Current and projected heatwave-attributable occupational injuries, illnesses, and associated economic burden in Australia.

INTRODUCTION: The costs of global warming are substantial. These include expenses from occupational illnesses and injuries (OIIs), which have been associated with increases during heatwaves. This study estimated retrospective and projected future heatwave-attributable OIIs and their costs in Australia. MATERIALS AND METHODS: Climate and workers' compensation claims data were extracted from seven Australian capital cities representing OIIs from July 2005 to June 2018. Heatwaves were defined using the Excess Heat Factor. OIIs and associated costs were estimated separately per city and pooled to derive national estimates. Results were projected to 2030 (2016-2045) and 2050 (2036-2065). RESULTS: The risk of OIIs and associated costs increased during heatwaves, with the risk increasing during severe and particularly extreme heatwaves. Of all OIIs, 0.13% (95% empirical confidence interval [eCI]: 0.11-0.16%) were heatwave-attributable, equivalent to 120 (95%eCI:70-181) OIIs annually. 0.25% of costs were heatwave-attributable (95%eCI: 0.18-0.34%), equal to $AU4.3 (95%eCI: 1.4-7.4) million annually. Estimates of heatwave-attributable OIIs by 2050, under Representative Concentration Pathway [RCP]4.5 and RCP8.5, were 0.17% (95%eCI: 0.10-0.27%) and 0.23% (95%eCI: 0.13-0.37%), respectively. National costs estimates for 2030 under RCP4.5 and RCP8.5 were 0.13% (95%eCI: 0.27-0.46%) and 0.04% (95%eCI: 0.66-0.60), respectively. These estimates for extreme heatwaves were 0.04% (95%eCI: 0.02-0.06%) and 0.04% (95%eCI: 0.01-0.07), respectively. Cost-AFs in 2050 were, under RCP4.5, 0.127% (95%eCI: 0.27-0.46) for all heatwaves and 0.04% (95%eCI: 0.01-0.09%) for extreme heatwaves. Attributable fractions were approximately similar to baseline when assuming theoretical climate adaptation. DISCUSSION: Heatwaves represent notable and preventable portions of preventable OIIs and economic burden. OIIs are likely to increase in the future, and costs during extreme heatwaves in 2030. Workplace and public health policies aimed at heat adaptation can reduce heat-attributable morbidity and costs.

Effects of high temperatures and heatwaves on dengue fever: a systematic review and meta-analysis.

BACKGROUND: Studies have shown that dengue virus transmission increases in association with ambient temperature. We performed a systematic review and meta-analysis to assess the effect of both high temperatures and heatwave events on dengue transmission in different climate zones globally. METHODS: A systematic literature search was conducted in PubMed, Scopus, Embase, and Web of Science from January 1990 to September 20, 2022. We included peer reviewed original observational studies using ecological time series, case crossover, or case series study designs reporting the association of high temperatures and heatwave with dengue and comparing risks over different exposures or time periods. Studies classified as case reports, clinical trials, non-human studies, conference abstracts, editorials, reviews, books, posters, commentaries; and studies that examined only seasonal effects were excluded. Effect estimates were extracted from published literature. A random effects meta-analysis was performed to pool the relative risks (RRs) of dengue infection per 1 °C increase in temperature, and further subgroup analyses were also conducted. The quality and strength of evidence were evaluated following the Navigation Guide systematic review methodology framework. The review protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO). FINDINGS: The study selection process yielded 6367 studies. A total of 106 studies covering more than four million dengue cases fulfilled the inclusion criteria; of these, 54 studies were eligible for meta-analysis. The overall pooled estimate showed a 13% increase in risk of dengue infection (RR = 1.13; 95% confidence interval (CI): 1.11-1.16, I2 = 98.0%) for each 1 °C increase in high temperatures. Subgroup analyses by climate zones suggested greater effects of temperature in tropical monsoon climate zone (RR = 1.29, 95% CI: 1.11-1.51) and humid subtropical climate zone (RR = 1.20, 95% CI: 1.15-1.25). Heatwave events showed association with an increased risk of dengue infection (RR = 1.08; 95% CI: 0.95-1.23, I2 = 88.9%), despite a wide confidence interval. The overall strength of evidence was found to be "sufficient" for high temperatures but "limited" for heatwaves. Our results showed that high temperatures increased the risk of dengue infection, albeit with varying risks across climate zones and different levels of national income. INTERPRETATION: High temperatures increased the relative risk of dengue infection. Future studies on the association between temperature and dengue infection should consider local and regional climate, socio-demographic and environmental characteristics to explore vulnerability at local and regional levels for tailored prevention. FUNDING: Australian Research Council Discovery Program.

Occupational heat stress and economic burden: A review of global evidence.

BACKGROUND: The adverse effects of heat on workers' health and work productivity are well documented. However, the resultant economic consequences and productivity loss are less understood. This review aims to summarize the retrospective and potential future economic burden of workplace heat exposure in the context of climate change. METHODS: Literature was searched from database inception to October 2020 using Embase, PubMed, and Scopus. Articles were limited to original human studies investigating costs from occupational heat stress in English. RESULTS: Twenty studies met criteria for inclusion. Eighteen studies estimated costs secondary to heat-induced labor productivity loss. Predicted global costs from lost worktime, in US$, were 280 billion in 1995, 311 billion in 2010 (≈0.5% of GDP), 2.4-2.5 trillion in 2030 (>1% of GDP) and up to 4.0% of GDP by 2100. Three studies estimated heat-related healthcare expenses from occupational injuries with averaged annual costs (US$) exceeding 1 million in Spain, 1 million in Guangzhou, China and 250,000 in Adelaide, Australia. Low- and middle-income countries and countries with warmer climates had greater losses as a proportion of GDP. Greater costs per worker were observed in outdoor industries, medium-sized businesses, amongst males, and workers aged 25-44 years. CONCLUSIONS: The estimated global economic burden of occupational heat stress is substantial. Climate change adaptation and mitigation strategies should be implemented to likely minimize future costs. Further research exploring the relationship between occupational heat stress and related expenses from lost productivity, decreased work efficiency and healthcare, and costs stratified by demographic factors, is warranted. Key messages. The estimated retrospective and future economic burden from occupational heat stress is large. Responding to climate change is crucial to minimize this burden. Analyzing heat-attributable occupational costs may guide the development of workplace heat management policies and practices as part of global warming strategies.

Aboriginal and Torres Strait Islander family access to continuity of health care services in the first 1000 days of life: a systematic review of the literature.

BACKGROUND: Aboriginal women and their infants experience significant disadvantage in health outcomes compared to their non-Aboriginal counterparts. Access to timely, effective and appropriate maternal and child healthcare can contribute to reducing these existing health disparities. However, accessing mainstream healthcare services often results in high levels of fear and anxiety, and low attendance at subsequent appointments among Aboriginal women, due to inefficient communication, poor service coordination and a lack of continuity of care. METHODS: This integrative literature review sought to explore factors that contribute to continuity of care and consider service features that contribute to positive care experiences and satisfaction with care received by Aboriginal women and their infants. In total, 28 studies were included in the review and were thematically analysed using Braun and Clarke's six steps of thematic analysis. This was followed by a collaborative, computer-assisted qualitative analysis, which resulted in the emergence of five key themes: lack of continuity of care, impact of lack of continuity of care, continuity of care interventions, impact of continuity of care interventions, and strategies to improve continuity of care. RESULTS: Most studies focused on health services in rural or remote Aboriginal communities and there was a lack of documented evidence of continuity of care (or lack thereof) for Aboriginal women living and birthing in regional and metropolitan areas. The majority of studies focused explicitly on continuity of care during the antenatal, birthing and immediate postnatal period, with only two studies considering continuity through to an infant's first 1000 days. CONCLUSION: The review highlights a lack of studies exploring continuity of care for Aboriginal families from the antenatal period through to an infants' first 1000 days of life. Included studies identified a lack of continuity in the antenatal, peri- and postnatal periods in both regional and metropolitan settings. This, along with identified strategies for enhancing continuity, have implications for communities, and healthcare services to provide appropriate and culturally safe care. It also marks an urgent need to incorporate and extend continuity of care and carer through to the first 1000 days for successful maternal and infant health outcomes for Aboriginal peoples.

Nonlinear Modelling for Predicting Patient Presentation Rates for Mass Gatherings.

IntroductionMass gatherings are common in Australia. The interplay of variables, including crowd density and behavior, weather, and the consumption of alcohol and other drugs, can pose a unique set of challenges to attendees' well-being. On-site health services are available at most mass gatherings and reduce the strain on community health facilities. In order to efficiently plan and manage these services, it is important to be able to predict the number and type of presenting problems at mass gatherings.ProblemThere is a lack of reliable tools to predict patient presentations at mass gatherings. While a number of factors have been identified as having an influence on attendees' health, the exact contribution of these variables to patient load is poorly understood. Furthermore, predicting patient load at mass gatherings is an inherently nonlinear problem, due to the nonlinear relationships previously observed between patient presentations and many event characteristics. METHODS: Data were collected at 216 Australian mass gatherings and included event type, crowd demographics, and weather. Nonlinear models were constructed using regression trees. The full data set was used to construct each model and the model was then used to predict the response variable for each event. Nine-fold cross validation was used to estimate the error that may be expected when applying the model in practice. RESULTS: The mean training errors for total patient presentations were very high; however, the distribution of errors per event was highly skewed, with small errors for the majority of events and a few large errors for a small number of events with a high number of presentations. The error was five or less for 40% of events and 15 or less for 85% of events. The median error was 6.9 presentations per event. CONCLUSION: This study built on previous research by undertaking nonlinear modeling, which provides a more realistic representation of the interactions between event variables. The developed models were less useful for predicting patient presentation numbers for very large events; however, they were generally useful for more typical, smaller scale community events. Further research is required to confirm this conclusion and develop models suitable for very large international events.Arbon P, Bottema M, Zeitz K, Lund A, Turris S, Anikeeva O, Steenkamp M. Nonlinear modelling for predicting patient presentation rates for mass gatherings. Prehosp Disaster Med. 2018;33(4):362-367.

Patient Presentation Trends at 15 Mass-Gathering Events in South Australia.

IntroductionMass gatherings are complex events that present a unique set of challenges to attendees' health and well-being. There are numerous factors that influence the number and type of injuries and illnesses that occur at these events, including weather, event and venue type, and crowd demographics and behavior.ProblemWhile the impact of some factors, such as weather conditions and the availability of alcohol, on patient presentations at mass gatherings have been described previously, the influence of many other variables, including crowd demographics, crowd behavior, and event type, is poorly understood. Furthermore, a large number of studies reporting on the influence of these variables on patient presentations are based on anecdotal evidence at a single mass-gathering event. METHODS: Data were collected by trained fieldworkers at 15 mass gatherings in South Australia and included event characteristics, crowd demographics, and weather. De-identified patient records were obtained from on-site health care providers. Data analysis included the calculation of patient proportions in each variable category, as well as the total number of patient presentations per event and the patient presentation rate (PPR). RESULTS: The total number of expected attendees at the 15 mass gatherings was 303,500, of which 146 presented to on-site health care services. The majority of patient presentations occurred at events with a mean temperature between 20°C and 25°C. The PPR was more than double at events with a predominantly male crowd compared to events with a more equal sex distribution. Almost 90.0% of patient presentations occurred at events where alcohol was available. CONCLUSION: The results of the study suggest that several weather, crowd, and event variables influence the type and number of patient presentations observed at mass-gathering events. Given that the study sample size did not allow for these interactions to be quantified, further research is warranted to investigate the relationships between alcohol availability, crowd demographics, crowd mobility, venue design, and injuries and illnesses.Anikeeva O, Arbon P, Zeitz K, Bottema M, Lund A, Turris S, Steenkamp M. Patient presentation trends at 15 mass-gathering events in South Australia. Prehosp Disaster Med. 2018;33(4):368-374.

Emergency nurses' knowledge and experience with the triage process in Hunan Province, China.

INTRODUCTION: Triage is implemented to facilitate timely and appropriate treatment of patients, and is typically conducted by senior nurses. Triage accuracy and consistency across emergency departments remain a problem in mainland China. This study aimed to investigate the current status of triage practice and knowledge among emergency nurses in Changsha, Hunan Province, China. METHOD: A sample of 300 emergency nurses was selected from 13 tertiary hospitals in Changsha and a total of 193 completed surveys were returned (response rate=64.3%). Surveys were circulated to head nurses, who then distributed them to nurses who met the selection criteria. Nurses were asked to complete the surveys and return them via dedicated survey return boxes that were placed in discreet locations to ensure anonymity. RESULTS: Just over half (50.8%) of participants reported receiving dedicated triage training, which was provided by their employer (38.6%), an education organisation (30.7%) or at a conference (26.1%). Approximately half (53.2%) reported using formal triage scales, which were predominantly 4-tier (43%) or 5-tier (34%). CONCLUSIONS: The findings highlight variability in triage practices and training of emergency nurses in Changsha. This has implications for the comparability of triage data and transferability of triage skills across hospitals.

Opportunities for general practitioners to enhance disaster preparedness among vulnerable patients.

Disasters occur frequently in Australia and will become more unpredictable and severe due to climate change. Some members of the Australian population, such as the elderly, the chronically ill and the socially isolated, are less likely to be prepared and more likely to be adversely affected by disasters. Although general practitioners (GPs) view the delivery of preventive health care as a priority, few preventive services focus on patients' resilience and ability to cope with unexpected stressors. This paper focuses on the individuals most vulnerable to disasters and the opportunities for GPs to facilitate the enhancement of disaster preparedness among these groups. General practitioners are ideally placed to identify vulnerable patients and refer them to services that may assist them in enhancing their disaster resilience. To reduce the burden on individual GPs, adjustments can be made to practice software systems that will use patient records to identify vulnerable individuals.

International Consensus on Key Concepts and Data Definitions for Mass-gathering Health: Process and Progress.

Mass gatherings (MGs) occur worldwide on any given day, yet mass-gathering health (MGH) is a relatively new field of scientific inquiry. As the science underpinning the study of MGH continues to develop, there will be increasing opportunities to improve health and safety of those attending events. The emerging body of MG literature demonstrates considerable variation in the collection and reporting of data. This complicates comparison across settings and limits the value and utility of these reported data. Standardization of data points and/or reporting in relation to events would aid in creating a robust evidence base from which governments, researchers, clinicians, and event planners could benefit. Moving towards international consensus on any topic is a complex undertaking. This report describes a collaborative initiative to develop consensus on key concepts and data definitions for a MGH "Minimum Data Set." This report makes transparent the process undertaken, demonstrates a pragmatic way of managing international collaboration, and proposes a number of steps for progressing international consensus. The process included correspondence through a journal, face-to-face meetings at a conference, then a four-day working meeting; virtual meetings over a two-year period supported by online project management tools; consultation with an international group of MGH researchers via an online Delphi process; and a workshop delivered at the 19thWorld Congress on Disaster and Emergency Medicine held in Cape Town, South Africa in April 2015. This resulted in an agreement by workshop participants that there is a need for international consensus on key concepts and data definitions.

Trends in migrant mortality rates in Australia 1981-2007: a focus on the National Health Priority Areas other than cancer.

INTRODUCTION: Migrants generally have more favourable mortality outcomes than the Australian-born population. The aim of this study is to update knowledge and inform future research in this field by examining mortality from musculoskeletal conditions, asthma, cardiovascular disease, diabetes mellitus, injuries and mental conditions between 1981 and 2007 among migrants in Australia. METHODS: Average annual sex- and age-standardised mortality rates were calculated for each migrant group, period of death registration and cause of death. RESULTS AND CONCLUSIONS: Mortality rates decreased among most groups for asthma, cardiovascular disease and motor vehicle accidents, with rates diverging in the later time periods. The reverse was true for mental disorders, where Australian-born individuals experienced the greatest increase in mortality. Migrants generally displayed more favourable mortality outcomes than their Australian-born counterparts. Migrants from Southern Europe appeared to have the greatest advantage. However, some migrants appeared to be over-represented in the areas of diabetes, suicide and mental health.

Self-rated dental health and dental insurance: modification by household income.

BACKGROUND: Previous studies have reported that socioeconomically disadvantaged Australians have poorer self-rated dental health (SRDH), are less likely to be insured for dental services and are less likely to have regular dental visits than their more advantaged counterparts. However, less is known about the associations between dental insurance and SRDH. The aim of this study was to examine the associations between SRDH and dental insurance status and to test if the relationship was modified by household income. METHODS: A random sample of 3,000 adults aged 30-61 years was drawn from the Australian Electoral Roll and mailed a self-complete questionnaire. Analysis included dentate participants. Bivariate associations were assessed between SRDH and insurance stratified by household income group. A multiple variable model adjusting for covariates estimated prevalence ratios (PR) of having good to excellent SRDH and included an interaction term for insurance and household income group. RESULTS: The response rate was 39.1% (n = 1,093). More than half (53.9%) of the participants were insured and 72.5% had good to excellent SRDH. SRDH was associated with age group, brushing frequency, insurance status and income group. Amongst participants in the $40,000- < $80,000 income group, the insured had a higher proportion reporting good to excellent SRDH (80.8%) than the uninsured (66.5%); however, there was little difference in SRDH by insurance status for those in the $120,000+ income group. After adjusting for covariates, there was a significant interaction (p < 0.05) between having insurance and income; there was an association between insurance and SRDH for adults in the $40,000- < $80,000 income group, but not for adults in higher income groups. CONCLUSIONS: For lower socio-economic groups being insured was associated with better SRDH, but there was no association for those in the highest income group. Insurance coverage may have the potential to improve dental health for low income groups.

Household income modifies the association of insurance and dental visiting.

BACKGROUND: Dental insurance and income are positively associated with regular dental visiting. Higher income earners face fewer financial barriers to dental care, while dental insurance provides partial reimbursement. The aim was to explore whether household income has an effect on the relationship between insurance and visiting. METHODS: A random sample of adults aged 30-61 years living in Australia was drawn from the Electoral Roll. Data were collected by mailed survey in 2009-10, including age, sex, dental insurance status and household income. RESULTS: Responses were collected from n = 1,096 persons (response rate = 39.1%). Dental insurance was positively associated with regular visiting (adjusted prevalence ratio (PR) = 1.18; 95% CI: 1.01-1.36). Individuals in the lowest income tertile had a lower prevalence of regular visiting than those in the highest income group (PR = 0.78; 95% CI: 0.65-0.93). Visiting for a check-up was less prevalent among lower income earners (PR = 0.65; 95% CI: 0.50-0.83). Significant interaction terms indicated that the associations between insurance and visiting varied across income tertiles showing that income modified the effect. CONCLUSIONS: Household income modified the relationships between insurance and regular visiting and visiting for a check-up, with dental insurance having a greater impact on visiting among lower income groups.

Stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for management of vestibular schwannomas: initial experience with 17 cases.

BACKGROUND: Nowadays radiation treatment of patients with vestibular schwannomas (VSs) applied either as stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) represents a real alternative to surgical tumor resection. METHODS: During 2010-2011, 17 consecutive patients (19-75 years old) with a VS underwent treatment with SRS or SRT in our center. Microsurgery was initially offered in all cases but was declined for various reasons. Five lesions recurred after the initial partial resection. Two other patients with neurofibromatosis type 2 underwent initial surgery for a large tumor on the contralateral side and had the only hearing ear on the side of the remaining neoplasm. Three elderly persons had somatic problems that were too severe for them to undergo craniotomy. Five small tumors without brain stem compression underwent single-fraction SRS (12.0-12.5 Gy at the 80 % isodose line). Other patients, mainly with large neoplasms that caused brain stem compression, were treated with hypofractionated SRT (five or six daily fractions at a dose of 4.5-5.0 Gy each). Treatment was performed with a dedicated linear accelerator (Elekta Axesse). Various stereotactic fixation devices were used: Leksell G frame, noninvasive HeadFIX frame, reinforced thermoplastic masks. RESULTS: No adverse reactions or complications were seen in any case. Within 3 months after treatment three tumors demonstrated shrinkage accompanied by improvement of the neurological functions. CONCLUSION: Radiation treatment, particularly hypofractionated SRT, can be safely applied even for large VSs that cause brain stem compression and are accompanied by prominent neurological symptoms.

The Closing the Gap Initiative - successes and ongoing challenges for divisions of general practice.

BACKGROUND: This article presents an evaluation of the activities undertaken by divisions of general practice to improve Indigenous Australians' access to mainstream primary care. METHODS: Data were obtained from 12 month reports for the 2009-10 reporting period. Data from 86 divisions were thematically analysed using NVivo 9 software. RESULTS: Most divisions provided positive comments regarding their involvement in the program. The main barriers to access among Indigenous Australians were cost, inadequate transport, lack of cultural sensitivity and staffing shortages. The activities undertaken to address barriers included awareness raising, distribution of resources, cultural safety training and employing Indigenous staff. Stakeholder involvement was achieved through community consultation and establishment of advisory committees. DISCUSSION: While most divisions were satisfied with their progress, ongoing challenges were identified with regard to effective identification of Indigenous patients and lack of interest among some practice staff. These need to be addressed though ongoing cultural awareness training.

Trends in cancer mortality rates among migrants in Australia: 1981-2007.

BACKGROUND: Previous studies have shown that migrants have lower cancer mortality rates compared to the Australian-born population, particularly for colorectal and breast cancers, which are associated with an affluent lifestyle. This study seeks to update knowledge in this field by examining mortality from colorectal, stomach, lung, melanoma, breast and bladder cancers, as well as all cancers combined between 1981 and 2007. METHODS: Data were obtained from the Australian Bureau of Statistics. Average annual age and sex-standardised mortality rates were calculated for each region of birth, period of death registration and cancer site. RESULTS: Generally, mortality rates declined over the study period for most conditions for the majority of migrant groups. Notable exceptions included migrants from South Eastern Europe and Eastern Europe who experienced a significant increase in mortality due to all cancers combined and Australian-born individuals who recorded a significant increase in mortality due to melanoma of the skin. Migrants generally had more favourable cancer mortality outcomes, particularly for colorectal cancer and melanoma. Migrants from Southern Europe, South Eastern Europe, Chinese Asia and Southern Asia had the greatest advantage. However, migrants displayed higher rates of stomach, lung and bladder cancers than the Australian-born population. CONCLUSION: The migrant advantage can in part be explained by the protective effects of diet, lifestyle and reproductive behaviours. Possible explanations for why some migrants display greater mortality from stomach and bladder cancer include the consumption of abrasive, salted and preserved foods and higher rates of smoking. Greater emphasis should be placed on targeting at-risk migrant groups through screening and education programs at migrant resource centres and community groups. The study calls for further research to explain the observed trends, which has the potential to uncover important risk and protective factors.

The health status of migrants in Australia: a review.

This review summarizes the findings of studies conducted in Australia between 1980 and 2008 that focused on the health status of migrants in one or more of Australia's National Health Priority Areas (NHPAs), identifies gaps in knowledge, and suggests further research directions. Systematic literature searches were performed on CINAHL, MediText, PsycINFO, and MEDLINE. It was found that the majority of migrants enjoy better health than the Australian-born population in the conditions that are part of the NHPAs, with the exception of diabetes. Mediterranean migrants have particularly favorable health outcomes. The migrant health advantage appears to deteriorate with increasing duration of residence. Many of the analyzed studies were conducted more than 10 years ago or had a narrow focus. Little is known about the health status of migrants with respect to a number of NHPAs, including musculoskeletal conditions and asthma.The health status of recently arrived migrant groups from the Middle East and Africa has not been explored in detail.

Requiring influenza vaccination for health care workers.

Annual influenza vaccination for health care workers has the potential to benefit health care professionals, their patients, and their families by reducing the transmission of influenza in the health care setting. Furthermore, staff vaccination programs are cost-effective for health care institutions because of reduced staff illness and absenteeism. Despite international recommendations and strong ethical arguments for annual influenza immunization for health care professionals, staff utilization of vaccination remains low. We have analyzed the ethical implications of a variety of efforts to increase vaccination rates, including mandatory influenza vaccination. A program of incentives and sanctions may increase health care worker compliance with fewer ethical impediments than mandatory vaccination.

How will Australian general practitioners respond to an influenza pandemic? A qualitative study of ethical values.

OBJECTIVES: To explore general practitioners' perceptions of their preparedness for an influenza pandemic, the changes they would make to their practice, and the ethical justifications for their planned actions. DESIGN AND SETTING: A qualitative study was performed among South Australian GPs between March and October 2007. A semi-structured interview was carried out with each participant in his or her practice, and the interviews were audio-recorded, transcribed and analysed thematically. PARTICIPANTS: 10 GPs were recruited: five from a metropolitan Division and five from a rural Division of General Practice. RESULTS: Some participants felt they would not be able to cope with an influenza pandemic, while others felt it would simply mean an increase in their workloads. Most respondents considered creating separate waiting rooms, moving the reception desk outside of the practice and delaying all non-urgent consultations in order to deal with a pandemic more effectively. Respondents mentioned the conflict between their various roles and responsibilities as a primary source of tension when thinking about the way they would organise their work in the event of a pandemic. A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients. CONCLUSIONS: Professional codes of ethics should include guidance about the scope of the duty to treat during infectious disease outbreaks. The community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic and are given the opportunity to be actively involved in pandemic preparedness planning.