoking bans after the birth of a baby.12,13 As in previous research, we found that the most disadvantaged Aboriginal and Torres Strait Islander people were the least likely to live in smoke-free homes, although this association did not hold for remoteness or area-level disadvantage.5

It is encouraging that few people reported any lapses in maintaining their home smoking bans, and more than half of those with no ban reported that a ban would be possible. People more often reported being uncomfortable telling elders or community leaders to smoke outside, rather than other visitors or householders. Local tobacco action workers could work with elders and community leaders to find respectful solutions, so that people do not feel uncomfortable about asking them not to smoke inside. Further research into the barriers to maintaining effective home smoking bans would be useful.

A literature review suggested that comprehensive national tobacco control programs to reduce smoking prevalence are the most effective in increasing the prevalence of smoke-free homes.14 Australia has boosted comprehensive national tobacco control activity in recent years, including programs specifically for Aboriginal and Torres Strait Islander peoples.15 This has been complemented by local tobacco control activity at the participating sites. Local and regional Aboriginal and Torres Strait Islander social marketing campaigns have focused on smoke-free homes (eg, “Smoking can kill those close to you” in the Northern Territory).16 However, the evidence for the impact of such campaigns on the prevalence of smoke-free homes is more modest, as is the evidence for direct counselling of families about smoke-free homes.3,14,17

Other research has demonstrated an increase in smoke-free homes after smoking bans have been implemented in public places, and we have similarly demonstrated an association between smoke-free homes and smoke-free workplaces.4 The previously demonstrated greater concern by Aboriginal people for the effects of smoking on family, especially children, rather than on their own health, further explains the rapid spread of home smoking bans.18 Introducing a home smoking ban is easier than successfully quitting, but the significant association we found between smoke-free homes and quitting suggests that smokers are not making their homes smoke-free as a substitute to quitting.

However, this optimism needs to be tempered by research that shows reported indoor home smoking bans reduce but do not eliminate children’s exposure to environmental tobacco smoke and its toxins.19,20

Smoke-free workplaces

It is good news that almost all Aboriginal and Torres Strait Islander people reported being protected by indoor smoking bans at work, as is reported by other Australians. We are not aware of comparable data to assess trends, but there has been considerable recent attention to promoting and supporting smoke-free policies at Aboriginal organisations. Improvements can still be made in the most disadvantaged and remote areas. Better monitoring and enforcement of existing indoor smoking bans, as well as their extension to outdoor public spaces (where people are close together), is a focus of the current National Tobacco Strategy.15

Association with quit attempts and wanting to quit

Our cross-sectional study is consistent with longitudinal ITC Project research, including Australian surveys, which showed that having a total indoor home smoking ban was associated with both quit intentions and making more and longer quit attempts.12 However, a cross-sectional study using earlier Australian Bureau of Statistics (ABS) Aboriginal and Torres Strait Islander survey data found only a non-significant association with quit attempts, but did find a significant association with successful past cessation.5 Making the home smoke-free might make it easier for a smoker to quit, but it is also likely that this association is in part due to smokers who are most concerned about their smoking making their homes smoke-free as part of the quitting process.

Strengths and limitations

This is a large nationally representative (albeit not random) survey of Aboriginal and Torres Strait Islander people. However, caution is needed as it relies on self-report of smoke-free homes and workplaces without biochemical verification. Due to inaccurate recall or social desirability bias, it is likely that some participants with reportedly effective total smoking bans are still being exposed to second-hand smoke. However, we think marked bias is unlikely as smoking is still very common and normalised in these communities. Our finding that 10% of smokers reported that some smoking occurred in the home despite not being allowed suggests there was minimal bias towards the most socially desirable response (complete adherence to the smoking ban).

Our questions were the same as in the ITC Project comparison survey, but they differed from those used in ABS surveys.5 The ABS asked whether any householders usually smoke inside, whereas we asked whether smoking (by anyone) was ever allowed inside, and whether people smoked in spite of bans. Therefore, our estimates for the percentage of daily smokers living in homes where smoking was either not allowed (53%) or with effective total home smoking bans (48%) were understandably lower than the 2008 ABS estimate for those living in homes where no householder usually smoked inside (56.3%; 95% CI, 52.4%–60.2%).

Analyses of longitudinal data using follow-up surveys to this baseline survey will provide more methodologically sound confirmation of likely causal directions of the observed cross-sectional associations.

In conclusion, we found that the gap has closed between the proportion of Aboriginal and Torres Strait Islander smokers and all Australian smokers who live in homes with smoking bans, and that these bans may help smokers to quit. Aboriginal and Torres Strait Islander non-smokers are also well protected from second-hand smoke at work.

1 Smoking bans in homes and workplaces*

	Australian ITC Project†	Talking About The Smokes project
	Daily smokers, % (95% CI)	Daily smokers, % (frequency)	Non-daily smokers, % (frequency)	Ex-smokers, % (frequency)	Never-smokers, % (frequency)

Home (n)	1010	1377	251	310	568
Total smoking ban	53.4% (47.7%–59.0%)	53% (735)	69% (173)	79% (246)	80% (455)
Partial smoking ban	31.0% (25.7%–36.8%)	23% (313)	18% (46)	15% (46)	14% (80)
No ban	15.7% (11.7%–20.6%)	24% (329)	13% (32)	6% (18)	5% (31)
Work (n)	604	461	89	131	284
Total indoor ban	88.5% (80.9%–93.3%)	88% (406)	89% (79)	95% (124)	93% (263)
Partial indoor ban	4.5% (2.0%–10.0%)	6% (27)	11% (10)	2% (2)	4% (11)
No ban	7.0% (3.3%–14.3%)	6% (28)	0	4% (5)	4% (10)

ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. † Australian ITC Project results are from Wave 8.5 (home), conducted September 2011 to February 2012, and Wave 8 (work), conducted July 2010 to May 2011, and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

2 Aboriginal and Torres Strait Islander smokers with effective home smoking bans,* by sociodemographic factors (n = 1643)

Characteristic	% (frequency)†	Odds ratio (95% CI)	P‡

Total	50% (812)
Age (years)
18–24	56% (193)	1.0	< 0.001
25–34	55% (242)	0.95 (0.71–1.28)
35–44	51% (199)	0.79 (0.54–1.16)
45–54	38% (102)	0.47 (0.31–0.70)
≥ 55	43% (76)	0.58 (0.39–0.86)
Sex
Female	53% (441)	1.0	0.15
Male	47% (371)	0.81 (0.61–1.08)
Number of infants in home
None	47% (670)	1.0	< 0.001
One or more	69% (139)	2.49 (1.79–3.48)
Number of children in home
None	39% (267)	1.0	< 0.001
One or more	58% (540)	2.11 (1.68–2.65)
Indigenous status
Aboriginal	49% (699)	1.0	0.04
Torres Strait Islander or both	60% (113)	1.61 (1.03–2.52)
Labour force status
Employed	56% (318)	1.0	0.02
Unemployed	47% (260)	0.69 (0.52–0.91)
Not in labour force	47% (232)	0.70 (0.53–0.94)
Highest education attained
Less than Year 12	44% (371)	1.0	< 0.001
Finished Year 12	57% (246)	1.69 (1.30–2.21)
Post-school qualification	56% (193)	1.58 (1.16–2.15)
Treated unfairly because Indigenous in past year
No	54% (369)	1.0	0.01
Yes	47% (425)	0.75 (0.60–0.93)
Smoking status
Daily smoker	48% (660)	1.0	0.003
Non-daily smoker	61% (152)	1.68 (1.20–2.34)
Remoteness
Major cities	52% (220)	1.0	0.66
Inner and outer regional	50% (412)	0.93 (0.68–1.27)
Remote and very remote	47% (180)	0.82 (0.53–1.26)
Area-level disadvantage
1st quintile (most disadvantaged)	51% (325)	1.0	0.30
2nd and 3rd quintiles	51% (348)	1.01 (0.74–1.37)
4th and 5th quintiles	45% (139)	0.78 (0.52–1.15)
Local health service has dedicated tobacco control resources
No	52% (244)	1.0	0.55
Yes	49% (568)	0.91 (0.67–1.25)

* An effective total ban is when smoking is both never allowed and never occurs. † Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. ‡ Wald test for each variable.

3 Aboriginal and Torres Strait Islander employed non-smokers with total indoor smoking bans at work, by sociodemographic factors (n = 417)

Characteristic	% (frequency)*	Odds ratio (95% CI)	P†

Total	93% (387)
Age (years)
18–24	95% (105)	1.0	0.17
25–34	89% (90)	0.47 (0.17–1.26)
35–44	96% (92)	1.31 (0.35–4.92)
45–54	96% (67)	1.28 (0.32–5.07)
≥ 55	89% (33)	0.47 (0.12–1.81)
Sex
Female	95% (204)	1.0	0.10
Male	91% (183)	0.50 (0.22–1.14)
Indigenous status
Aboriginal	94% (349)	1.0	0.43
Torres Strait Islander or both	90% (38)	0.65 (0.23–1.90)
Highest education attained
Less than Year 12	94% (103)	1.0	0.99
Finished Year 12	94% (118)	1.00 (0.32–3.13)
Post-school qualification	93% (165)	0.93 (0.32–2.72)
Treated unfairly because Indigenous in past year
No	95% (193)	1.0	0.35
Yes	92% (188)	0.67 (0.29–1.55)
Smoking status
Ex-smoker	95% (124)	1.0	0.43
Never-smoker	93% (263)	0.71 (0.30–1.67)
Remoteness
Major cities	95% (116)	1.0	0.01
Inner and outer regional	96% (197)	1.13 (0.40–3.18)
Remote and very remote	85% (74)	0.29 (0.11–0.80)
Area-level disadvantage
1st quintile (most disadvantaged)	88% (111)	1.0	0.02
2nd and 3rd quintiles	97% (202)	3.90 (1.50–10.1)
4th and 5th quintiles	93% (74)	1.67 (0.61–4.56)

* Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. † Wald test for each variable.

4 Quitting-related outcomes of Aboriginal and Torres Strait Islander smokers, by home and work smoking bans

	Made quit attempt in past year			Want to quit			Quit attempt of 1 month or longer*
	% (frequency)†	OR (95% CI)	P‡	% (frequency)†	OR (95% CI)	P‡	% (frequency)†	OR (95% CI)	P‡

Home (n)	1594			1540			970
No ban or partial ban	45% (363)	1.0		65% (502)	1.0		45% (201)	1.0
Effective total ban	54% (425)	1.39 (1.10–1.75)	0.006	74% (574)	1.55 (1.22–1.97)	< 0.001	53% (277)	1.38 (1.08–1.77)	0.01
Work (n)	538			515			352
No ban or partial ban	47% (30)	1.0		68% (42)	1.0		51% (19)	1.0
Total ban	52% (246)	1.22 (0.68–2.19)	0.50	76% (344)	1.50 (0.81–2.79)	0.20	59% (186)	1.37 (0.66–2.83)	0.40

OR = odds ratio. * For those with at least one quit attempt in the past 5 years. † Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. ‡ Wald test for each variable.

AMA proposes pharmacy and GP team to improve patient care

The AMA has provided the Federal Government with their proposal to integrate non—dispensing pharmacists as a key part of the general practice health care team.

According to AMA President, A/Prof Brian Owler, the ‘Pharmacist in General Practice Incentive Program (PGPIP)’ would create greater efficiencies for general practices, better care for patients, new career opportunities for pharmacists, and significant Budget savings across the whole health system.

“Under this program, pharmacists within general practice would assist with things such as medication management, providing patient education on their medications, and supporting GP prescribing with advice on medication interactions and newly available medications,” A/Prof Owler said.

“Evidence shows that the AMA plan would reduce fragmentation of patient care, improve prescribing and use of medicines, reduce hospital admissions from adverse drug events (ADE), and deliver better health outcomes for patients.”

The proposal is backed by an independent analysis from the highly respected Deloitte Access Economics, which shows that the AMA proposal delivers a benefit-cost ratio of 1.56, which means that every $1 invested in the program generates $1.56 in savings to the health system.

Deloitte Access Economics estimates that, if 3,100 general practices took up the PGPIP, it would cost the Federal Government $969.5 million over four years. However, this would be more than offset through broader savings to the health system in the following areas:

hospital savings of $1.266 billion – due to reduced number of hospital admissions following a severe ADE;
PBS savings of $180.6 million – due to the reduced number of prescriptions from better prescribing and medication compliance;
individual patient savings of $49.8 million – reduced co-payments for medical consultations and medicines; and.
MBS savings of $18.1 million – due to reduced number of GP attendances following a moderate or severe ADE.

The AMA has developed this model in consultation with the Pharmaceutical Society of Australia (PSA), and it has the full backing of the PSA.

The AMA proposal for the Pharmacist in General Practice Incentive Program (PGPIP), including the Deloitte Access Economics analysis, is at https://ama.com.au/article/general-practice-pharmacists-improving-patient-care

Why the measles vaccine works for life

A new study has found the reason why measles only needs a two-dose vaccine in childhood to provide immunity for life.

The study, published in Cell Reports, has found that while influenza mutates regularly, the surface proteins the measles virus uses to enter cells are ineffective if they suffer a mutation. Therefore any changes to the virus would come at a great cost.

The researchers mutated all the genes in a virus using a high-throughput approach. They inserted the mutations across the measles genome and looked to see whether the viruses were still incapable of infection.

Unlike the influenza virus, measles could not tolerate any mutations to the proteins that are recognised by the human immune system.

Senior study author Nicholas Heaton, a microbiologist at the Icahn School of Medicine at Mount Sinai, New York said they didn’t expect such results.

“The almost complete lack of tolerance to insertional mutation of the measles proteins was surprising. We thought that they may be less tolerant than the influenza proteins, but we were surprised by the magnitude of the difference,” he said.

Heaton says they don’t yet know why the measles virus would find an evolutionary advantage to being so rigid.

“If we can better understand why flexibility or rigidity is imposed at a molecular level, we may be able to understand more about why we see different dynamics of viral evolution.”

The verdict’s in: we must better protect kids from toxic lead exposure

The National Health and Medical Research Council (NHMRC) today released new guidelines aimed at reducing children’s harmful exposure to lead. Soil, dust, water and air-based exposure to lead can interfere with the development of the nervous systems and cause behavioural and developmental problems.

The effects of lead exposure are greatest in unborn children and those aged under five years, when their growing brains absorb high levels of calcium. Because lead (Pb2+) mimics calcium (Ca2+), children in lead-rich environments absorb larger amounts of lead in place of calcium.

The NHMRC is lowering the level of lead in children’s blood at which the sources of exposure are to be investigated, from ten to five micrograms per decilitre. This marks an important milestone in Australian public health; maximum blood lead levels for Australian’s children were last lowered in 1993, from 25 to ten micrograms per decilitre.

Still, reaching this new, more protective intervention level of five micrograms per decilitre has taken far too long – and the NHMRC’s message doesn’t go far enough to protect children.

More cautious than overseas regulators

The conclusions from the review that formed the basis of the new guidelines indicate the NHMRC may be more interested in minimising the evidence linking low-level lead toxicity than minimising widespread exposure to a widely recognised poison.

The NHRMC is far more cautious than other international scientific advisory panels. The NHMRC concluded that:

The evidence for health effects occurring as a result of blood lead levels less than ten micrograms per decilitre is less clear.

This conclusion contrasts starkly with the more strongly worded conclusions of other federal and international agencies. The United States Environmental Protection Agency report, for example, identified that childhood blood lead levels between two and eight micrograms per decilitre were causally related to decrements in cognitive function.

The United Nations Environmental Programme and the US Centers for Disease Control concluded that:

there is no evidence of a “threshold” or safe exposure.

The US National Toxicology Program reported that there was sufficient evidence to conclude that blood lead concentrations less than five micrograms per decilitre are associated with intellectual deficits (lower IQ score), academic disabilities, attention-related behaviours and problem behaviours:

National Toxicology Program Monograph on Health Effects of Low-Level Lead

Children in mining communities

The most heavily contaminated children are located in Australia’s premier lead mining and smelting towns where lead emissions in the air and dust remain far too high: Mount Isa, Port Pirie and Broken Hill.

Not surprisingly, approximately 50% of children under five years of age have a blood lead above five micrograms per decilitre. These levels are comparable with children from lower-income, rapidly industrialising countries.

To be fair, there have been significant recent financial investments to improve environmental quality in Australia’s major lead mining and smelting towns:

The upgrade of the smelter at Port Pirie will cost in excess of A$500 million.
The Mount Isa Mine will spend more than A$600 million on critical projects to improve environmental performance and reduce pollution by the end of 2016.
The New South Wales government funded a new environmental lead program for Broken Hill in early 2015 at a cost of A$13 million over five years.

Nevertheless, emissions from mining and smelting are the primary source of exposure in these communities, and local children’s blood lead levels signify a public health crisis.

A detailed plan to dramatically lower lead emissions and reduce the fraction of children who have blood lead levels above five micrograms per decilitre to zero by the year 2020 should be established immediately.

What about other Australian children?

The NHMRC was unable to estimate the average level of lead in Australian children’s blood outside of lead mining and smelting towns because there is no surveillance.

A 2008 study of a small cohort of children in Sydney showed 7.5% had a blood lead level more than ten micrograms per decilitre. If that number is remotely reflective of current exposures, we are failing to protect a very large number of children.

It’s critical to conduct a random survey of Australian children to quantify lead exposure, including enrichment of children from higher risk areas. These data are essential to develop policies to protect children and develop evidence-based policies.

The NHMRC report wrongly focuses on managing suspected cases of lead exposure, when, in fact, the key to preventing lead poisoning – and the reason for the dramatic reduction in blood lead levels over the past 40 years – is the universal reduction of ongoing contamination of lead exposure.

The NHMRC strategy is to target high-risk children. But unless there is a threshold, the high-risk approach will inevitably fail to protect the majority of those affected, albeit at lower levels. This is called the prevention paradox.

Lead-associated IQ deficits offer a compelling example. Targeting children who have a blood lead concentration above five micrograms per decilitre is efficient because it captures individuals most affected; the average lead-associated IQ loss for these children is about 6.2 IQ points.

However, in a six-year cohort of US children, those who have a blood lead concentration above five micrograms per decilitre account for fewer than three million (around 18%) of the 23 million IQ points lost due to lead toxicity.

So, by focusing only on high-risk children, we will ultimately fail to protect the majority of children who are affected adversely by lead and other toxins.

Towards cleaner air, soil and water

Early and effective intervention is important because the emerging evidence shows that the effects of childhood lead exposure do not remit with age.

Proper, long-term intervention won’t be easy, but reducing lead exposure is extraordinarily cost-beneficial. American economist Elise Gould estimated that for every US$1 invested in reducing childhood lead exposure from residential hazards, society would benefit from US$17 to US$221, a cost-benefit ratio comparable with childhood vaccines (US$1 to US$16.5).

So, now that interventions are expected to occur at the new lower level of five micrograms per decilitre, it is important that the relevant environment and health agencies promulgate better standards for the most likely sources of exposure in children: air, dust, soil and water.

Air and dust quality are the most important aspects for mining and smelting communities, because contaminant emissions form toxic depositions in yards, homes, and on surfaces that children interact with resulting in subsequent exposure.

In environments where legacy emissions have contaminated soils, it will be important to lower the acceptable standard for soils in domestic residences from 300 mg/kg to something that aligns with California’s acceptable level of 80 mg/kg to provide proper protection.

In these situations, exposure risks are well known and because they are modifiable, we have duty to act in terms of dealing with the ongoing contemporary sources of emissions.

However, these initiatives will not work without continued pressure to improve environmental standards along with significant efforts to ensure lead-safe messages are both current and constant.

Mark Patrick Taylor is Professor of Environmental Science at Macquarie University.
Bruce Lanphear is Professor of Children’s Environmental Health at Simon Fraser University.

This article was originally published on The Conversation.
Read the original article.