DOCUMENT 1 FOI 25/26-0555

Research Request – Repetitive Transcranial Magnetic Stimulation

Brief

Is rTMS (repetitive transcranial magnetic stimulation) a clinical treatment for Bipolar Affective Disorder?
If yes, is there evidence to indicate that it is recognised as a recommended treatment for Bipolar Affective Disorder? (please include frequency of treatment)
What are the recommended treatments/therapies (both clinical and non-clinical) for Bipolar Affective Disorder with a focus on diagnosis with Obsessive Compulsive Tendencies?

Date 15/07/2020

Requester Naomi Rredacted: s22(1)(a)(ii) - irre (AAT Senior Technical Advisor)

Researcher Jane Sredacted: s22(1)(a)(ii) - irre (Research Team Leader)

Cleared by Jane Sredacted: s22(1)(a)(ii) - irre (Research Team Leader)

Summary ………………………………………………………………………………………………………………………………. 3 What is Transcranial Magnetic Stimulation? ……………………………………………………………………………… 3 Bipolar disorder types …………………………………………………………………………………………………..———— 3 Bipolar I Disorder (mania or a mixed episode) ……………………………………………………………………….. 3 Bipolar II Disorder (hypomania and depression) …………………………………………………………………….. 3 Cyclothymia (hypomania and mild depression) ……………………………………………………………………… 3 Peer Reviewed Literature Investigating Repetitive Transcranial Magnetic Stimulation for Bipolar Disorder……………………………………………………………………………………………………………………………… 4 Frequency of treatment ………………………………………………………………………………………………………….. 5 Clinical Management of Bipolar Disorder ………………………………………………………………………………….. 5 Management of Mania ……………………………………………………………………………………………………….. 5 Severe Mania …………………………………………………………………………………………………………………. 5 Hypomania ………………………………………………………………………………………………………………… 5 Mania ……………………………………………………………………………………………………………………………. 6 Clinical Management of Bipolar Depression ……………………………………………………………………… 6 Pharmacological …………………………………………………………………………………………………………. 6 Monotherapy …………………………………………………………………………………………………………………. 6 Combination ………………………………………………………………………………………………………………… 6

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Psychological interventions …………………………………………………………………………………………………. 6 Electroconvulsive therapy and other brain stimulation methods (rTMS) …………………………… 7 Complementary therapies ……………………………………………………………………………………. 7 Management of comorbid bipolar and obsessive compulsive disorder …………………………… 7 Repetitive Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder …………….. 7 Reference List ………………………………………………………………………………………………………………………… 8

Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

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Summary

• rTMS has been proven as an effective treatment for treatment-resistant depression. o The Royal Australian and New Zealand College of Psychiatrists states that research specifically focusing on bipolar is in its infancy, however, there is no evidence to suggest that bipolar patients are less likely to respond to rTMS than patients with unipolar depression. • Precise treatment protocols for bipolar do not have consensus agreement at present. However, recommendations for depression include o Monday to Friday over 4 to 6 weeks o Daily stimulation for between 30 and 45 minutes o Repeated short bursts of high frequency stimulation (~10Hz) to the left dorsolateral prefrontal cortex • First line treatment for bipolar is pharmacological (Antipsychotics, Mood stabilising agents, Antidepressants), followed by psychotherapy, electroconvulsive therapy or rTMS based on the discretion of the treating medical professional • The treatment of comorbid bipolar disorder and obsessive compulsive disorder is extremely complex. o No consensus regarding the best available evidence-based treatment for OCD in manic, depressed, or remitted phases of BD exists o Best treatment based on current evidence is that mood stabilizers along with adjuvant topiramate or with olanzapine-SSRI/clomipramine combination can be used to treat OCD in BD o Meta-analysis found that there is no effect of rTMS on OCD

What is Transcranial Magnetic Stimulation?

Transcranial magnetic stimulation (TMS) is a relatively new, non-invasive therapeutic option that involves the application of magnetic pulses on hyperactive or hypoactive cortical brain areas with the aim of modulating brain networks [1]. To administer TMS, the clinician places an electromagnetic coil on a pre-specified region of the patient’s scalp. Magnetic pulses from the coil travel through the skull toward a target cortical area, resulting in neural activation changes.

Bipolar disorder types

Bipolar I Disorder (mania or a mixed episode) – This is the classic manic-depressive form of the illness, characterized by at least one manic episode or mixed episode. Usually—but not always— Bipolar I Disorder also involves at least one episode of depression.

Bipolar II Disorder (hypomania and depression) – In Bipolar II disorder, you don’t experience full- blown manic episodes. Instead, the illness involves episodes of hypomania and severe depression.

Cyclothymia (hypomania and mild depression) – Cyclothymia is a milder form of bipolar disorder that consists of cyclical mood swings. However, the symptoms are less severe than full-blown mania or depression.

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Peer Reviewed Literature Investigating Repetitive Transcranial Magnetic Stimulation for Bipolar Disorder

To date, rTMS has received the most consistent clinical and research application in the treatment of treatment-resistant depression. All substantive evaluations of the efficacy of rTMS have been conducted in patients with some degree of treatment resistance with many of the trials including patients who have failed to respond to 2 or more antidepressant medication trials where the likelihood of further medication response is low. These clinical trials have included patients with bipolar depression, however, they were not analysed individually.

In the context of depression, rTMS has established efficacy, as confirmed by multiple meta-analyses [2, 3]. It has also been recommended by the Royal Australian and New Zealand College of Psychiatrists [4] for patients with non-psychotic depression. Therefore, it is a sensible treatment option in patients who have failed to respond to initial antidepressant therapy, or who have significant problems with tolerating medication treatment.

Although initial trials did not specifically investigate bipolar, there is no evidence that bipolar patients are less likely to respond to rTMS than patients with unipolar depression [4]. More recently, trials have focused on investigating the efficacy of rTMS for the treatment of bipolar. A recent literature review by Gold et al (2019) [5] is summarised below.

Inclusion criteria: Studies across the various bipolar mood stages were included (bipolar depression, mania, mixed episodes). Articles which didn’t separate participants with unipolar and bipolar were excluded.

Results

Bipolar depression

More than >80% of included studies saw improved depression related symptoms, including a reduction in Hamilton Rating Scale for Depression, Montgomery–Åsberg Depression Rating Scale, Clinical Global Impression Score or reduction in beta frequency.

The potential to reduce depressive symptoms is clear, though findings varied in relation to the most effective rTMS treatment protocol (e.g., high-frequency vs. low-frequency, right-sided vs. left-sided, bilateral vs. unilateral). Several studies concluded that older patients with a longer, more refractory, and more severe bipolar depression may require more rTMS sessions than patients with a shorter, less chronic bipolar depression [6].

Mania

TMS for mania has been the focus of fewer clinical trials and yielded more inconsistent findings with three studies finding improvements in depressive symptoms and three finding no difference. The only randomized controlled trial found no benefit of rTMS over a sham treatment for mania.

Side effects of TMS

Side effects have been described as mild. The most common among the studies bipolar depression were headaches and insomnia with other side effects including local pain at the site of administration, fatigue, memory difficulties, and dizziness.

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Frequency of treatment

As noted above, consensus has not been reached on precise treatment protocols for varying levels of bipolar depression. The Royal Australian and New Zealand College of Psychiatrists [3] provides the most commonly administered protocols for treatment-resistant depression which has been supported by several meta-analyses (Level I evidence) [2, 3]:

• Monday to Friday over 4 to 6 weeks • Stimulation is applied daily for between 30 and 45 minutes • Repeated short bursts of high frequency stimulation (~10Hz) to the left dorsolateral prefrontal cortex (DLPFC). o There is also significant evidence to support the antidepressant efficacy of low frequency rTMS (an alternate form of rTMS) applied to the right DLPFC (Level I evidence) [2]. • Patients receiving rTMS do not require a general anaesthetic and are typically able to return to work or drive immediately after • Effective as a monotherapy or in conjunction with antidepressants • Bilateral rTMS does not appear to produce better results than unilateral rTMS, and therefore unilateral approaches that can be generally delivered more quickly are preferable [7].

Clinical Management of Bipolar Disorder

Management of Mania [4]

Manic symptoms can occur within depression as mixed features, and with increasing severity from hypomania and mania through to mania with psychosis.

Severe Mania

Acute mania is a medical emergency, and often necessitates use of mental health legislation [4]. Care should be provided in a low stimulus environment with support from health professionals. Treatment usually requires short-term use of a combination of; • Benzodiazepines • Antipsychotics • Electroconvulsive therapy (ECT) (for delirious mania and mania with catatonic features not attributable to an organic cause)

Hypomania

By definition hypomania is self-limiting and often resolves with only modest use of medications and psychosocial interventions, but usually some adjustments to treatment are necessary and these should follow the general principles of managing mania [4].

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Mania

It is crucial to taper and cease any agents with mood-elevating properties (e.g. antidepressants, stimulants) and institute general measures such as reducing stimulation, lowering activity level, delaying the individual from making important decisions and maintaining a structured routine [4]. • Pharmacotherapy of mania involves treatment with anti-manic agents (a combination of medications is often necessary). Individual clinical judgement is used to determine specific medications. • Counselling of family members/carers • ECT • rTMS is not recommended for mania due to insufficient evidence • Unstructured supportive psychotherapy (which may include psychoeducation about bipolar disorder)

Clinical Management of Bipolar Depression

The treatment of bipolar depression is difficult and outcomes are often poor, partly because no medications have been specifically developed to treat this phase of bipolar disorder but also because management requires careful consideration of complex issues, such as treatment emergent affective switching (TEAS) into mania or hypomania, possible cycle acceleration, and the precipitation of mixed symptoms [4].

Pharmacological

Monotherapy

Comprises two groups of medications: • Second generation antipsychotics (SGAs) o quetiapine, lurasidone and olanzapine • Mood stabilising agents (MSAs) o lithium, lamotrigine and valproate

Combination

The SGA’s and MSA’s with efficacy as monotherapy agents can be combined or used in conjunction with antidepressants.

SGA’s: Effective monotherapy options can be added to either mood stabilising agents or antidepressants.

MSA: Lithium can be combined with all other monotherapy options; valproate can similarly be combined with all monotherapy options but should be used with caution in women of childbearing age and when combined with lamotrigine.

Antidepressants: antidepressants can be added to all effective monotherapy options with the exception of lamotrigine, however the benefits of this strategy remain unclear.

Psychological interventions

Strong clinical consensus that the highly prevalent and highly impairing depressive phase of bipolar disorder should be managed in a comprehensive biopsychosocial manner, and adjunctive structured psychological interventions should be offered to help stabilise depressive episodes. These interventions include: • Cognitive-Behavioural Therapy (CBT)

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• Interpersonal and Social Rhythm Therapy (IPSRT) • Family-Focused Therapy (FFT)

Electroconvulsive therapy and other brain stimulation methods (rTMS)

ECT has been shown to be equally effective for both bipolar and non-bipolar depression with some evidence that the response was more rapid in bipolar depression.

As mentioned previously, rTMS for the treatment of bipolar has only recently been investigated. There is no evidence that bipolar patients are less likely to respond to rTMS than patients with unipolar depression [4].

Complementary therapies

Omega-3-fatty acids [8], N-acetyl cysteine (NAC) [9] and other nutraceuticals [10] may also be considered.

Management of comorbid bipolar and obsessive compulsive disorder

Obsessive-compulsive disorder (OCD) is one of the most frequently associated comorbidities in bipolar disorder. For clinicians, it is a real challenge to manage patients with BD-OCD comorbidity because both mood stabilizing and management of OCD should go hand in hand. However, the serotonin reuptake inhibitors (SRIs) which are the first-line treatment for OCD can induce manic/mixed mood states in BD [11].

Effects of combined pharmacological treatments and psychotherapeutic treatments are less studied, and no convincing upper hand for a specific modality is observed in OCD comorbid with BD. No consensus regarding the best available evidence-based treatment for OCD in manic, depressed, or remitted phases of BD exists [11].

Based on current evidence mood stabilizers along with adjuvant topiramate or with olanzapine- SSRI/clomipramine combination can be used to treat OCD in BD [11]. Furthermore, there is consistent evidence that active treatment of major depression is associated with improvement in personality disorder symptoms [12, 13].

Repetitive Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder

A meta-analysis [3] has found that there is no significant effect (0.15, p = 0.52) of rTMS for the treatment of OCD. In spite of the small numbers of studies, the results were homogeneous. This indicates that OCD is not a psychiatric indication for rTMS [3].

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Reference List

Brunelin, J., Jalenques, I., Trojak, B., Attal, J., Szekely, D., Gay, A.,Poulet, E. (2014). The efficacy and safety of low frequency repetitive transcranial magnetic stimulation for treatment‐resistant depression: The results from a large multicenter French RCT. Brain Stimulation, 7(6), 855–863.
Schutter DJ. Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta- analysis. Psychological medicine. 2009 Jan;39(1):65-75.
Slotema CW, Dirk Blom J, Hoek HW, Sommer IE. Should we expand the toolbox of psychiatric treatment methods to include Repetitive Transcranial Magnetic Stimulation (rTMS)? A meta- analysis of the efficacy of rTMS in psychiatric disorders. Journal of Clinical Psychiatry. 2010 Jul 1;71(7):873.
Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, Hopwood M, Lyndon B, Mulder R, Murray G, Porter R. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian & New Zealand Journal of Psychiatry. 2015 Dec;49(12):1087-206.
Gold AK, Ornelas AC, Cirillo P, Caldieraro MA, Nardi AE, Nierenberg AA, Kinrys G. Clinical applications of transcranial magnetic stimulation in bipolar disorder. Brain and Behavior. 2019 Oct;9(10):e01419.
Cohen, R. B., Brunoni, A. R., Boggio, P. S., & Fregni, F. (2010). Clinical predictors associated with duration of repetitive transcranial magnetic stimulation treatment for remission in bipolar depression: A naturalistic study. The Journal of Nervous and Mental Disease, 198(9), 679–681.
Chen JJ, Liu Z, Zhu D, et al. (2014) Bilateral vs. unilateral repetitive transcranial magnetic stimulation in treating major depression: A meta-analysis of randomized controlled trials. Psychiatry Research 219: 51–57.
Sarris J, Mischoulon D and Schweitzer I (2012) Omega-3 for bipolar disorder: Meta-analyses of use in mania and bipolar depression. Journal of Clinical Psychiatry 73: 81–86
Berk M, Copolov DL, Dean O, et al. (2008) N-acetyl cysteine for depressive symptoms in bipolar disorder—A double-blind randomized placebo-controlled trial. Biological Psychiatry 64: 468–475.
Sarris J, Mischoulon D and Schweitzer I (2011) Adjunctive nutraceuticals with standard pharmacotherapies in bipolar disorder: A systematic review of clinical trials. Bipolar Disorders 13: 454–465.
Kazhungil F, Mohandas E. Management of obsessive-compulsive disorder comorbid with bipolar disorder. Indian journal of psychiatry. 2016 Jul;58(3):259.
Fava M, Farabaugh AH, Sickinger AH, et al. (2002) Personality disorders and depression. Psychological Medicine 32: 1049–1057
Mulder RT, Joyce PR and Frampton CM (2010) Personality disorders improve in patients treated for major depression. Acta Psychiatrica Scandinavica 122: 219–225.

DOCUMENT 2 FOI 25/26-0555

Research – Adverse effects of bidet use


Brief	Does habitual bidet toilet use lead to an increase in adverse health concerns (e.g. urological infections, haemorrhoids, bacterial vaginitis, and aggravation of vaginal microflora)? Does this differ between biological sexes? Is there a significant increase in adverse health concerns from bidet use when compared to the general population (e.g. increased likelihood of infection caused by bidet use, or infections are typically present in general population regardless of bidet use)?
Date	16/04/2021
Requester(s)	Claire M`redacted: s22(1)(a)(ii)` - Senior Technical Advisor (TAB)
Researcher	Jane S`redacted: s22(1)(a)(ii)` - Research Team Leader (TAB)
Cleared	N/A

Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

1 Contents

2 Summary …………………………………………………………………………………………………………….. 1 3 Evidence of infections…………………………………………………………………………………………… 2 4 Hygiene status of bidet toilets ……………………………………………………………………………….. 3 5 Association with pre-term birth …………………………………………………………………………….. 3 6 Implementing bidet in aged care or disability settings ……………………………………………… 3 7 References ………………………………………………………………………………………………………… 18

2 Summary

• Literature investigating the adverse effects of bidet use is sparse

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• There is some evidence to suggest that habitual bidet use can cause haemorrhoids, irritated perianal skin, urological infection, vulvar pruritus and bacterial vaginitis o Apart from irritated perianal skin, there are no differences between sexes in infection rate • There is conflicting evidence around the use of bidet use and pre term birth • The implementation of bidets in nursing homes has shown that only 50% of residents and nurses are supportive of bidet use, and that in the majority of cases residents remain unclean and still require toileting assistance (duplication of supports) o One study found that more 28% of bidet users were still required to wipe using toilet paper multiple times • A single study has found that bidet use can assist in reducing toileting time for people with spinal cord injury. However, further studies are required to confirm its effectiveness

3 Evidence of infections

There is some evidence of a positive relationship between haemorrhoids, irritated perianal skin, urological infection, vulvar pruritus and bacterial vaginitis in those considered habitual bidet users [1, 2]. These findings were obtained from moderate quality retrospective surveys that included up to 18,000 participants. It was also found that 28 % of the bidet users wiped off excess water with toilet paper many times [3].

When comparing incidence of non-genital related conditions, Asakura, Nakano [1] found that men more commonly reported subjective symptoms of irritated skin around the anus, which were newly experienced during follow-up than non-habitual users (adjusted risk ratio 1.36 (95% confidence interval 1.06–1.75)). Furthermore, Tsunoda, Takahashi [3] found that men were more commonly affected by an “itch on the anus” because they had faecal leakage more frequently (OR = 3.82) and used a bidet more actively. Other than men being more likely to use a bidet, there were no other gender differences found.

A cross sectional study investigating the possible relevancy of bidet usage to changes in vaginal microflora in 268 women found that normal microflora (Lactobacillus species) was not present in 42.86% of bidet toilet users, compared to 8.77% of non-users. Faecal bacteria were detected in 50 of the 268 cases (18.66%), 46 cases in users (92%) and only 4 cases in non-users (8%). Contamination by other pathogens was 4 to 6 times higher in users than in non-users.

Various case studies have reported that bidet use can cause:

• Anal fissure in the anterior midline

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• Rectal mucosal prolapse syndrome • Scald burn in the perianal region

4 Hygiene status of bidet toilets

A handful of studies have investigated the hygiene status of bidet toilets in public restrooms such as hospitals and Universities. They have found that:

• Pseudomonas aeruginosa is present on about 2% of the toilet seats. P. aeruginosa was found to remain for long durations in biofilms that formed inside warm-water tanks [4] • 86.9% of bidet toilets were found to be contaminated by one or more of the following organisms [5]: o S. aureus, Streptococcus spp o Enterococcus spp o Enterobacteriaceae o non-glucose-fermenting rods (NFR) o other Gram-negative bacteria • The nozzle surface of 87% and 94% of the spray water were found to be contaminated by one or more of the following organisms [6]: o Enterobacteriaceae o Enterococcus spp., o Staphylococcus spp., o non-glucose-fermenting rods, o other Gram-negative bacteria, o other Gram-positive bacteria o Candida spp.

5 Association with pre-term birth

Two studies investigated the bidet use and the association with pre term birth. Both came to differing conclusions. Asakura, Nakano [7] found that normal use of bidet toilets by pregnant women does not pose any clinical health risk with regard to preterm birth. In contrast, Kim, Kim [8] found that chronic bidet toilet use, before and during pregnancy, is associated with abnormal vaginal colonization by gram-negative bacteria (mostly by E coli) and preterm birth.

6 Implementing bidet in aged care or disability settings

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Two studies have investigated the use of bidet toilets in an aged care facility [9] and a spinal cord injury rehabilitation setting [10]. Both of these studies were of low quality with small sample sizes. In the nursing home setting, it was found that only 50% of nurses and residents responded positively to the use of the bidet. Logbook entries revealed that residents were rated as clean only 49% of the time, as slightly dirty 34% of the time, and in the range from somewhat to very dirty for the remaining 17% of the times that they used the wash-and-dry toilets. Therefore, residents still required cleaning following the use of a bidet in most instances.

In those with spinal cord injury time needed for bowel management with the modified bidet device was shorter than that with patients’ usual manner of bowel care (P 0.01). However, residual stools were found in 8 of the 15 patients.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
Evidence of infections
Asakura, Nakano [1]	To assess the relationship between bidet toilet use and haemorrhoids or urogenital infections.	Retrospective cross sectional survey A total of 18,562 people were randomly selected using a computer programme, to whom a web survey questionnaire was randomly delivered until the number of respondents exceed 10 000. A total of 10 305 individuals were involved in the baseline survey. 1-year and 3-year follow up studies were also conducted. See methods given in Kiuchi, Asakura [2] below for full details of questionnaire.	Final number of subjects analysed was 7759, giving a follow-up rate of 75.3%. 50.1% of respondents were habitual bidet users. They were more likely to be older, married and wealthier. In men, more habitual users reported subjective symptoms of irritated skin around the anus, which were newly experienced during follow-up than non-habitual users (adjusted risk ratio 1.36 (95% confidence interval 1.06—1.75)). Risk ratio based on prevalence of haemorrhoids diagnosed by a physician, subjective symptoms of haemorrhoids and subjective symptoms of irritated perianal skin were significantly higher in habitual users. Regarding women, no cumulative incidence of outcomes was significantly associated with bidet toilet use.	MODERATE Large sample, followed over many years. Still low prevalence rates of some conditions to determine an effect. Large number of respondents eliminated due to inconsistent outcomes.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
Garg [11]	Preliminary report of various cases of anterior fissure-in-ano.	Multiple Case Reports	10 patients of anal fissure in anterior Midline. Two patients presented with acute and eight patients had chronic fissures. 9 men and 1 female patient Age ranged from 22 to 46 years (median 36 years). Duration of symptoms ranged from 4 to 7 days in acute cases and 3-8 months (median 5 months) in patients with chronic fissure. All the patients reported using a bidet-toilet and exposing the perianal region to water stream for a few minutes (range: 1–5 min). They were recommended to stop the usage of such a water stream and were advised to use water poured from a container. Conservative treatment was also continued. All except one patient responded well to the treatment and became asymptomatic within 2–3 weeks. The patient who did not respond to the treatment required an operation.	VERY LOW Very brief report. Only descriptions provided. Considering the rarity of anterior fissure in men and the ‘cause and effect’ relationship seen in these cases, the water stream of the bidet-toilet being the causative factor of anterior fissure in these cases looks probable.
Kiuchi, Asakura [2]	To assess the relationship between habitual bidet toilet use and the incidence of haemorrhoids or urogenital infection.	Prospective web based survey 18,562 people were randomly selected from an online database to receive the questionnaire. A total of 10,305 individuals were involved in the baseline survey.	A total of 7637 subjects were analysed using single or multiple logistic regression models. The prevalence odds ratios (ORs) between bidet toilet users and non-users	MODERATE There is a positive relationship between habitual bidet toilet use and haemorrhoids and urogenital symptoms, except

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		A follow-up web survey was conducted in February 2014. 8255 of the baseline subjects participated again (follow up rate 80.1%). Survey questions • Frequency of bidet use: “never used”, “use less than once a week”, “use every day or more than once a week • Physician diagnosis and subjective symptoms of haemorrhoids, irritated perianal skin, cystitis, pyelonephritis, candida vaginitis, bacterial vaginitis, and vulvar pruritus. Baseline included questions about smoking, drinking, fitness, sleeping, showering/bathing, bowel movements, direction of wiping the anus after defecation, menstrual status, sexual activity, academic background, and past/current histories of diseases.	for haemorrhoids, urological infections, and vulvar pruritus were significantly >1.0 but their incidence ORs were not significant. The adjusted incidence OR for bacterial vaginitis symptoms was significant (2.662, 95% confidence interval [CI] [1.315–5.520]). No gender differences in relation to prevalence of disease/symptoms. Males more likely to be habitual bidet users.	bacterial vaginitis, were due to reverse causation. The incidence of bacterial vaginitis might be caused by bidet toilet use, but the incidence rates were too small to make a definite conclusion, and further studies are needed.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
Miura, Kimura [12]	Presentation a case of adverse effect after excessive bidet use.	Case Study 14-year-old boy presented to Hospital because of passage of blood and bloody stools for several months. The patient’s height was 165 cm, his weight was 45 kg. No physical abnormal findings of anus/rectum on examination. Laboratory data were all within reference ranges. Stool culture was negative. The patient had used a bidet since he was 2 years old. Recently he had been remaining in the bathroom for nearly an hour, using a stream of water at the highest flow setting.	An irregular, elevated, inflamed lesion in the rectal canal was found. At 10 cm from the anus, a raised, haemorrhagic lesion involving the posterior and right rectal wall was also found. Rectal mucosal prolapse syndrome diagnosed and caused by overuse of bidet.	VERY LOW Single case study.
Ogino, Iino [13]	The present study was designed to clarify the possible relevancy of bidet usage to changes in vaginal microflora	Cross Sectional Study Participants were recruited in a hospital setting, after attending for complaints relating to vaginal discharge. Inclusion criteria	268 women participated 57.6% were habitual bidet users. Normal microflora (Lactobacillus species) was not present in 42.86% of bidet toilet users, compared to 8.77% of non-users.	MODERATE Cross sectional, uncontrolled study. Relatively small sample to be able to generalise to the greater population.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		Women of reproductive age (from 19 to 40 years). All patients were questioned whether or not they were habitual bidet toilet users. Habitual users were defined as those who use bidet toilets every time at toileting. An aliquot of cervicovaginal secretion was obtained by a sterilized cotton swab and transferred into culture tubes	Faecal bacteria were detected in 50 of the 268 cases (18.66%), 46 cases in users (92%) and only 4 cases in non-users (8%). Contamination by other pathogens was 4 to 6 times higher in users than in non-users.
Shulman, Wolf [14]	Presentation a case of scald burn in the perianal region caused by using a bidet	Single Case Study 69-year-old female was admitted to the emergency room with a complaint of a pain in the right side of her perineum as a result of hot water from a bidet. Medical history Multiple sclerosis diagnosed 2 years prior to her admission and treated with immunoglobulins. In the last 6 weeks she had received high dose hydrocortisone due to exacerbation of the disease. As	Physical examination on arrival revealed a deep third degree burn in the right perianal region measuring less than 1% of total body surface area. The burn wound was debrided, its margins, close to the anal orifice were sutured. A course of oral antimicrobial treatment was initiated. Conservative treatment was maintained and recovery of the burn occurred within 9 weeks. No infection or other complications were observed.	VERY LOW Single case design. Lowest level on evidence hierarchy. In the case described, a lack of motor coordination in conjunction with sensory problems, caused a deep third degree burn to the right perianal region.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
Tsunoda, Takahashi [3]	To investigate the use of bidet toilets among community dwelling Japanese people and explored the correlates for an itch on the anus.	part of her disease she suffered from diminished sensation in the lower part of her body. Cross sectional survey Convenience sample Subjects were hospital outpatients and employees or students and employees at two technical colleges Inclusion criteria Aged >14 years old Data collection occurred over 2 weeks. Questionnaire • Basic demographic information (age and sex) • General questions on bidet toilet use • Questions targeting those who use bidet toilets before defecation • Questions targeting those who use bidet toilets after defecation	4,963 respondents included in the final analysis (3,190 (64 %) women and 1,773 men) The mean ± standard deviation (SD) (range) age of the respondents was 49.6 ± 20.2 years 55 % (2,724/4,952) of respondents washed the anus either before or after defecation 83 % (2,253/2,724) of the respondents reported that they had a bidet toilet at home Men, and older people (aged >50 years) used bidets more actively. Washing the anus before defecation was associated with constipation (p = 0.005). 28 % (698/2,500) of the respondents wiped off excess water with toilet paper many times.	MODERATE Convenience sample, subjective responses

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		• Questions targeting women who use bidet toilets to wash their genitals	Men might be affected by an itch on the anus, because they had faecal leakage more frequently (OR = 3.82) and used a bidet more actively.
Hygiene status of bidet toilets
Iyo, Asakura [4]	To survey the state of residual chlorine and microbial indicators in the spray water of warm-water tanks of bidet toilet seats. To evaluated the disinfection status and microbial hygiene of the spray water.	Prospective survey (of bacterial presence) Residual chlorine and microorganism indicators in the spray water from the warm-water bidet toilet seats were surveyed twice. Spray water Spray water was collected directly as it came out of the nozzle, and tap water was used as a control. Tap water Approximately 50 mL of tap water was collected for residual chlorine testing in sterilized bottles.	A total of 127 seats were analysed. There were 43 toilet seats for men’s use, 71 for women’s use, and 13 for barrier-free use. Spray water from the toilet seats had less residual chlorine than their tap water sources. However, the total viable microbial count was below the water-quality standard for tap water. Heat of the toilet seats’ warm-water tanks caused bacteria in the source tap water to proliferate inside the nozzle pipes and the warm water tanks. Pseudomonas aeruginosa was detected on about 2% of the toilet seats. P. aeruginosa was found to remain for long durations in biofilms that formed inside warm-water tanks.	LOW The existence of P. aeruginosa in spray water, even at low levels is concerning. This has the potential to cause opportunistic infections, especially in immunocompromised individuals.
Kanayama Katsuse, Takahashi [5]	To investigate the distribution of antimicrobial-resistant	Cross sectional survey	254 (86.9%) were found to be contaminated by one or more of the	MODERATE

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
	bacteria recovered from bidet toilets at a university-affiliated hospital in Japan.	All 292 electronic bidet toilets at a single hospital in Japan were sampled for bacterial contamination. Swabs were used to sample the warm spray jet from nozzles and toilet seats. Chromosomal DNA analysis by pulsed-field gel electrophoresis of S. aureus, E. coli and P. aeruginosa isolates were performed.	following organisms: S. aureus, Streptococcus spp., Enterococcus spp., Enterobacteriaceae, non-glucose-fermenting rods (NFR) and other Gram-negative bacteria. Enterobacteriaceae were isolated from 84 (28.8%) bidet toilets: E. coli, Enterobacter spp., Klebsiella spp., Citrobacter spp. and other Enterobacteriaceae were found in warm-water nozzles of 38 (13.0%), 22 (7.5%), 13 (4.5%), five (1.7%) and six (2.1%) bidet toilets, respectively.	Single cross sectional study. Unable to confirm ongoing contamination. Authors conclude that warm-water nozzles of bidet toilets are contaminated with a wide range of bacteria, making them a potential vehicle for infection. In the hospital setting, shared use of bidet toilets must consider the clinical background of patients. Based on these findings, bidet toilets must be part of the risk management programme, and steps should be included for monitoring and disinfection.
Tsunoda, Otsuka [6]	To evaluate the hygiene status of bidet toilets	Prospective survey (of bacterial presence) A total of 192 tank type bidet toilets were surveyed, of those 103 were in an inpatient ward (48 individual, 55 shared), 34 were in an outpatient clinic, and 55 were in a research building for employees. Sampling protocol	Of the 192 toilets sampled, the nozzle surface of 167 (87%) and the spray water of 181 (94%) were found to be contaminated by one or more of the following organisms: • Enterobacteriaceae • Enterococcus spp., • Staphylococcus spp., • non-glucose-fermenting rods, • other Gram-negative bacteria, • other Gram-positive bacteria • Candida spp.	LOW Because the interval of scrubbing the toilets did not have an influence on the contamination of the spray water, self-cleaning mechanisms of spray water should be developed to prevent patients’ possible infections.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		• Nozzle surface was sampled using swabs before spray water • Spray water was collected directly as it came out of the nozzle • Tap water for control specimens was collected from faucets in the restrooms which were surveyed	An extended spectrum of $\beta$-lactamase producing Escherichia coli was found in one nozzle surface and one spray water. The frequency of colonization from the nozzle surface was significantly greater in the toilets scrubbed every week than that in the units scrubbed every day. The nozzle surface and the spray water in the bidet toilets were contaminated with a wide range of bacteria.
Association with pre-term birth/pregnancy
Asakura, Nakano [7]	To estimate the association between bidet toilet use and preterm birth, as well as the effect of bidet toilet use on bacterial vaginosis, in pregnant women.	Retrospective cross sectional survey All women who gave birth between 2006 and 2010, at Keio University Hospital in Tokyo were invited to participate. A structured, 6-page questionnaire containing 27 questions about bidet toilet use and other lifestyle factors was sent via mail.	The final response rate was 64.1% Of 1,293 women, 63.3% were users of bidet toilets. The incidence of preterm birth was 15.8% among bidet users and 16.0% among nonusers. Incidence was 9.8% for late preterm birth and 6.0% for early preterm birth. No association between bidet toilet use and the incidence of preterm birth (adjusted OR 1.04, 95% confidence interval [CI] 0.72 — 1.48).	MODERATE Big sample, however, retrospective surveys lack reliabilities due to recall bias. Not generalizable to greater female population. Normal use of bidet toilets by pregnant women does not pose any clinical health risk with regard to preterm birth.

Table 1. Literature Review

Author	Aim/Objective	Methods	Results	Level & Quality of evidence
	To evaluate the association of bidet toilet use with abnormal vaginal microbial colonization and preterm birth (PTB) in high-risk pregnancies.	Analysis focused on those who had a microbiological screening test conducted at approximately 35 weeks. Bidet toilet use before and during pregnancy, was collected by a self-report questionnaire. Primary outcome of this study was the incidence of preterm birth. Preterm birth, delivery before 33 weeks of gestation was defined as early preterm birth. Secondary outcome was bacterial vaginosis estimated by the balance of lactobacilli and non-lactobacillus microbes. Prospective Cohort Study Pregnant women, who were hospitalized in high-risk units from April 2015 to July 2017, in two tertiary hospitals in Seoul, South Korea were recruited. Cases with delivery due to maternal foetal indications (N = 4) were excluded.	No association was observed between bidet toilet use and bacterial vaginosis (adjusted OR 0.96, 95% CI 0.70—1.33). No association between bidet toilet use and intestinal bacteria (adjusted OR 0.97, 95% CI 0.68—1.38) or between bidet toilet use and bacterial vaginosis– related bacteria (adjusted OR 1.00, 95% CI 0.73-1.36). Detection rate of fungi was significantly higher among bidet toilet users (adjusted OR 1.68, 95% CI 1.14-2.48) 32.8% of the patients responded as users of a bidet toilet. There were no significant differences in the maternal baseline characteristics, such as the age, the rate of primiparity, and pre pregnancy BMI. Abnormal vaginal microbial colonization was significantly higher in the bidet user group, compared to the nonuser group (60.7% vs 44.2%, P = 0.036).	MODERATE Prospective, more precise questions asked and swabs used to determine infection rather than recall. Authors conclude that chronic bidet toilet use, before and during pregnancy, is associated with abnormal vaginal colonization by gram-negative

Table 1. Literature Review

Research — Adverse effects of bidet use

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Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		Patients completed a questionnaire which included questions, such as bidet use, purpose of use, duration, mode (feminine mode: cleansing genital lesion, general mode: cleansing anus, or both mode), frequency, time, and strength of the bidet toilet. Vaginal cultures were taken at the time of admission.	This higher rate of abnormal vaginal colonization was attributed to the increased colonization of gram negative bacteria (16.4% vs 6.7%, P = 0.039), especially E. coli (13.1% vs 3.3%, P = 0.023). Preterm delivery rate of bidet users was significantly higher than that of non-users (87.3% vs 73.0%, P = 0.040).	bacteria (mostly by E coli) and preterm birth.
Implementing bidet in aged care or disability settings
Cohen-Mansfield and Biddison [9]	To investigate the feasibility of using a “wash-and-dry” toilet in the nursing home.	Pseudo randomised trial Luscence Luxury Lavage toilet used. Recruitment focused on female residents who had been identified by nursing staff as having difficulty with cleanliness or toileting care. Participants randomised to experimental or control group. 15 women received new toilets and were included in the experimental group and 13	14 experimental and 8 comparison participants. 27 nursing assistants, of whom 82% were female were interviewed. 8 (57%) of participants in the experimental group had some difficulty in communicating or could not always answer all the questions. Feasibility 64% (n = 9) of residents were not able to operate the remote control and therefore required staff assistance.	LOW Not completely randomised, small sample, significant drop out rate, self-reported questionnaires used, however, high percentage of participants were unable to provide responses. This severely effects the reliability of the study. The toilet offered some help with cleaning and drying residents, it was not sufficiently

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Table 1. Literature Review

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Author	Aim/Objective	Methods	Results	Level & Quality of evidence
		women were included in the comparison group Procedure Interviews conducted each week with the nursing assistant and residents participating. Following toilet instillation all baseline assessments were repeated each week, an additional toilet reaction scale was administered to the experimental group. Final assessments administered after 2 months. Outcome measures • Resident questionnaires: toileting experience and reaction • Nursing staff questionnaires: toileting experience • Urine test • Demographic data	Nursing assistants often not willing to use the bidet as easier to change an adult diaper. 50% (n = 7) of residents were reported to be physically or mentally disabled and consequently difficult to either verbally persuade or physically lift onto the toilet. Reaction questionnaire Approximately half of staff and residents responded positively to the use of the bidet. Logbook entries revealed that residents were rated as clean 49% of the time, as slightly dirty 34% of the time, and in the range from somewhat to very dirty for the remaining 17% of the times that they used the wash-and-dry toilets. 86% of participants in the comparison group versus only 36% in the experimental group had significant bacterial growth in their urine. Toilet installation was more complex than anticipated.	thorough in this regard, and it requires further development.

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Table 1. Literature Review

Research — Adverse effects of bidet use

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Author	Aim/Objective	Methods	Results	Level & Quality of evidence
Uchikawa, Takahashi [10]	To study the effectiveness of a modified washing toilet seat equipped with a CCD camera monitor and an electronic bidet to facilitate precise hitting of the anal area with water streams to stimulate bowel movement in patients with spinal cord injury.	Multiple Case Study Design Washing toilet seat equipped with an electronic bidet, a CCD camera and a light. All participants had traumatic SCI. All patients were at least 5 months post-acute injury and could independently transfer to the toilet seat and change their position on it while watching the CCD monitor. The maximum duration of stimulation was set at 30 mins, and the maximum power of the water stream was used. After 30 mins, the amount of residual stool in the rectum was examined using digital evacuation.	20 patients, all males, mean age was 46.3 years (SD 17.9, range 18–73). The level of injury was cervical in 11 patients, thoracic in 7 patients, and lumber in 2 patients. Fourteen of the 20 patients (70%) could not direct the water stream precisely to the anorectal area without the use of the monitor. Bowel movement was successfully induced with the modified device within 30 mins [average time 17mins (range 3–28)] in 75% of patients. Time needed for bowel management with the modified device was shorter than that with patients’ usual manner of bowel care (P 0.01). Time required for successful bowel movement was shortened in 11 of 13 patients (85%) who had spent more than 30 mins with their usual manner of bowel management. However, residual stools were found in 8 of the 15 patients.	LOW Small sample, no control group. No complications were observed, however, further research is needed to confirm positive results.

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7 References

Asakura K, Nakano M, Omae K. Relationship between bidet toilet use and haemorrhoids and urogenital infections: a 3-year follow-up web survey. Epidemiology and infection [Internet]. 2018; 146(6):[763-70 pp.]. Available from: doi:10.1017/S0950268818000584.
Kiuchi T, Asakura K, Nakano M, Omae K. Bidet toilet use and incidence of hemorrhoids or urogenital infections: A one-year follow-up web survey. Preventive medicine reports [Internet]. 2017; 6:[121-5 pp.]. Available from: https://dx.doi.org/10.1016/j.pmedr.2017.02.008.
Tsunoda A, Takahashi T, Arika K, Kubo S, Tokita T, Kameda S. Survey of electric bidet toilet use among community dwelling Japanese people and correlates for an itch on the anus. Environmental health and preventive medicine [Internet]. 2016; 21(6):[547-53 pp.]. Available from: https://doi.org/10.1007/s12199-016-0578-3.
Iyo T, Asakura K, Nakano M, Yamada M, Omae K. Bidet toilet seats with warm-water tanks: residual chlorine, microbial community, and structural analyses. Journal of water and health [Internet]. 2016; 14(1):[68-80 pp.]. Available from: https://dx.doi.org/10.2166/wh.2015.057.
Kanayama Katsuse A, Takahashi H, Yoshizawa S, Tateda K, Nakanishi Y, Kaneko A, et al. Public health and healthcare-associated risk of electric, warm-water bidet toilets. The Journal of hospital infection [Internet]. 2017; 97(3):[296-300 pp.]. Available from: https://dx.doi.org/10.1016/j.jhin.2017.07.021.
Tsunoda A, Otsuka Y, Toguchi A, Watanabe K, Nishino R, Takahashi T. Survey on bacterial contamination of bidet toilets and relation to the interval of scrubbing these units. Journal of water and health [Internet]. 2019; 17(6):[863-9 pp.]. Available from: https://dx.doi.org/10.2166/wh.2019.234.
Asakura K, Nakano M, Yamada M, Takahashi K, Sueoka K, Omae K. Effect of bidet toilet use on preterm birth and vaginal flora in pregnant women. Obstetrics and gynecology [Internet]. 2013; 121(6):[1187-94 pp.]. Available from: https://dx.doi.org/10.1097/AOG.0b013e318291bc16.
Kim Y-M, Kim JY, Lee M-Y, Choi S-J, Oh S-Y, Shim J-Y, et al. Prospective study of bidet toilet use: Association of abnormal vaginal colonization and preterm birth in high-risk pregnant women. The journal of obstetrics and gynaecology research [Internet]. 2019; 45(6):[1134-42 pp.]. Available from: https://dx.doi.org/10.1111/jog.13953.
Cohen-Mansfield J, Biddison JR. The potential of wash-and-dry toilets to improve the toileting experience for nursing home residents. The Gerontologist [Internet]. 2005; 45(5):[694-9 pp.]. Available from: https://doi.org/10.1093/geront/45.5.694.
Uchikawa K, Takahashi H, Deguchi G, Liu M. A Washing Toilet Seat with a CCD Camera Monitor to Stimulate Bowel Movement in Patients with Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation [Internet]. 2007; 86(3). Available from: https://journals.lww.com/ajpmr/Fulltext/2007/03000/A_Washing_Toilet_Seat_with_a_CCD_Camera_Monitor_to.6.aspx.
Garg P. Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: a preliminary report. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland [Internet]. 2010; 12(6):[601-2 pp.]. Available from: https://dx.doi.org/10.1111/j.1463-1318.2009.01867.x.
Miura T, Kimura K, Sato Y, Kanai N. Rectal mucosal prolapse syndrome and a bidet. Pediatrics international : official journal of the Japan Pediatric Society [Internet]. 2003; 45(4):[467-8 pp.]. Available from: https://ci.nii.ac.jp/naid/10011918291/.
Ogino M, Iino K, Minoura S. Habitual use of warm-water cleaning toilets is related to the aggravation of vaginal microflora. The journal of obstetrics and gynaecology research [Internet]. 2010; 36(5):[1071-4 pp.]. Available from: https://doi.org/10.1111/j.1447-0756.2010.01286.x.

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Shulman O, Wolf Y, Hauben DJ. Perianal burn caused by using the bidet. Burns : journal of the International Society for Burn Injuries [Internet]. 2001; 27(4):[413-4 pp.]. Available from: https://doi.org/10.1016/S0305-4179(00)00124-8.

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DOCUMENT 3

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For Internal Use Only

Smoke Alarm Regulations by Australian State and Territory Legislation

The content of this document is OFFICIAL.

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research question: What are the legislated smoke alarm requirements across Australian States and Territories?

Date: 21/3/22

Researcher: Stephanie Predacted: s22(1)(a)(ii) - irrelevant

Cleared by: Stephanie Predacted: s22(1)(a)(ii) - irrelevant

1. Contents

Smoke Alarm Regulations by Australian State and Territory Legislation …………………………….. 1

Contents ……………………………………………………………………………………………………….. 1
Introduction ……………………………………………………………………………………………………. 2
Australian Capital Territory ………………………………………………………………………………. 3
New South Wales …………………………………………………………………………………………… 3
Northern Territory…………………………………………………………………………………… 4
Queensland …………………………………………………………………………………………………… 5
South Australia……………………………………………………………………………………………….. 6
Tasmania ………………………………………………………………………………………………………. 6
Victoria ………………………………………………………………………………………………………….. 7
Western Australia ……………………………………………………………………………………………. 9
References ………………………………………………………………………………………………….. 10
Appendix 1 …………………………………………………………………………………………………… 12

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Appendix 2 …………………………………………………………………………………………………… 14
Version control ……………………………………………………………………………………………… 15

2. Introduction

Smoke alarm regulations for residential properties vary between Australian States and Territories. This paper provides a description of the legislated requirements and guidance provided by the State Governments in each State and Territory of Australia regarding installation of smoke alarms in residential dwellings.

Residential dwellings include: Class 1a buildings (typically standalone dwellings: detached houses, terrace houses, town houses and villa units), class 1b buildings (shared accommodation with floor area less than 300m2 and less than 12 people living in it), class 2 buildings (typically multilevel residential buildings: apartments, home units, flats), class 3 buildings (shared accommodation as for 1b but greater capacity: boarding house, hostel, backpackers, hotel, bed and breakfast), class 4 buildings (caretakers flats, single residences above shops), and relocatable homes such as campervans and caravans but excluding tents (Australian Building Codes Board, 2020; Fire and Rescue New South Wales, 2021a).

In each state, smoke alarms are regulated by Australian Standard AS3786:2014 – smoke alarms that use scattered light, transmitted light or ionization. This standard includes both ionization and photoelectric smoke detectors, however in some states photoelectric smoke detectors are mandatory.

Most states acknowledge that Deaf and Hard of Hearing people should have specialised smoke alarms that have strobe light and/or vibrating pad that are activated when smoke alarms sound. These devices are regulated by Australian Standard AS1603.17-2011 Automatic Fire Detection and Alarm Systems. Warning equipment for people with hearing impairment includes smoke alarms. However, this standard is not mandatory for Deaf and Hard of Hearing people (Fire and Rescue New South Wales, 2021b). Subsidy schemes provided by Victoria and Queensland for these specialised devices are described within the

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state information. The Tasmania Fire Service suggests there is a subsidy scheme, however no details were available at the time of this paper (Tasmania Fire Service, 2022).

In 2014, a National Construction Code was developed that stipulates all new (post-Jan 2014) or renovated dwellings with more than one smoke alarm must have the alarms interconnected to provide one common alarm (Australian Building Codes Board, 2016). There is variability in implementing this code. For example, in Queensland homeowners are required to retrofit interconnected alarms for all residential dwellings by 2027 whereas Victoria only requires new or renovated dwellings to have interconnected alarms.

This paper has been developed to assist TAB advisors who provide advice on fire safety assistive technology and should be read in conjunction with:

RES 2020/0077 Access, Egress and Fire Safety

3. Australian Capital Territory

Working smoke alarms that meet requirements of Australian Standard AS3786 are compulsory in the ACT (ACT Emergency Services Agency, 2019). Where possible, alarms should be interconnected. Photoelectric smoke alarms are recommended but not mandatory.
Properties must comply to the Building Code of Australia 3.7.2. – homes must have at least one smoke alarm per floor, and one in each space between bedrooms as illustrated in Appendix 1 (Smoke Alarm Testing Services, 2022a).
Minimum smoke alarm requirements (Smoke Alarm Testing Services, 2022a):
- Residential, constructed pre-Aug 1994: Stand-alone 9V battery powered smoke alarms
- Residential, constructed, renovated or extended after Aug 1994: Hard wired smoke alarms connected to 240V mains with back up battery

4. New South Wales

Clause 146A of the Environmental Planning and Assessment Act 1979 and Division 7A or Part 9 of the Environmental Planning and Assessment Regulation 2000 state that at least one working smoke alarm must be installed on each level in all buildings in NSW where people sleep (Fire and Rescue New South Wales, 2021c). This is a

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minimum level of protection; Fire and Rescue NSW recommend higher levels of protection for homeowners and occupants.

For rental properties, smoke alarms should be installed on or near the ceiling in each hallway connected to a bedroom or, if no hallway, then between the section of the home between the bedroom and rest of the dwelling (Smoke Alarm Testing Services, 2022b).
Landlords are responsible for the installation of smoke alarms; tenants are responsible for testing the batteries. For battery operated alarms the tenant is responsible for changing the battery; landlords are responsible for changing the battery in hard-wired battery backup alarms (Fire and Rescue New South Wales, 2021b).
Prior to June 2017, New South Wales had a Smoke Alarm Subsidy Scheme for Deaf and Hard of Hearing people, however the scheme ended 31 May 2017 (Combined Pensioners and Superannuants Association, 2018).

5. Northern Territory

Photoelectric smoke alarms must be installed in all residential premises or movable dwellings (e.g. caravans); they can be either hardwired to the home’s power supply or have a sealed lithium battery unit with 10-year life (Northern Territory Government, 2022).
Minimum smoke alarm requirements (Northern Territory Government, 2022):
- Residential, constructed pre-Jan 1998: 10-year battery or hard-wired photoelectric alarm
- Residential, constructed, renovated or extended post-Jan 1998: Hard wired photoelectric smoke alarm with back up battery
Homeowners with non-approved smoke alarms are not required to replace them until they stop working. If ionisation alarms have been installed, they do not need to be replaced with hardwired photoelectric alarms until: the ionisation alarm fails, the premises are sold or rented, a tenancy agreement is renewed or extended, or a hire agreement for the premises is entered into, renewed or extended (Northern Territory Government, 2022).
Property owners who sell or lease must have an approved photoelectric smoke alarm installed. Tenants are required to test each smoke alarm at least once every 12 months.

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Recommended placement is illustrated in Appendix 1 (Northern Territory Government, 2022):
- It is recommended that smoke alarms are installed on or near the ceiling. For cathedral ceilings, install the alarm between 50cm and 150cm from the apex to the top of the alarm. If it is necessary to install on a wall, the smoke alarm should be 30cm to 50cm below the ceiling.
- Smoke alarms should be placed between each bedroom area and the rest of the house; if a person sleeps with their door closed, there should be an alarm in that bedroom. For multilevel homes, an additional alarm should be in the stairway between each level.

6. Queensland

From January 2017, all smoke alarms manufactured more than 10 years ago must be replaced with photoelectric smoke alarms which comply with AS3786-2014 (Queensland Fire and Emergency Services, 2021).
Existing battery smoke alarms that need replacing must be replaced with a photoelectric smoke alarm. Existing hardwired smoke alarms that need replacement must be replaced with a hardwired photoelectric smoke alarm (Queensland Fire and Emergency Services, 2021).
From January 2022, landlords must install interconnected smoke alarms in all residential properties (Queensland Fire and Emergency Services, 2021). From January 2027 all homeowners must install interconnected photoelectric smoke alarms in every bedroom, hallway and every level (see Appendix 2); these must either be hardwired into 240V mains or have a non-removable 10yr battery (Queensland Fire and Emergency Services, 2021). A combination of mains powered and battery powered smoke alarms is allowed, and interconnectivity can be wired or wireless.
Queensland Fire and Emergency Services recommend that smoke alarms be installed on the ceiling close to the centre of the room and at least 30cm away from a wall. If the ceiling is not possible, then install on a wall between 30cm and 50cm from the ceiling.
Queensland have a smoke alarm subsidy scheme for Deaf or hard of hearing people. A specialised smoke alarm retails for $754.60 however can be provided for $50 without a concession, or $20 with a concession (Deaf Connect, 2022). Additional smoke alarms

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are available for $209.80 to comply with new Queensland legislation. Deaf Connect support NDIS participants who want to use their plan funding to access the subsidy scheme (Deaf Connect, n.d.).

7. South Australia

Homes or residential rental properties purchased pre-Feb 1998 require a replaceable battery powered smoke alarm (Government of South Australia, 2022)
Homes or residential rental properties purchased on or post-Feb 1998, as per Regulation 76B of the Development Regulations 2008 and Regulation 95 of the Planning, Development and Infrastructure (General) Regulations 2019, require a smoke alarm(s) to be installed within six months of title transfer. The smoke alarm(s) must be either: a) 240V mains powered or b) 10-year life, non-replaceable, non-removeable, permanently connected battery powered smoke alarm (Government of South Australia, 2022).
For homes or residential rental properties built post-Jan 1995, a 240V mains powered smoke alarm is required (Government of South Australia, 2022).
From May 2014, smoke alarms are required to be interconnected in all new Class 1 dwellings, within sole-occupancy unit of a class 2 or 3 building and in a class 4 part of a building (Department of Planning, Transport and Infrastructure, 2014). This also applies to new additions to existing dwellings, although they do not need to be interconnected with the older section of the dwelling. Subsequent building additions will need to have interconnected alarms (Department of Planning, Transport and Infrastructure, 2014).
Smoke alarms should be placed strategically, such as hallways outside of bedrooms, and there may be a need for more than one smoke alarm. One smoke alarm is required per level (Government of South Australia, 2022).
Monitored smoke detecting/security systems utilising smoke detectors and sounders may not comply with AS3786 and therefore not comply with regulation 76B. In these cases, owners and installers need to ensure that one or more AS3786 complying smoke alarms are also installed within each dwelling (Department of Planning, Transport and Infrastructure, 2014).

8. Tasmania

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From 1 August 1997, all new residential buildings and residences that have had renovations requiring a building permit are required to have at least one smoke alarm on each level and be connected to mains power supply (Master Electricians Australia, 2022).
Legislation requires that there is a smoke alarm in every hallway and at the top of stairways (Tasmania Fire Service 2022). It is recommended that smoke alarms are in bedrooms (see Appendix 1).
Smoke alarms should be replaced after 10 years.
Residential Tenancy (Smoke Alarm) Regulations 2012 outline the requirements for rental properties. From 1 May 2016, all residential rental properties must have smoke alarms installed on every level and either mains powered or use a 10-year non-removable battery (Master Electricians Australia, 2022; Tasmania Fire Service, 2022).
Subsidised smoke alarm packages for the Deaf and hard of hearing may be available from Expression Australia.

9. Victoria

All Victorian residential properties must have smoke alarms on every level that comply with AS3786 (Fire Rescue Victoria, 2020). Minimum requirements are listed in Table 1.
Minimum requirements for smoke alarms (Fire Rescue Victoria, 2020):
- Residential, constructed pre-Aug 1997 - stand-alone 9V battery powered smoke alarms
- Residential, constructed, renovated or extended post-Aug 1997 - Hard wired smoke alarms connected to 240V mains with back up battery
- Mandatory placement of smoke alarms and further recommendations are illustrated in Appendix 1.
Optimal placement of smoke alarms (Fire Rescue Victoria, 2020):
- outside each sleeping area and on each level in a multi-storey home
- on the ceiling close to the centre of the room and at least 30cm away from a wall. If the ceiling is not possible, then install on a wall between 30cm and 50cm from the ceiling

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cathedral ceilings need further consideration: smoke alarms should be between 50cm and 150cm of the apex, or on a side wall between 30cm and 50cm from the level ceiling
consideration also needs to be given to placement of windows, doors, air conditioners, heaters, fans, air vents and other temperature control devices that may impact the performance of the smoke alarm
smoke alarms should not be installed in kitchens or bathrooms
Interconnected smoke alarms provide the best protection. These can be hardwired by an electrician or wireless connecting via a blue-tooth connection.
If using a 9V battery it needs to be replaced every year. Smoke alarms should be replaced every 10 years maximum.
In rental properties, it is the landlord’s responsibility to install smoke alarms, ensure they are kept in good repair, and replace batteries each year. Tenants are responsible for testing smoke alarms monthly (Fire Rescue Victoria, 2020).
Residents of public housing have a smoke alarm powered by mains with 10yr lithium back up battery (Fire Rescue Victoria, 2020). The battery cannot be changed but should be tested monthly.
People who are deaf or hard of hearing should have specialised smoke alarms. Some have vibrating pads, strobe lights or emit different sounds. Each alarm should have at least two sensory alert types (Fire Rescue Victoria, 2020).
- The Victorian Government provides a subsidy for smoke alarms that alert via flashing light and vibrating pad (Expression Australia, 2022). To be eligible:
  - severe to profound loss or a severe high frequency hearing loss ≥ 70dB (2, 3 & 4kHz).
  - resident of Victoria
  - not eligible for other funding such as NDIS
- This unit retails at $629; eligible people will be $50 out of pocket; concession card holders can have the fee waived.
No subsidy scheme is highlighted for people with other disabilities. It is suggested that smoke alarms in residences of people with a disability should be connected to a personal alarm system that is monitored externally (Fire Rescue Victoria, 2020).

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10. Western Australia

Smoke alarms must comply with the Building Code of Australia, which specifies the relevant Australian Standard for residential smoke alarms (AS 3786) and the location of installation (Department of Fire and Emergency Services, n.d.). Appendix 1 illustrates mandatory and recommended placement of additional smoke alarms.
Smoke alarms can be either ionisation or photoelectric as they both comply with the Building Code of Australia, however photoelectric are recommended (Department of Mines, Industry Regulation and Safety, n.d.).
Compliant smoke alarms are not older than 10yrs, are in working order, and are permanently connected to mains power supply (Department of Mines, Industry Regulation and Safety, n.d.).
Battery powered smoke alarms may be approved where mains power is not connected to the dwelling or there is no hidden space in the existing dwelling for wiring in existing dwellings. Battery powered smoke alarms must have a non-removable 10yr life battery (Department of Mines, Industry Regulation and Safety, n.d.)
Smoke alarms connected to home security may not comply with the code – smoke alarms need to be permanently connected to mains power (some home security systems can be disconnected and therefore are not suitable for smoke alarm systems) (Department of Mines, Industry Regulation and Safety, n.d.).
Interconnection of smoke alarms is not applicable to dwellings with construction approval prior to 1 May 2015 (Department of Mines, Industry Regulation and Safety, n.d).
Owners are required to maintain the smoke alarm: ensure working order, permanently connected to mains power, less than 10yrs old or has not reached the expiry printed on the back, has a 10yr battery in the event mains power is not available (Department of Mines, Industry Regulation and Safety, n.d.).
The owner of a dwelling must have compliant smoke alarms installed prior to the sale of the property or if being made available under tenancy agreement.

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11. References

ACT Emergency Services Agency. (2019). Smoke alarms. [Fact sheet]. Accessed 18/3/22 from https://esa.act.gov.au/sites/default/files/2021-03/Smoke%20Alarm%20fact%20sheet%201b_Acc.pdf

Australian Building Codes Board. (2016). National Construction Code 2016 Volume 2 Part 3.7.2 Smoke alarms. Accessed 18/3/2022 from https://ncc.abcb.gov.au/editions/2016/ncc-2016-volume-two/part-37-fire-safety/part-372-smoke-alarms

Australian Building Codes Board. (2020). Building classifications. Understanding the NCC. [Fact sheet]. Accessed 18/3/22 from https://ncc.abcb.gov.au/sites/default/files/resources/2020//UTNCC%20Building%20classifications.PDF?msclkid=5bcccba0a63a11ecb3fc56c4868cffe6

Combined Pensioners and Superannuants Association. (2018). Hearing impaired robbed of smoke alarm subsidy. Accessed 18/3/22 from https://cpsa.org.au/article/hearing-impaired-robbed-of-smoke-alarm-subsidy/?msclkid=8914dfdaa65111ec808f947dadaab724

Country Fire Authority. (2021). Installation and Maintenance. Accessed 8/3/22 from https://www.cfa.vic.gov.au/plan-prepare/fires-in-the-home/smoke-alarms/installation-and-maintenance

Deaf Connect. (2022a). Smoke alarm subsidy scheme. Accessed 18/3/22 from https://deafconnect.org.au/community-resources/smoke-alarm-subsidy-scheme

Deaf Connect. (n.d.). Smoke alarm subside scheme application form. Accessed 18/3/22 from https://deafconnect.org.au/wp-content/uploads/2022/03/Smoke-Alarm-Subsidy-Scheme-SASS-Application-Form.pdf

Department of Fire and Emergency Services. (n.d.). Installing smoke alarms. Government of Western Australia. Accessed 18/3/2022 from https://www.dfes.wa.gov.au/site/fire-in-the-home/smoke-alarms.html?msclkid=e03f58e1a64d11eca25c7f270f75b011

Department of Mines, Industry Regulation and Safety. (n.d.). Smoke alarm laws for existing dwellings. [Fact sheet]. Government of Western Australia. Accessed 11/3/22 from Smoke-alarm-laws-for-existing-dwellings%20DMIRS%202021-07-01.pdf%20(dfes.wa.gov.au)

Department of Planning, Transport and Infrastructure. (May 2014). Building advisory notice 05/14 [fact sheet]. Government of South Australia.

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https://plan.sa.gov.au/__data/assets/pdf_file/0005/285368/Building-advisory-notice-05-14-Technical-New-requirements-for-the-interconnection-of-smoke-alarms.pdf

Expression Australia. (2022). Smoke alarm subsidy. Accessed 8/3/22 from https://www.expression.com.au/services/smoke-alarm-subsidy

Fire and Rescue New South Wales. (2021a). Smoke alarms in the home. Accessed 18/3/22 from https://www.fire.nsw.gov.au/page.php?id=288

Fire and Rescue New South Wales. (2021b). Smoke alarms for the deaf and hearing impaired. [Fact sheet] Accessed 8/3/22 from https://www.fire.nsw.gov.au/page.php?id=629

Fire and Rescue New South Wales. (2021c). What is the law? Accessed 8/3/22 from https://www.fire.nsw.gov.au/page.php?id=439

Fire Rescue Victoria. (26/06/2020). Smoke alarms. Accessed 8/3/22 from https://www.frv.vic.gov.au/smoke-alarms

Government of South Australia. (2022). Smoke alarms. https://www.sa.gov.au/topics/planning-and-property/owning-a-property/smoke-alarms

Master Electricians Australia. (2022). Smoke alarm requirements. Accessed 11/3/22 from Smoke Alarm Requirements (masterelectricians.com.au)

Northern Territory Government. (2018). Smoke alarms. https://nt.gov.au/emergency/community-safety/fire-safety-at-home/smoke-alarms#:~:text=Under%20Northern%20Territory%20%28NT%29%20law%2C%20approved%20smoke%20alarms,or%20agent%20if%20an%20alarm%20does%20not%20work.

Queensland Fire and Emergency Services. (2021). Smoke alarms. For existing dwellings. Accessed 11/3/22 from https://www.qfes.qld.gov.au/prepare/fire/smoke-alarms/existing-properties

Smoke Alarm Testing Services. (2022a). ACT Smoke Alarm Legislation. Accessed 8/3/22 from https://www.sats.com.au/act/

Smoke Alarm Testing Services. (2022b). NSW Smoke Alarm Legislation. Accessed 8/3/22 from https://www.sats.com.au/nsw/

Tasmania Fire Service. (2022). Smoke alarms. Rental properties. Accessed 11/3/22 from https://www.fire.tas.gov.au/Show?pageId=colSmokeAlarm

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12. Appendix 1

Illustration of mandatory and optional smoke alarm placement diagrams as indicated by Victoria, ACT, Northern Territory, Tasmania, and Western Australia (Country Fire Authority, 2021; Department of Fire and Emergency Services, n.d.; Fire Rescue Victoria, 2020; Northern Territory Government, 2018; Tasmania Fire Service, 2022)

Diagram 1

MASTER BEDROOM	DINING	KITCHEN	BEDROOM
LIVING	ENTRY	BATH	BEDROOM

🟢 Optimal smoke alarm
🔴 Required smoke alarm

Diagram 2

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Diagram 3

House with cathedral ceilings (not to scale)

Smoke alarm can be located in this space; between 50cm and 150cm of the top apex

Dead air space

30cm min distance

50cm max distance

Smoke alarm can be located in this space; between 30cm and 50cm of the ceiling at a Side wall

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13. Appendix 2

Mandatory placement of smoke alarms in all residential dwellings as per Queensland legislation from 1 January 2027 (Queensland Fire and Emergency Services, 2021)

Diagram 4

Diagram 5

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14. Version control

Version	Amended by	Brief Description of Change	Status	Date
0.1	SJP131	Initial draft	Draft	11/3/22
0.2	SJP131	Draft revision	Draft	17/3/22
0.3	AHR908	Draft review	Draft	17/3/22
0.4	SJP131	Draft revision	Draft	18/3/22
1.0	SJP131	Clearance		21/3/22

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Effectiveness of standard and specialised smoke alarms to wake children and adults

The content of this document is OFFICIAL.

Please note:

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

What evidence is available on the effectiveness of:

Standard fire/smoke alarms (may need to consider domestic and commercial settings?)
Adaptive fire/smoke alarms (visual and tactile or vibration alarms)

Is there any literature that relates specifically to people with hearing impairments versus those without a hearing impairment?

Is there evidence regarding any age groups that typically be awakening and appropriately responding to fire/smoke alarm independently without assistance from an adult/parent?

Expected cost range for visual and tactile/ vibration alarms (hardwired /battery options)

How could current literature inform advice provided against the R&N criteria?

Date: 4/4/2022

Requestor: Karyn Mredacted: s22(1)(a)(ii) - irrelevant

Endorsed by (EL1 or above): N/A

Researcher: Stephanie Predacted: s22(1)(a)(ii) - irrelevant

Cleared by: Stephanie Predacted: s22(1)(a)(ii) - irrelevant

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1. Contents

Effectiveness of standard and specialised smoke alarms to wake children and adults ………….. 1

Contents ……………………………………………………………………………………………………….. 2
Summary ………………………………………………………………………………………………………. 3
Background ……………………………………………………………………………………………………. 3 3.1 Types of smoke alarm ………………………………………………………………………………….. 3 3.2 Characteristics of fires ………………………………………………………………………………….. 4 3.3 Domestic vs commercial fires ……………………………………………………………………… 4 3.4 Summary of domestic fire statistics in Australia 2003-2017 …………………………… 5
Assessment of Smoke Alarms ………………………………………………………………………….. 5 4.1 Standard smoke alarm reliability …………………………………………………………………….. 5 4.2 Standard smoke alarm waking effectiveness …………………………………………. 6 4.3 Vibration and strobe light smoke alarm waking effectiveness …………………………… 7 4.4 Low frequency and voice alarm waking effectiveness ……………………………………….. 8 4.5 Factors influencing effectiveness of smoke alarms …………………………………………. 9
Price for popular visual/tactile smoke alarm systems………………………………………… 10 5.1 Brooks ………………………………………………………………………………………………….. 10 5.2 Bellman Visit Smoke Alarm pack ……………………………………………………….. 11 5.3 Visualert ……………………………………………………………………………………………….. 12 5.4 Google Nest Protect Smoke Alarm ……………………………………………………….. 13
Reasonable and necessary ……………………………………………………………………………. 13 6.1 Ages 0-4 years ………………………………………………………………………………………….. 14 6.2 Ages 5-12 years ………………………………………………………………………………………… 14 6.3 Ages 13-17 years ……………………………………………………………………………………. 15 6.4 18+ / Adult ………………………………………………………………………………………………… 15
Visualert quote ……………………………………………………………………………………………… 17
References ………………………………………………………………………………………………….. 18
Version control ……………………………………………………………………………………………… 21

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2. Summary

Smoke alarms have been proven to save lives. For people who are Deaf or Hard of Hearing, there are specialised smoke alarm systems that use strobe light and/or a pillow vibration device to create an alert signal. There is some evidence in the literature that standard and specialised alarm systems do not reliably wake children, placing them at risk in the event of a residential fire if they are not assisted to escape. There is evidence in the literature that smoke alarms with vibration devices are effective in waking adults who are Deaf or Hard of Hearing from a deep sleep, which would increase the likelihood of a safe escape in the event of a residential fire. The literature indicates that strobe lights are much less effective than vibration devices in waking adults.

3. Background

3.1 Types of smoke alarm

The two most common types of smoke alarm in Australia are the ionisation smoke alarm and photoelectric smoke alarm (Fire and Rescue New South Wales (FRNSW), 2017). The Australian standard for smoke alarms, AS 3786:2014 – smoke alarms using scattered light, transmitted light or ionization, encompasses both of these smoke alarm technologies (Standards Australia, 2022). However, some states in Australia are beginning to mandate the use of photoelectric smoke alarms in Australian dwellings – this is covered in the research paper RES 231 Smoke alarm regulations by Australian State.

A standard for sound and pitch of smoke alarms is not specified, however the most used sound in Australian residential smoke alarms is a continuous 3.1 kHz beep (Thomas & Bruck, 2010a). Ionisation and photoelectric smoke alarms are available in 9V replacement battery, long-life lithium battery and hardwired to mains power options.

Most Australian states and territories recommend smoke alarms adapted for the Deaf and Hard of Hearing in their regulations, however these are not mandatory to install – see RES 231 Smoke alarm regulations by Australian State for further information. Alarm kits for the Deaf and Hard of Hearing people include a smoke alarm connected to a strobe light and/or vibrating

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device (Willoughby, 2009). Standards Australia provides requirements for the individual components used in fire warning systems, including visual and vibrating components, for people with hearing impairment – AS 1603.17:2020 (Standards Australia, 2022).

3.2 Characteristics of fires

Fire and Rescue New South Wales (2017) describe two main types of fire: flaming and smouldering. Flaming fires have a visible flame and all combustible surfaces have reached ignition temperature resulting in full room involvement (FRNSW, 2017). A common source of flaming fires is in the kitchen while cooking (Department of Fire and Emergency Services, n.d.). Smouldering fires are slower to develop, lower temperature and flameless (FRNSW, 2017). Overload of electrical appliances or smoking materials such as cigarettes or incense are common causes of a smouldering fire (Department of Fire and Emergency Services, n.d.).

It was found by FRNSW (2017) that ionisation alarms are activated more quickly with flaming fires and photoelectric alarms activate earlier with smouldering fires. As 62.5% of smouldering fires transition to a flaming fire, the FRNSW (2017) recommend dual smoke alarms that have ionisation and photoelectric technology.

3.3 Domestic vs commercial fires

A study by He and Nelson (2007) reflected that while commercial fires generally have a greater potential for loss of life and property, residential dwellings is where most fire fatalities and injuries occur in Australia. It was proposed this may be because commercial building regulations and legislative requirements are more stringent than in residential dwellings. Additionally, commercial buildings typically have a greater egress timeframe (in the tens of minutes) due to higher smoke reservoir, smoke control systems and sprinklers. Whereas residential buildings might only have a few minutes for safe egress and relies on satisfactory conditions for escape routes through hallways or directly via windows (He and Nelson, 2007).

It was also determined that greater communication during evacuation from commercial buildings, either from staff direction or following other people, increases the effectiveness of smoke alarms in a commercial setting (He and Nelson, 2007).

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3.4 Summary of domestic fire statistics in Australia 2003-2017

In a report commissioned by the Australian Government Department of Industry, Innovation and Science, it was found that children between the age of 0-4 years had the greatest number of deaths for any five-year age range during the 2003-2017 period accounting for 7.8% of fatalities (Coates et al, 2019). The age group most at risk of dying in a preventable residential fire was found to be people over 65 years, accounting for 36.4% of fatalities during this period (Coates et al, 2019). Of all fatalities recorded in this period, 61.8% were people with a disability (Coates et al, 2019).

The report found that the most common time for fires was between midnight and 4am when most people are asleep. However, data suggested that fatalities for people with a disability were most often between 8am and 12pm (Coates et al, 2019). It was suggested that the disability contributed to being unable to escape rather than not waking to the smoke alarm, but more research into this data was recommended (Coates et al, 2019).

4. Assessment of Smoke Alarms

4.1 Standard smoke alarm reliability

He and Nelson (2007) described the ability for smoke alarm systems to operate as required and sound quickly after detecting smoke as their reliability, and their ability to wake people from sleep as effectiveness. The FRNSW (2017) report found that ionisation alarms were quicker to alert with a flaming fire, and photoelectric alarms were quicker when the fire was smouldering.

Room of fire origin smoke alarms were found to be most reliable to activate quickly in the presence of smoke (FRNSW, 2017). Smoke alarms located behind a closed door to the room of fire origin were not found to be reliable to activate (FRNSW, 2017), which is relevant in the context of those Australian states and territories that only have mandatory smoke alarms in hallways outside of bedrooms (see RES 231 Smoke alarm regulations by Australian State for further information). Furthermore, when the room of fire origin was located on a second story, ionisation and photoelectric alarms on the lower level were found to activate only 50% of the

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time (Thomas & Bruck, 2010b). For these reasons, Thomas and Bruck determined that the type of smoke alarm installed was less important than where they were installed.

A higher percentage of fires reported to United States fire departments are in homes without smoke alarms (Gilbert, 2021). FRNSW (2017) found a moderate negative relationship between smoke alarms and fatalities (r = - 0.55), suggesting the presence of working smoke alarms reduced the risk of dying in a preventable residential fire. This data is supported by a German study that examined the impact of mandatory smoke alarm installation which found the fire fatality risk was reduced in 12 of 13 states after the regulation was introduced, with 5 of the 12 being statistically significant (Festag, 2021). Additionally, when the German regulations included installing smoke alarms in existing buildings there was a reduced risk of fatality in 6 of 6 states, with 5 of these 6 being statistically significant (Festag, 2021).

4.2 Standard smoke alarm waking effectiveness

A study by Bruck (1999) evaluated the effectiveness of the standard Australian smoke alarm in waking children and adults without a hearing impairment. They tested a smoke alarm level of 60dB at the pillow, which simulated the loss of sound intensity for a hallway alarm, and sounded the alarm for three minutes. All the adults woke within 32 seconds while only 23% of children (6-17 years old) woke to the three-minute alarm; when considering only the 6-15-year-old children the percentage reduced to 14% that woke with the alarm. The effectiveness of the standard Australian smoke alarm to wake adults without hearing impairment has been replicated in studies by Du Bois (2005) and He and Nelson (2007). He and Nelson (2007) also demonstrated that children aged 6-17 are less likely to wake with a standard smoke alarm, with only 32% waking to the standard alarm in their study.

Standard smoke alarms have not been found as effective to wake adults who are Hard of Hearing compared to adults who are not hearing impaired. Du Bois et al (2005) found only 57% of adults with hearing loss between 20-90dB woke to a standard smoke alarm, and Bruck and Thomas (2007) concluded only 56% of adults with hearing loss between 25-70dB in each ear waking to the standard Australian smoke alarm. As expected, the study by Du Bois et al (2005) found that standard smoke alarms did not wake Deaf adults.

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4.3 Vibration and strobe light smoke alarm waking effectiveness

A 1999 study by Underwriters Laboratories, Nortbrook, cited by Smedberg and Ronchi (2021), demonstrated 95% of adults woke to bed shakers with vibration frequency 100 Hz for four minutes. Of the 77 Deaf children, aged between 10 and 19 years old, between 77-100% woke with the stimulus. The effectiveness for children was shown to depend on the age group however the original paper could not be located for further information. Smedberg and Ronchi also noted this study did not control for sleep stage, so data was not collected with respect to whether participants were in a light sleep or deep sleep at the time of waking.

No further studies regarding the effectiveness of smoke alarm vibration devices in waking children were identified, however two studies for the effectiveness of nocturnal enuresis alarms were found. One study by Tobias and McCain (2001) compared the effectiveness of an audio alarm to a vibration device worn on the body for children between 6 and 12 years old. It was found one third of children in each group were either not awakened by the alerting signal or had an undesirable response such as being frightened by the alarm, disorientation, or throwing the alarm away. Another study by Teles and Lordelo (2016), participant ages were not reported, compared the effectiveness of sound, vibration, and code word enuresis alarms through a review of the literature. It was found alarms with code words improved the waking process compared to the other alarm technologies.

Current literature suggests that strobe lights as a stand-alone strategy is not effective in waking adults. A 1995 study by Bowman et al found only 35% of adults without hearing impairment woke with a strobe light when in deep sleep. Du Bois et al (2005) extended this research to evaluate the waking effectiveness of audible, visual and vibrational alarms for adults with and without hearing impairment: 32 participants were Deaf, 45 Hard of Hearing and 34 had no hearing impairment. The strobe light was most effective in waking Deaf participants, with 57% waking, followed by 34% of the Hard of Hearing participants and 32% of adults with no hearing impairment. The continuous bed shakers were effective in waking across all groups, with 93% of Deaf participants waking, 82% of Hard of Hearing participants and 92% of adults with no hearing impairment. Bed shakers that had an intermittent pattern woke 100% of participants in all groups.

Supporting this research, a 2009 study by Thomas and Bruck compared the waking effectiveness of strobe lights, pillow shakers and bed shakers for Hard of Hearing adults

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(mean age 54.4 years, age range 18-77 years). Results showed that the strobe light woke only 25% of participants, while the bed and pillow shakers woke 84% and 80% respectively.

No research that explored the effectiveness of waking children with a strobe light was found.

4.4 Low frequency and voice alarm waking effectiveness

As a result of the ineffectiveness of the standard smoke alarm to wake children and Hard of Hearing adults, research has been conducted to determine whether sounding a different alarm frequency or using spoken phrases would be more effective in awakening these cohorts.

In a study comparing the effectiveness of a voice alarm, low frequency sound pattern and standard Australian (3.1kHz) beeping alarm to wake sleeping children (aged 6-10 years), it was found that the voice alarm woke the children 100% of the time it was presented, the low pitch pattern 96.4% and the standard alarm only 57% of the time (Bruck et al, 2004). Additionally, the voice alarm and low frequency pattern were quicker to rouse the sleeping children than the standard alarm. Of the children who woke to the standard alarm, over 25% of them took up to 3 minutes to wake whereas the two other alarm systems woke the children within one minute (Bruck et al, 2004).

A further study by Smith et al (2020) compared the effectiveness of female voice, male voice and hybrid voice-low frequency tone smoke alarms with the standard Australian smoke alarm in waking children from deep sleep (aged 5-12 years old). Data showed the male voice (85%), female voice (87%) and hybrid voice-low frequency tone alarms (89%) more effective in waking the children than the standard smoke alarm (56%) (Smith et al, 2020). The studies by Bruck et al (2004) and Smith et al (2020) demonstrate a voice alarm and low frequency pattern are statistically similar in waking children from deep sleep, and statistically superior to the standard Australian smoke alarm.

Further highlighting the benefit of voice alarms for children, as discussed in Section 4.3 of this paper, a study evaluating the effectiveness of sound, vibration and code-word nocturnal enuresis alarms found code-word alarms improved the waking process compared to other alarms (Teles & Lordelo, 2016).

The 2009 study by Thomas and Bruck, discussed in Section 4.3, also evaluated the effectiveness of a low frequency 520Hz square wave signal compared to a strobe light, a vibration device and a standard Australian alarm for Hard of Hearing adults. The low frequency

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alarm was the most effective alerting signal, waking 92% of participants when presented at 75dBA and 100% at 95dBA. Therefore they concluded the most effective alert signal to wake a Hard of Hearing adult was a low frequency alarm; the vibration device was second most effective.

4.5 Factors influencing effectiveness of smoke alarms

Overall smoke alarm effectiveness is a combination of their ability to wake dwelling occupants from deep sleep and wake them quickly enough for adequate egress time.

4.5.1 Factors that influence waking

The ability to wake up to a smoke alarm follows several necessary steps (Bowman et al, 1995):

The brain receives the stimulus
The brain analyses the stimulus
If the stimulus is personally significant then impulses are sent to the appropriate brain area to evoke arousal from sleep

It has been theorised that as the prefrontal cortex matures between 12 and 24 years old, which is believed to be the brain area responsible for judgement decision-making including when asleep, the ability of a younger child’s brain to detect an alerting stimulus to wake the child may not have fully developed (Bruck et al, 2004). On the other hand, adults have the ability to continue to monitor the environment while they are asleep which makes sleep alarms more effective in waking them (Bruck et al, 2004).

Additionally, it has been suggested that alarms are less effective for children because they sleep for longer periods and experience more slow wave/deep sleep compared to adults (Bruck et al, 2004; Smith et al, 2020). The amount of slow wave sleep experienced declines as teenagers mature (Agostini & Centofanti, 2021), which is in line with the data that suggests smoke alarms become more effective to wake teenagers as they get older (Bruck, 1999). Children also have a higher auditory threshold than adults (Splaingard et al, 2007), so the average auditory stimulus required to wake a child is greater than that of an adult for each sleep stage (Smith et al, 2020).

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4.5.2 Factors that influence escape

The time it takes for an alarm to be triggered influences the likelihood of escape, which in turn is influenced by the type of fire, location of alarms and location of exits (FRNSW, 2017). Australian states and territories have their own regulations for the location of smoke alarms in residential dwellings – outlined in RES 231 Smoke alarm regulations by Australian State. Thomas and Bruck (2010b) found that the type of smoke alarm used was much less important than where they were installed and that they should be interconnected.

FRNSW (2017) report that children are unlikely to fully awaken from auditory stimulation by smoke alarms. Children experience greater sleep inertia than adults (Splaingard, 2007; Thomas & Bruck, 2010a), which is the impairment of cognitive and motor functioning on waking from deep sleep. Sleep inertia is responsible for the disorientation and confusion on waking (Smith et al, 2022), making it difficult for children to fully rouse and respond appropriately to an alarm. The unreliable awakening reaction of children to an alarm is another factor that influences the escape process (He & Nelson, 2007; Willoughby, 2009). It has been noted that in the event of an alarm some might children freeze with fear or hide (National Fire Protection Association, 2022; Willoughby, 2009) while others become disorientated as noted by Tobias and McCain (2001).

The ability to open windows and doors and navigate smoky corridors is another issue when it comes to escape for children and people with a disability (Tannous & Agho, 2018). Creating and regularly practising a family fire escape plan with different methods of escape will increase the likelihood of occupants escaping from the dwelling (Queensland Fire and Emergency Services, 2022; Tannous & Agho, 2018).

5. Price for popular visual/tactile smoke alarm systems

5.1 Brooks

Brooks is an ‘off the shelf’ option for both hardwired and long-life lithium battery photoelectric smoke alarm systems that can integrate with a hardwired strobe light (with battery backup) and vibration pad (Brooks Australia, 2022). The strobe light is designed to be wall mounted and, as it needs to be connected to the vibration pad, the mounting position must be close to the head of the bed (see Figure 1 below).

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Additional smoke alarms and strobe lights can be connected in living areas for daytime use. The price of one photoelectric smoke alarm, one strobe light and one vibrating pad ranges from $663 (hardwired smoke alarm) to $775.20 (lithium battery smoke alarm) plus electrician fees for hardwire installation. The price breakdown is as follows (Brooks Australia, 2022):

Photoelectric hardwired smoke alarm with battery backup $117.70, or
Photoelectric RadioLINK long-life lithium battery smoke alarm $229.90, and
Strobe with vibration pad $545.30

The Queensland Government smoke alarm subsidy for Deaf and Hard of Hearing people supply the Brooks system (Deaf Connect, n.d.).

Figure 1

Installation of Brooks smoke alarm, strobe light and pillow vibrator

(Brooks Australia, 2018)

5.2 Bellman Visit Smoke Alarm pack

The Bellman Visit Smoke Alarm pack is an ‘off the shelf’ alerting system for Deaf and Hard of Hearing people. The package retails for approximately $629 (Expression Australia, 2022) and includes one photoelectric smoke alarm powered by 9V lithium battery, one strobe light that includes mains adaptor and battery backup and one bed shaker to place under the pillow or mattress - the strobe light connects to the bed shaker. When the smoke alarm is activated it sends a radio signal to the strobe light which in turn activates the bed shaker (Expression Australia, 2022a).

Additional smoke alarms can be connected to the system. Further technology, such as doorbell kits and pager receivers, can also be added to the home alert system (Expression Australia, 2022a).

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An advantage of this system is that installation does not need to be done by an electrician and individual components can be replaced easily in the event of damage to the item.

The Victorian Smoke Alarm Subsidy scheme for the Deaf and Hard of Hearing people supplies the Bellman smoke alarm package (Expression Australia, 2022b).

(Expression Australia, 2022a)

5.3 Visualert

Visualert is a customisable alert system that is provided after consultation with the provider Assistive Tech Suppliers. There is limited information about Visualert systems on their website as enquiries are directed through a quote process. One system is highlighted on the website, The U-Fire Panel, which is hardwired and includes: 5 red LED cornice lights, 1 bed shaker and 2 smoke detectors. Pricing is not available on the Visualert website (Visualert™ U-Fire Panel | Visualert).

Pricing information for a Visualert system was obtained from a TAB advice dated 14/02/2022, which totalled $7483.91 (quote provided in Section 7 of this paper). The package included one Visualert ‘starter system’, one doorbell with sound, one additional smoke detector, and postage and handling. Electrician installation was not included in this price, a further quote for electrical installation was included for $2992.00. The electrician’s quote was for installation of 1 video intercom, 2 smoke detectors, 5 corner flashing LED lights, 1 bed vibrator and 1 light vibration muting button.

Although the literature does not support strobe lights as an effective mechanism to wake sleeping adults, strobe lights in each corner of the room may increase the probability of providing a strobe light alarm with sufficient brightness to wake the room occupant. However there is no evidence in the literature to support increasing the number of lights is more

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effective. A disadvantage of this system could be that people renting might not be able to install all the necessary hardwired components in their dwelling.

5.4 Google Nest Protect Smoke Alarm

Google Nest Protect is an ‘off the shelf’ item with hardwired and long-life lithium battery options. It uses advanced photoelectric technology to sense smoke then send an alarm signal to a phone or tablet (iOS or android). The Google Nest Protect also senses carbon monoxide levels in the home. The Google Nest is designed to give an early warning that there is smoke or increased carbon monoxide levels detected by giving a voice warning and also sending a message to the mobile device. If smoke or carbon monoxide levels become critical, Google Nest Protect will sound the alarm, pulse red and voice where the emergency is as well as send an emergency notification to the mobile device. The smoke alarm can also be set so a ‘Pathlight’ can be activated to help leave the dwelling. The device has a 10-year warranty.

Potential disadvantages of this system are that it relies on a charged functioning mobile phone and WI-FI network. Advantages are this system provides escape instructions by voice and phone message – which may be beneficial after waking and overcoming sleep inertia. Also, notifications can be received by mobile phone while out of the house meaning fire services can be contacted quickly in the event someone is known to be home.

Google Nest Protect Smoke Alarm (hardwired and battery) $189

(JB Hi-Fi, 2022)

6. Reasonable and necessary

Reasonable and Necessary assessment as guided by the literature has been conducted by age group to reflect the differing needs and abilities of these cohorts.

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6.1 Ages 0-4 years

Children under five years old represent the greatest number of fatalities from preventable residential fires of any other 5-year age range (Coates et al, 2019). This age group are dependent on their parents and cannot be expected to open windows or doors to safely evacuate on their own (Smith et al, 2020; Willoughby, 2009). Additionally, children under 5 are at risk of being disorientated, freezing or hiding after being woken by an alarm (FRNSW, 2017). There is no supporting evidence in the literature that providing a specialised smoke alarm system would improve the outcome for this age group in the event of a residential fire. Therefore, funding specialised smoke alarms for this age group would be unlikely to meet Reasonable and Necessary criteria.

6.2 Ages 5-12 years

Children between 5-12 years old have an unreliable waking response (He & Nelson, 2007). This age group have a higher fatality rate in residential fires than teenagers or adults as they are likely to sleep through an alarm (He & Nelson, 2007; Smith et al, 2022).

There was limited literature supporting vibrational devices waking 77-100% of children between 10-17 years old, however the original 1991 paper could not be sourced for further analysis of the data. No literature was discovered in relation to the effectiveness of strobe lights waking children from deep sleep.

When children do wake from deep sleep by an alarm, studies have shown some children in this age range have an undesirable response such as being disorientated, afraid and therefore hiding which increases their risk of perishing in the fire, or throwing the alarm (FRNSW, 2017; Splaingard et al, 2007; Tobias & McCain, 2001; Willoughby, 2009).

Successful self-escape from a residential fire relies on the ability to recall an escape plan, open doors and windows and navigate smoky corridors to make an escape (Tannous & Agho, 2018). Due to the unreliable waking response of this age group, as noted above, this cohort is still reliant on support to escape in the event of a fire. Ultimately, it was concluded by Willoughby (2009), that it is the parents’ or carers’ responsibility to safely support this age group to evacuate. Therefore, providing specialised smoke alarm systems for this age group is unlikely to meet reasonable and necessary criteria.

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6.3 Ages 13-17 years

While some researchers have concluded that children over 13 years can respond well in an emergency (Smith et al, 2020; Willoughby, 2009), it still needs to be considered on an individual basis whether a child has the physical, emotional and cognitive capacity to initiate self-rescue when woken by a specialised smoke alarm. Successful escape from a residential fire depends on their ability to recall their escape plan and ability to open doors, windows and navigate smoky corridors to make their escape (Tannous & Agho, 2018).

Current literature notes the unpredictability of children under 17 years old to wake up from deep sleep by an alarm (Bruck, 1999; He and Nelson, 2007), therefore it would be reasonable to trial a smoke alarm system to ensure the child between 13-17 years can consistently be woken by a specialised smoke alarm. The Bellman Visit Smoke Alarm pack and Brooks smoke alarm systems are the most cost-effective options to trial the effectiveness of a specialised smoke alarm system for children in this age group.

6.4 18+ / Adult

Residential smoke alarms have been proven to save lives. The typical residential smoke alarm emits a high frequency signal that has been shown to be ineffective in waking Deaf or Hard of Hearing people (Du Bois et al, 2005). Therefore, it is reasonable and necessary to provide Deaf or Hard of Hearing adults with a specialised smoke alarm system.

There is some evidence that strobe lights wake Deaf people, however they have been shown to be less effective for Hard of Hearing people (Du Bois et al, 2005; Thomas and Bruck, 2009). Vibrational devices have been shown to be more effective in waking Hard of Hearing people from deep sleep (Du Bois et al, 2005; Thomas and Bruck, 2009).

Some of the common specialised smoke alarms available have been discussed in Section 5. The Bellman Visit Smoke Alarm pack is the system provided by the Victorian Government subsidy scheme while the Queensland subsidy scheme provides a Brooks smoke detector, flashing strobe light and vibration pad (Deaf Connect, n.d.; Expression Australia, 2022b).

The commercial price of the lithium battery operated Bellman and Brooks systems are $629 and $775 respectively, and both systems provide a photoelectric smoke alarm, strobe light and vibrating device.

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The Visualert system must be hardwired and, as per the obtained quote, has more components in the package, including a video intercom. There is no evidence in the literature demonstrating a video intercom improves the effectiveness of a residential smoke alarm system. The Visualert system provides a greater number of strobe lights to place in the corner of the room, however there is no evidence in the literature to show that a greater number of lights will result in waking from deep sleep. The Visualert system is custom designed for each purchaser so a set price is unable to be determined, however the provided quote was almost $7,500. It is unlikely this system would meet reasonable and necessary criteria given there are more cost-effective options available, and these other options are considered suitable and utilised by state government subsidy schemes.

A newer option available commercially is the Google Nest Protect smoke alarm. While this alarm may not be suitable for adults who are Deaf or experience severe hearing loss, it may be beneficial for adults with high frequency hearing loss but can still hear the spoken evacuation instructions that are sounded by the alarm. This is a simpler system than the Bellman or Brooks systems, incorporating only a smoke alarm and a downloaded app onto a mobile device. The smoke alarm itself changes colour when alerting and activates the mobile device. For people who sleep with a mobile device in their bedroom, this may be a sufficient warning system for the detection of smoke or carbon monoxide.

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7. Visualert quote

Quote (09/11/2021) from Visualert™ for:
- 1 x Visualert™ Starter System - $5998.80
- 1 x doorbell with sound - $245
- 1 x additional smoke detector - $134.75
- Postage and Handling - $425
- GST - $680.36
  - TOTAL=$7483.91
Quote from Beal Electrical for:
- Wire and install Visualert system as per plan
  - 1 x video intercom
  - 2 x smoke detectors
  - 5 x corner flashing LED lights
  - 1 x bed vibrator
  - 1 x light vibration muting button TOTAL: $2992.00

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8. References

Agostini, A., & Centofanti, S. (2021) Normal sleep in children and adolescence. Child and Adolescent Psychiatric Clinics of North America, 30(1), 1-14. http://dx.doi.org/10.1016/j.chc.2020.08.011

Bowman, S. K., Jamieson, D. G., & Ogilvie, R. D. (1995). Waking effectiveness of visual alerting signals. Journal of rehabilitation research and Development, 32(1), 43-45. PMID: 7760267.

Brooks Australia. (2022). Home smoke alarms. Available from https://www.brooks.com.au/home-smoke-alarms/

Brooks Australia. (2018) Deaf & Hearing Impaired RadioLINK Alarm System. Available from https://www.brooks.com.au/index.cfm/_api/render/file/?method=inline&fileID=EDDAD047-4DBA-4A45-AF31FCAA98564B83

Bruck, D. (1999). Non-awakening in children in response to a smoke detector alarm. Fire Safety Journal, 32(4), 369-376. https://doi.org/10.1016/S0379-7112(98)00035-6

Bruck, D., Reid, S., Kouzma, J., & Ball, M. (2004). The effectiveness of different alarms in waking sleeping children. In Interscience Communications, pp 279-290. The 3rd International Symposium on Human Behaviour in Fire, Belfast, Northern Ireland, London. Available from https://vuir.vu.edu.au/447/1/kids_-_belfast.pdf?msclkid=167428cdb0a611ecac7a8b4f283d37ca

Coates, L., Kaandorp, G., Harris, J., van Leeuwen, J., Avci, A., Evans, J., George, S., Gissing, A., van den Honert, R., & Haynes, K. (2019). Preventable residential fire fatalities in Australia July 2003 to June 2017. Bushfire and Natural Hazards CRC. Available from https://www.bnhcrc.com.au/publications/biblio/bnh-5807?msclkid=8ef233e6b08411ec99f7de8076986451

Deaf Connect. (n.d.). How to install your new smoke alarm [fact sheet]. Available from https://deafconnect.org.au/wp-content/uploads/2022/03/SASS-How-to-install-smoke-alarm-.pdf

Department of Fire and Emergency Services. (n.d.). Types of smoke alarms [fact sheet]. Government of Western Australia. Available from https://www.dfes.wa.gov.au/safetyinformation/fire/fireinthehome/FireintheHomeFactsheets/DFES-Smoke-Alarm-Fact-Sheet1-Types-of-Smoke-Alarms.pdf?msclkid=f4ff8e83b14011ec898b0b3ac98843d5

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Du Bois, J., Ashley, E., Klassen, M., & Roby, R. (2005). Waking effectiveness of audible, visual and vibratory emergency alarms on people of all hearing levels. Available from https://tap.gallaudet.edu/Emergency/Nov05Conference/Papers/Du%20Bois.html

Expression Australia. (2022a). Bellman Visit Smoke Alarm Package. Available from https://shop.expression.com.au/products/bellman-visit-smoke-alarm-pack?msclkid=0d6d6a7bb09811ec9341760fe9e184ee

Expression Australia. (2022b). Smoke alarm subsidy. Available from https://www.expression.com.au/services/smoke-alarm-subsidy#:~:text=The%20Victorian%20smoke%20alarm%20subsidy%20scheme%20is%20a,ensure%20safety%20within%20your%20home%2C%20particularly%20when%20asleep.?msclkid=bed44a07b16211ecb532bb163ed3f879

Festag, S. (2021). Analysis of the effectiveness of the smoke alarm obligation — experiences from practice. Fire Safety Journal, 119. https://doi.org/10.1016/j.firesaf.2020.103263

Fire and Rescue New South Wales. (2017). Smoke alarms in homes: an analysis. Fire research report. New South Wales Government. Available from https://www.fire.nsw.gov.au/gallery/files/pdf/research/Fire%20research%20report%20%20Smoke%20Alarms%20in%20Homes%20An%20Analysis.pdf

Gilbert, S. W. (2021). Estimating smoke alarm effectiveness in homes. Fire Technology, 57, 1497-1516. https://doi.org/10.1007/s10694-020-01072-z

He, Y., & Nelson, D. (2007). A comparative study of effectiveness of smoke alarms in two types of buildings. Journal of Fire Sciences, 26, 415-434.

JB Hi-Fi. (2022). Google Nest Protect Smoke Alarm (Battery). Available from https://www.jbhifi.com.au/products/google-nest-protect-smoke-alarm-battery?msclkid=36af9d0eb09811ecb052b87fb0271064

National Fire Protection Association. (2022). When you hear a smoke alarm, get outside and stay outside. Available from https://www.nfpa.org/Public-Education/Teaching-tools/Learn-not-to-burn/Learn-Not-to-Burn-Preschool-Program/When-you-hear-a-smoke-alarm-get-outside-and-stay-outside

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Queensland Fire and Emergency Services. (2022). Fire escape. Available from https://www.qfes.qld.gov.au/Fire-Escape#Create

Smedberg, E., & Ronchi, E. (2021). Review of alarm technologies for Deaf and Hard of Hearing populations [Report 3238]. Department of Fire Safety Engineering, Lund University, Sweden. Available from https://www.nfpa.org//-/media/Files/News-and-Research/Fire-statistics-and-reports/Detection-and-signaling/RFAlarmsForDeafHOH.ashx

Smith, G. A., Chounthirath, T., & Splaingard, M. (2020). Comparison of the effectiveness of female voice, male voice and hybrid voice-tone smoke alarms for sleeping children. Pediatric Research, 88, 769-775. https://doi.org/10.1038/s41390-020-0838-1

Smith, G. A., Kistamgari, S., Splaingard, M. (2022). Optimizing smoke alarm signals for those at highest risk for residential fire-related death: testing the effectiveness of children’s smoke alarms for sleeping older adults. Fire Technology, 58, 311-326.

Splaingard, M., Hayes, J., & Smith, G. A. (2007). Impairment of reaction time among children awakened during stage 4 sleep. SLEEP, 30(1), 104-108. http://dx.doi.org/10.1093/sleep/30.1.104

Standards Australia. (2022a). Standards catalogue. AS 3786:2014. Available from https://www.standards.org.au/standards-catalogue/sa-snz/building/fp-002/as--3786-colon-2014

Standards Australia. (2022b). Standards catalogue. AS 1603.17:2020. Available from https://www.standards.org.au/standards-catalogue/sa-snz/building/fp-002/as--1603-dot-17-colon-2020

Tannous, W. K., & Agho, K. E. (2018). Factors associated with home fire escape plans in New South Wales: a multinomial analysis of high-risk individuals and New South Wales population. International Journal of Environmental Research and Public Health, 15. https://dx.doi.org/10.3390%2Fijerph15112353

Teles, A., & Lordelo, P. (2016). Alarm for the treatment of enuresis: review of treatment types and treatment efficacy. Journal of Sleep Medicine & Disorders, 3(6). Available from https://www.researchgate.net/profile/Patricia-Lordelo/publication/311100785_Journal_of_Sleep_Medicine_Disorders_Central_Alarm_for_the_Treatment_of_Enuresis_Review_of_Treatment_Types_and_Treatment_Efficac

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/links/583d82c208ae61f75dc43e1f/Journal-of-Sleep-Medicine-Disorders-Central- Alarm-for-the-Treatment-of-Enuresis-Review-of-Treatment-Types-and-Treatment-

Efficacy. pdf

Thomas, I., & Bruck, D. (2009). Strobe lights, pillow shakers and bed shakers as smoke alarm signals. Fire Safety Science, 9. http://dx.doi.org/10.3801/IAFSS.FSS.9-415

Thomas, I., & Bruck, D. (2010a). Awakening of sleeping people: a decade of research. Fire Technology, 46, 743-761. https://doi.org/10.1007/s10694-008-0065-5

Thomas. I., & Bruck, D. (2010b). Smoke alarms in dwellings: timely activation and effective

notification [Technical report]. Victoria University, Melbourne.

Tobias, N. E. & McCain, G. C. (2001). A comparison of two enuresis alarms. Urologic Nursing, 21(5), 349-353. PMID: 11998300.

Willoughby, L. (2009). Review of the fire alarm subsidy scheme for Deaf and hard of hearing

Victorians. The Victorian Deaf Society, Melbourne.

9. Version control

Version	Amended by	Brief Description of Change	Status	Date
0.1	SJP131	Document creation	Draft	1/4/22
1.0	SJP131	Final document	Cleared	4/4/22

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Machine translation and speech to text

technology for Deaf and hard of hearing

The content of this document is OFFICIAL. Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

What is the accuracy of translation technology including text-to-text (English-to-Mandarin, Mandarin-to-English) and speech-to-text software (English-to-English, English-to-Mandarin, Mandarin-to-English) compared to a live translator?
What are the benefits or drawbacks of using translation technologies to navigate everyday encounters for a Deaf person with a limited knowledge of AUSLAN compared to using a live AUSLAN interpreter?

Date: 15/2/2024 Requestor: Sam V redacted: s22(1)(a)(ii) - irrelevant material Endorsed by: Naomi R redacted: s22(1)(a)(ii) - irrelevant material Researcher: Aaron H redacted: s22(1)(a)(ii) - irrelevant material Cleared by: Stephanie P redacted: s22(1)(a)(ii) - irrelevant material

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1. Contents

Machine translation and speech to text technology for Deaf and hard of hearing …………………. 1

Contents ……………………………………………………………………………………………………….. 2
Summary ………………………………………………………………………………………………………. 2
Sign language recognition technology ……………………………………………………………….. 3
Speech to text ………………………………………………………………………………………………… 3 4.1 Speech to text for people who are Deaf or hard of hearing ………………………………… 4
Combined translation and speech to text ……………………………………………………………. 5 5.1 Mandarin-English translations ……………………………………………………………………….. 6 5.2 Combined translation and speech to text for people who are Deaf or hard of hearing 6
Sub heading ………………………………………………………… Error! Bookmark not defined.
References ……………………………………………………………………………………………………. 7

2. Summary

Automated Speech Recognition (ASR) and machine translation are artificial intelligence tools used to convert one type of linguistic input into a different type of linguistic output. ASR converts spoken language into text. Machine translation converts an input from one language into another. These tools may be combined in applications that translate spoken utterances of one language into text of another language.

Some ASR tools approach human levels of accuracy in certain scenarios, such as simple words or phrases delivered in environments free from noise. Performance of these tools is significantly worse in environments with lower signal to noise ratios. Commercially available ASR tools are currently used by people who are Deaf or hard of hearing. Usefulness of these tools varies by context and goals of the user.

Machine translation tools generally produce less accurate translations than human interpreters. Accuracy varies by source and target language. Machine translation tools are generally more accurate in translating between European language rather than between European and Asian languages. Studies evaluating accuracy of translations between English and Mandarin find accuracy rates of between 36% and 82%. No research was found that addresses use of machine translation technologies for people who are Deaf or hard of hearing.

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Researchers and users suggest machine translation and ASR may be useful in situations where human interpreters are not available or where the risks associated with miscommunication are low. Additional safeguards are recommended in situations where accuracy is important (such as educational, medical or legal contexts). These tools may be more useful in situations that do not require immediate response, for example, situations where a transcript is produced and might be considered for accuracy.

Research shows that accuracy of both machine translation and ASR is improving with refinements of individual tools and advances in artificial intelligence.

3. Sign language recognition technology

Sign language recognition technology (SLR) is … Implementations of SLR vary widely, with emphasis on different features and purposes. The technology is often still in an experimental phase. There are some commercially available options which may be useful in some specific situations. However, SLR has certain drawbacks and often shows a lack of understanding of sign language grammar and Deaf cultural considerations. For further details on SLR, refer to RES ### for further information about Sign Language Recognition technology.

4. Speech to text

Automatic Speech Recognition (ASR) tools convert speech into text using advanced machine learning tools and sophisticated language models. These models employ grammatical rules alongside statistical analyses and predictive algorithms to disambiguate the speech signal and produce the most likely arrangement of words (Pucci, 2023; O’Shaughnessy, 2023; Dhanjal & Singh, 2023). The technology is also used widely in other commercial products. Most mobile phones have built in speech to text features (e.g. Siri, Alexa). Microsoft Teams, Zoom and YouTube use ASR to generate captions for meetings, calls or videos (Kustritz et al, 2023; O’Shaughnessy, 2023; Millet et al, 2021).

ASR is often assessed using word error rate. This is an objective measure that tracks how many words in a speech are incorrectly transcribed. However, this measure does not differentiate between high risk and low risk errors (Pucci, 2023; Kustritz et al, 2023; O’Shaughnessy, 2023; Weigel, 2021). Some studies attempt to differentiate between raw word error rate and meaningful error rate. For example, Kustritz et al (2023) differentiate between raw word error rate and medically significant error rate. A medically significant error is one which would have changed the meaning of a sentence and taught the student something medically incorrect. Millet describes the experience of encountering a meaningful error in a real-life situation:

Poor captioning produced by speech recognition software is in fact worse than no captioning, in my opinion, as it is distracting and requires extra processing time on the part of the reader to identify whether it is in fact an error, to decide whether to ignore it or not. If it is a meaning-laden word or term, the listener must then use precious time

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and cognitive processing resources to figure out what was actually said. I used an example in a recent presentation of a “real-time” YouTube-provided caption (from a video produced by a university), which showed “anxiety is particularly important because it is one of the Communist mental health problems” instead of what was actually said, which was “anxiety is particularly important because it is one of the commonest mental health problems.” Audience members reported being immediately distracted by the error, and noted that it took them a few seconds to get back to paying attention to the actual text (by which time, they had missed a sentence or two of content) (Millet, 2022).

Generally, ASR is found to be less accurate than human speech recognition when measured by word error rate, especially in environments with lower signal to noise ratios or when input includes words and phrases that sound similar (e.g. like, likes, liked). Humans are skilled at disambiguating words based on meaningful context, but this is still a hurdle for ASR tools (Kustritz et al, 2023; O’Shaughnessy, 2023; Pragt et al, 2022; Millet, 2022; Ngueajio & Washington, 2022). However, ASR tools vary widely in accuracy. Studies have found mixed results for variables such as accent, gender and speech velocity (Dhanjal & Singh, 2023; Kustritz et al, 2023; Ferrero et al, 2023; Millet, 2022; Ngueajio & Washington, 2022; Pragt et al, 2022). Some tools may approach human level accuracy in certain contexts, such as single words and short phrases or environments with clear sound quality (such as audio recorded in a studio) (Dhanjal & Singh, 2023; Kustritz et al, 2023; Ferrero et al, 2023; Millet, 2021). For example, ASR is effective when identifying strings of numbers when used in telephone Interactive Voice Response services (O’Shaughnessy, 2023). Millet et al (2021) found ASR used by YouTube, Otter, Google Slides and Microsoft Stream could reach 98-99% in optimal conditions. Kustritz et al (2023) found no statistically significant difference between raw word error rate or medically significant error rate between human generated captions and YouTube generated captions. However, word error rate was doubled in tools used by Zoom and Kaltura. Ferrero et al (2023) assessed 10 ASR tools and found word error rate was significantly linked to type and quality of input. Different tools performed better when tested on different datasets, but no tool performed best all round.

4.1 Speech to text for people who are Deaf or hard of hearing

ASR may be useful for people who are deaf or hard of hearing, though this will depend on the person’s level of hearing loss, their goals and the speech situation. ASR users prefer speed of transcription over accuracy in low-risk situations, whereas in situations requiring high levels of understand (educational environments, legal or medical contexts), accuracy is prioritised over speed of transcription (Pucci, 2023). In one study of ASR accuracy, Pragt et al note that in high signal-to-noise environments “ASR apps performed similarly to a person with a moderate hearing loss. In noise, the ASR apps performed more poorly than most profoundly deaf people using a hearing aid or cochlear implant” (2022, p.1).

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ASR might also be used as a supplemental tool and not the only communication tool by some sign language users. For example, this could involve a sign language interpreter and ASR app working simultaneous (Pucci, 2023; Burner et al, 2023). An early study comparing the effect of sign language interpretation and human generated transcription in a classroom found no significant differences in levels of understanding of the Deaf or hard of hearing students (Marschark et al, 2006). They suggest that using both signed interpretation and text supports did not improve understanding in an educational context. However, no other studies were found that compare efficacy of signed and text supports.

5. Combined translation and speech to text

Machine translation tools are programs which automate features of the translation process aiming to produce a complete translation of a text from one language to another (Bowker, 2023; Yang et al, 2023). Machine translation has progressed rapidly in recent years. Earlier systems worked using a combination of vocabulary and grammatical rules to construct translation. Modern systems employ technology like that used by ASR, including advanced machine learning techniques and statistical analyses to predict a correct translation. These systems require very high volumes of digital texts to improve the accuracy of translations. They work better for languages or domains where these resources are available. For languages with less available data or for specialist or niche subject matters, modern machine translation tools may be less reliable (Bowker, 2023; Phrase, 2023). For example, a 2021 study found Google Translate’s accuracy rate for Spanish to English translation was 94%, but 67.5% for Farsi to English and 55% for Armenian to English (Phrase, 2023).

In some cases, output may be edited by a professional translator before it is used. Combining human and machine translation saves time and reduces possibility of error. However, this would not be practical in situations where real-time translation is required, such as medical appointments or social interactions (Bowker et al, 2023; Yang et al, 2023; Herrera-Espejel & Rach, 2023).

Machine translation tools can be combined with ASR to offer real-time speech-to-text translation. Such technology combines the errors acquired in the ASR process with the errors acquired in the machine translation process. Acceptability of a translation depends on the context. In situations where misunderstanding is likely to have significant consequences, such as legal or medical contexts, the threshold for acceptable translation may be higher than for low stakes social contexts (Bowker et al, 2023).

Several studies caution that machine translation technology is not a suitable replacement for professional interpretation services (Bowker, 2023; Lee et al, 2023; Taira et al, 2021; Panayiotou et al, 2019). Some studies recommend qualified use of the technology in higher stakes situations such as healthcare (Hunter et al, 2023; Herrera-Espejel & Rach, 2023). For example, an Australia review into translation apps looked at 15 different apps and found only 2 that may be suitable for everyday communication in the healthcare setting (CALD Assist and

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TalkToMe). However, these apps were only found to be suitable when including simple preset health phrases (Panayiotou et al, 2019).

5.1 Mandarin-English translations

Translation technology is strongest between related languages. For example, translations from English using Google Translate were shown to be most accurate when translated into other European languages and lowest when translated into African or Asian languages (Yang et al, 2023; Phrase, 2023; Hunter et al, 2023; Panayiotou et al, 2019). Assessments of the accuracy of translations between English and Mandarin vary widely between 36% to 81.7% (Hunter et al, 2023; Lee et al, 2023; Tiara et al, 2021).

Lee et al (2023) compared the translations between Mandarin and English by three machine translation apps (Google Translate, Apple iTranslate, and Microsoft Translator). They found translation was more accurate when translated from English rather than to English. Overall Microsoft Translator had the highest accuracy when translating from English to Mandarin at 76% and equal highest accuracy (with Apple iTranslate) from Mandarin to English at 39% (refer to Table 1). Hunter et al suggest English-Mandarin translation are especially problematic “due to linguistic differences such as divergent syntactic structures, omitted pronouns in Mandarin, and a higher prevalence of English morphology” (2023, p.2).

Table 1 Accuracy (%) of Mandarin-English translations using three machine translation apps (Source: Lee et al, 2023, p.2335)

Translation app	From English	To English
Apple iTranslate	62	39
Google Translate	74	36
Microsoft Translator	76	39

5.2 Combined translation and speech to text for people who are Deaf or

hard of hearing

No papers were found that addressed the use of machine translation combined with ASR tools for Deaf people or those with a hearing impairment. One study (Saloni & Singh, 2020) mentions that these technologies may be of use to the Deaf community, however no detail is provided.

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6. References

Berner, K., & Alves, A. N. (2023). A scoping review of literature using speech recognition technologies by individuals with disabilities in multiple contexts. Disability and Rehabilitation: Assistive Technology, 18(7), 1139-1145, https://doi.org/10.1080/17483107.2021.1986583 Bowker, L. (2023). De-mystifying Translation: Introducing Translation to Non-translators. Taylor & Francis. Dhanjal, A.S., Singh, W. (2023). A comprehensive survey on automatic speech recognition using neural networks. Multimedia Tools and Applications. https://doi.org/10.1007/s11042-023-16438-y Ferraro, A., Galli, A., La Gatta, V., & Postiglione, M. (2023). Benchmarking open source and paid services for speech to text: an analysis of quality and input variety. Frontiers in big data, 6, 1210559. https://doi.org/10.3389/fdata.2023.1210559 Fresno, N. (2023). Live captioning accuracy in English-language newscasts in the USA. Universal Access in the Information Society. https://doi.org/10.1007/s10209-023-01030- w Hunter, D., Oates, R., Anderson, N., Kok, D., Sapkaroski, D., & Wright, C. (2023). Validation testing of a language translation device for suitability in assisting Australian radiation therapists to communicate with Mandarin-speaking patients. Technical innovations & patient support in radiation oncology, 26, 100207. https://doi.org/10.1016/j.tipsro.2023.100207 Hwang, K., Williams, S., Zucchi, E., Chong, T. W. H., Mascitti-Meuter, M., LoGiudice, D., Goh, A. M. Y., Panayiotou, A., & Batchelor, F. (2022). Testing the use of translation apps to overcome everyday healthcare communication in Australian aged-care hospital wards- An exploratory study. Nursing open, 9(1), 578–585. https://doi.org/10.1002/nop2.1099 Kustritz, M. R., Rupprecht, R., & Zhitnitskiy, P. (2023). Comparison of accuracy of machine- generated or human-generated captions of Zoom live lectures in a comparative theriogenology course. Clinical Theriogenology, 15, 52-56. https://doi.org/10.58292/ct.v15.9596 Marschark, M., Leigh, G., Sapere, P., Burnham, D., Convertino, C., Stinson, M., Knoors, H., Vervloed, M. P., & Noble, W. (2006). Benefits of sign language interpreting and text alternatives for deaf students’ classroom learning. Journal of deaf studies and deaf education, 11(4), 421–437. https://doi.org/10.1093/deafed/enl013 Millet, P. (2022). Improving Accessibility with Captioning: An Overview of the Current State of Technology. Canadian Audiologist. https://canadianaudiologist.ca/issue/volume-6-issue- 1-2019/column/in-the-classrooms/

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Millett, P. (2021). Accuracy of Speech-to-Text Captioning for Students Who are Deaf or Hard of Hearing. Journal of Educational, Pediatric & (Re) Habilitative Audiology, 25. Ngueajio, M.K., Washington, G. (2022). Hey ASR System! Why Aren’t You More Inclusive?. In: Chen, J.Y.C., Fragomeni, G., Degen, H., Ntoa, S. (eds) HCI International 2022 – Late Breaking Papers: Interacting with eXtended Reality and Artificial Intelligence. HCII 2022. Lecture Notes in Computer Science, vol 13518. Springer, Cham. https://doi.org/10.1007/978-3-031-21707-4 30 Panayiotou, A., Gardner, A., Williams, S., Zucchi, E., Mascitti-Meuter, M., Goh, A. M., You, E., Chong, T. W., Logiudice, D., Lin, X., Haralambous, B., & Batchelor, F. (2019). Language Translation Apps in Health Care Settings: Expert Opinion. JMIR mHealth and uHealth, 7(4), e11316. https://doi.org/10.2196/11316 Phrase. (2023). How Accurate Is Google Translate? 2023 Performance Report https://phrase.com/blog/posts/is-google-translate-accurate/#google-translate-accuracy- overview Pragt, L., van Hengel, P., Grob, D., & Wasmann, J. A. (2022). Preliminary Evaluation of Automated Speech Recognition Apps for the Hearing Impaired and Deaf. Frontiers in digital health, 4, 806076. https://doi.org/10.3389/fdgth.2022.806076 Pucci, M. (2023). Towards Universally Designed Communication: Opportunities and Challenges in the Use of Automatic Speech Recognition Systems to Support Access, Understanding and Use of Information in Communicative Settings. In Design for Inclusion (Garofolo & Bencini, Eds.). 18-25. O’Shaughnessy, D. (2024). Trends and developments in automatic speech recognition research. Computer Speech and Language, 83. C. https://doi.org/10.1016/j.csl.2023.101538 Romero-Fresco, P.& Fresno, N. (2023). Accuracy of automatic and human live captions in English. Linguistica Antverpiensia, New Series: Themes in Translation Studies, 22, 114–133. https://doi.org/10.52034/lans-tts.v22i.774 Roychowdhury, P., Castillo-Bustamante, M., Gandhi, D., Knoll, R. M., Wu, M. J., Kozin, E. D., & Remenschneider, A. K. (2023). Evaluating the accuracy of speech to text applications for cochlear implant candidates during COVID-19. Cochlear implants international, 24(1), 1–5. https://doi.org/10.1080/14670100.2022.2120450 Saloni & Singh, W. (2020). Multilingual speech to text conversion. Advances in Mathematics: Scientific Journal. 9(6). https://doi.org/10.37418/amsj.9.6.77 Stevens, M. N., Dubno, J. R., Wallhagen, M. I., & Tucci, D. L. (2019). Communication and Healthcare: Self-Reports of People with Hearing Loss in Primary Care Settings. Clinical gerontologist, 42(5), 485–494. https://doi.org/10.1080/07317115.2018.1453908

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Su, W., Li, D. (2023). The effectiveness of translation technology training: a mixed methods study. Humanities and Social Sciences Communications, 10, 595. https://doi.org/10.1057/s41599-023-02066-2 Taira, B. R., Kreger, V., Orue, A., & Diamond, L. C. (2021). A Pragmatic Assessment of Google Translate for Emergency Department Instructions. Journal of general internal medicine, 36(11), 3361–3365. https://doi.org/10.1007/s11606-021-06666-z Tian, S., Jia, L., & Zhang, Z. (2023). Investigating students’ attitudes towards translation technology: The status quo and structural relations with translation mindsets and future work self. Frontiers in psychology, 14, 1122612. https://doi.org/10.3389/fpsyg.2023.1122612 Yang, Y., Liu, R., Qian, X., & Ni, J. (2023). Performance and perception: machine translation post-editing in Chinese-English news translation by novice translators. Humanities and Social Sciences Communications, 10(1), 1-8. https://doi.org/10.1057/s41599-023- 02285-7

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DOCUMENT 6 FOI 25/26-0555

Research Request – Audio Description Televisions

Brief	Information on which TV’s have the ability to turn on the audio description function
Date	08/10/2020
Requester	Kate A `redacted: s22(1)(a)` (Director – TAB)
Researcher	Jane S `redacted: s22(1)(a)(ii) - irre` (Research Team Leader)

Please note: The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

                      A u d  i o  D e s c r  i p t  i o n  T e  l e v  i s  i o n s
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Audio description (AD) capability is generally not listed within the specifications section on a supplier’s website. Participants will have to check the instruction manual of their current television or on-screen settings menus. Retailers or manufacturers may also be able to provide advice when purchasing a new device.

Some older devices (manufactured before 2014) may not support (AD). However, a set top box capable of receiving AD may be required to connect to an existing TV.

The ABC and Vision Australia have independently tested television brands in Australia to determine which receive AD (See table below).

A quick internet search shows that a 24 inch Ffalcon television can be purchased from JB HiFi for $169 or a 24 inch Hisense for $195 at Harvey Norman.

TV brand	Compatible with universal remotes?
Samsung	Yes
Panasonic	Yes
JVC TV	Yes
Sony	Yes
LG	Yes
Hisense	Yes
Kogan	Yes
TLC	Yes
Soniq	Yes
Hitachi	Yes
Philips	Yes
Seiki	Yes
Ffalcon	Yes
Linsar	Yes
Blaupunkt	Yes
ChiQ	Yes

Audio Description Televisions

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Research Request – Customised visual alert system for hearing loss

Brief (Lauren M redacted: s22(1)(a)(ii) - irrelevant material):

redacted: s47F - personal privacy The participant is seeking a customised visual alert system for hearing loss. The participant resides in a detached house in Queensland.

Can you please collate the relevant applicable QLD state based legislation, regulations, rules etc applying to domestic fire alarm systems (relevant to the building type of the participant - she resides in a detached house - class 1a)
In response to q 1, can you please summarise the key points of domestic fire alarm requirements for residential houses Queensland. Including, but not limited to the following key details. a. Power source rules (e.g. hard wired only, hard wired after 2017, 10 year lithium battery etc.) b. Type of smoke alarm required (e.g. photoelectric only, ionisation or Photoelectric etc.) c. Minimum number of detectors and required locations (e.g. one per floor, in each bedroom etc.) d. Replacement rules (e.g. all detectors must be replaced after 10 years, can only replace hard wired with hard wired, must replace with hardwired or 10 year lithium battery by 2027 or whenever it is replaced after 2017 etc.)
Can you please collate the following Australian Standards: (no need to summarise at this stage. Based on what I have read in the past, I anticipate the following may be the most relevant ones to have access to for this advice since I am doing a bit more technical digging than I usually have time for. redacted: s47F - personal privacy it might be worth having an official copy rather than me using other access I have outside of work) a. AS1603.17-2011 “Warning equipment for people with hearing impairment” b. AS 1670.1:2018 “Fire detection, warning, control and intercom systems - System design, installation and commissioning - Fire” c. AS 1603.11-2018 “Automatic fire detection and alarm systems Visual warning devices”
Can you please contact one or more suppliers of Bellman and Brooks hearing alert systems (e.g. Word of Mouth Technologies) and ask the following: a. On the Bellman and Symfon website they advertise coloured silicone slips that can be purchased to put on the flash receiver. Can these be purchased in Australia. If not available, why not? b. On the Bellman and Symfon website they advertise a signal repeater (code: BE1510), can this be purchased in Australia. If not available, why not? c. Is there an option for a signal repeater/range extender (other than the one BE1510) that can be purchased and used to improve the Radio Frequency signals used by Brooks and Bellman products

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d. Are they aware of any common problems with Bellman and/or Brooks products, including, but not limited to: i. Reliability of the radio frequency system used to connect transmitters and receivers/components? ii. Reliability of power sources, either primary and/or backup sources. iii. If so, what are the common solutions that they might suggest for each problem a person might commonly experience? iv. Fragility of the strobe lights (if there used to be an issue, has this changed, if so when) v. Reliability of the bed shaker to alert the person to the triggering of the fire alarm during sleep. vi. Can any receivers be worn or placed for visibility from outdoor and wet areas, if not, any additional comments.

Date	June, 2020
Requesters	Jane S `redacted: s22(1)(a)`, Shannon A `redacted: s22(1)(a)`, Lauren M `redacted: s22(1)(a)(ii) - irrelevant material`
Researcher	Craig O `redacted: s22(1)(a)` (Tactical Research Advisor – TAB/AAT) Jane S `redacted: s22(1)(a)(ii) - irre` (Research Team Leader)

Participant’s dwelling ………………………………………………………………………………………………………. 3
Queensland Smoke Alarm Legislation ……………………………………………………………………………….. 3 Existing Dwellings from January 01, 2017………………………………………………………………………………. 3 Replacement and Upgrading ……………………………………………………………………………………………. 3 Location of Alarms ………………………………………………………………………………………………………….. 4 Existing Dwellings from January 01, 2027………………………………………………………………………………. 4
Responses from Word of Mouth Technology ……………………………………………………………………… 4
Responses from Brooks Australia ……………………………………………………………………………………… 7
References ………………………………………………………………………………………………………………… 9

Please note:

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

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The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

1. Participant’s dwelling

The Participant resides in a class 1a dwelling defined as a single dwelling being a detached house or one or more attached dwellings, including a row house, terrace house, town house or villa unit. The Queensland domestic smoke alarm legislation applies to Class 1a and Sole Occupancy Units in Class 2 Buildings. [1]

2. Queensland Smoke Alarm Legislation

Existing Dwellings from January 01, 2017

Source: Queensland Government, Queensland Fire & Emergency Services, For Existing Dwellings, https://www.qfes.qld.gov.au/community-safety/smokealarms/Pages/existing-properties.aspx. Accessed 10 June 2020. [2]

Replacement and Upgrading

Existing smoke alarms manufactured more than 10 years ago must be replaced with photoelectric smoke alarms which comply with Australian Standards (AS) 3786-2014.
Smoke alarms that do not operate when tested must be replaced immediately.
When replacing smoke alarms, they must be of a photoelectric type which complies with Australian Standard (AS) 3786-2014.
When being replaced or upgraded they must be interconnected with every other ‘required’ smoke alarm in the dwelling so all activate together.
Existing hardwired smoke alarms that need replacement, must be replaced with a hardwired photoelectric smoke alarm.
In existing domestic dwellings, it is possible to have a combination of smoke alarms (240v and battery operated) and interconnectivity can be both wired and/or wireless.
Legislation for existing dwellings after January 01, 2017 and prior to January 01, 2027, does not indicate an option for alarms to be powered by a non-removable 10-year battery.

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Location of Alarms

Alarms should be placed:

on each storey
in each bedroom
in hallways that connect bedrooms and the rest of the dwelling
if there is no hallway, between the bedroom and other parts of the storey; and
if there are no bedrooms on a storey, at least one smoke alarm must be installed in the most likely path of travel to exit the dwelling.

Existing Dwellings from January 01, 2027

All existing private homes, townhouses and units will require photoelectric interconnected smoke alarms.
Alarms must be either a hardwired (eg. 240v) or non-removable 10 year battery powered type alarm.
From January 01, 2027 legislation requires smoke alarms must be installed as outlined above for existing dwellings from January 01, 2017.

3. Responses from Word of Mouth Technology

Below are responses from Andrew Willis at Word of Mouth Technology

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a) On the Bellman and Symfon website they advertise coloured silicone slips that can be purchased to put on the flash receiver. Can these be purchased in Australia? If not available, why not?

Word of Mouth Technology did have some stock of the silicone covers for the Flash Receiver, however we did not sell one cover in the time that we had them. In our own testing, we found that the covers actually reduced the visibility of the flashing light, with some colours being barely noticeable unless you are directly looking at the receiver (blue in particular). The normal operation of the bright white light and coloured LED is suitable for most clients as you can clearly identify the colours from a distance of a few metres (this allows you to determine which alert is being activated)

b) On the Bellman and Symfon website they advertise a signal repeater (code: BE1510), can this be purchased in Australia. If not available, why not?

The repeater is not available in Australia as it uses the frequency of 868MHz. This frequency is not permitted to be used in Australia for these devices. It is reserved by the ACMA for other applications.

c) Is there an option for a signal repeater/range extender (other than the one BE1510) that can be purchased and used to improve the Radio Frequency signals used by Brooks and Bellman products

We can only advise on Bellman products and there is no repeater option. If a client has a specific need we can provide work around solutions – i.e. if they are having issues with coverage of the door transmitter only we can resolve this by using a third party door chime and placing our transmitter in a central position in the house. We don’t have a very high incident of complaints around transmission distance, in most cases when reported it is the users of the push button doorbell transmitter used in a house with brick façade and some internal brick walls or a large home.

d) Are they aware of any common problems with Bellman and/or Brooks products, including, but not limited to:

i) Reliability of the radio frequency system used to connect transmitters and receivers/components?

Word of Mouth Technology have been distributing Bellman products for 15 years. We have some clients whose products would be over 10 years old and still working, even when new or additional components are purchased. All Bellman devices are backwards compatible with previous products. We believe this makes it a very reliable system.

Transmission range for Bellman Visit products is approximately 40m. This is true for all transmitters except the Bellman Push Button Transmitter, which has a reduced range of approximately 20m. Range is also affected by barriers such as metals or thick walls in client’s homes.

The system operates on a frequency that is approved for such devices. While other equipment uses this frequency the products have specific coding which means interference from external sources is not common. When it does occur we can change the radio key of the product to limit possibility of interference.

This question is sometimes asked by clients, we advise that our system being a closed platform is more stable than some systems that use wifi and rely on third parties allowing their systems to work together. I think there was an issue with this between Google and the Nest products. Some users had found their systems didn’t work anymore because Google and Amazon were not

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allowing/sharing their coding. We advise that the Bellman system does not rely on an internet connection, and provides a battery backup for all devices in the instance of a power failure.

I can’t provide comment on the Brooks products, we don’t sell them.

ii) Reliability of power sources, either primary and/or backup sources.

All Bellman receivers have a battery back up in them, which allows them to work without connection to mains power. For all products the backup battery is replaceable by the user. The power supplies are rated conservatively, and therefore not subject to a high failure rate. Battery backup in receivers will operate for up to three days in normal use.

We are currently recalling (voluntarily) The Bellman Flash Receiver (BE1442) for units purchased between 2016 and 2019 due to a software fault which relates to the charging of the backup batteries, this fault has been rectified in the current production models. Recalled units are also being fixed by an update to the firmware. There is information about this recall here https://bellman.com/en/for-professionals/be1442-product-recall-overview-page/

iii) If so, what are the common solutions that they might suggest for each problem a person might commonly experience?

1 – If a person requires greater range than the standard doorbell push button BE1250 we suggest a normal doorbell with our BE1023 transmitter.

2 – If a person finds they are getting false alarms we advise them to reset their receiver (we refer them to our YouTube channel which has captioned videos)

3 – False alarms from smoke alarms. Usually because the alarm chamber is contaminated with Dust. We tell the user to clean the alarm or return to us for service if they cannot complete that task.

iv) Fragility of the strobe lights (if there used to be an issue, has this changed, if so when)

The Flash Receiver (BE1442) has a xenon globe that we have found to be very durable over the years. The Bellman Alarm Clocks all use LED technology for strobe alerts, so they are even more long lasting than the xenon globe. There has been no change to the reliability of the strobe in any of our Bellman products over time. We would deem the failure rate of the flash receiver globe/Zenon to be extremely low (less than 1%)

v) Reliability of the bed shaker to alert the person to the triggering of the fire alarm during sleep.

This is quite subjective, and depends on the individual person. We recommend placing the bedshaker between the mattress and the sheet under the pillow area, and this tends to provide good strength vibrations for most people. Some clients prefer to put the bedshaker under the mattress, which can give a reduced vibration, but can still be felt with most mattresses. Alternatively people can place it in the pillowcase, or directly under the pillow, however this could be prone to falling out if the person moves around a lot in their sleep.

In summary the bed shaker is very reliable as it works every time, if a user states they are a heavy sleeper we will always suggest they use our flash receiver or alarm clock with the bed shaker. Lights and vibration are going to increase the reliability of alerting the user.

vi) Can any receivers be worn or placed for visibility from outdoor and wet areas, if not, any additional comments.

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Bellman has a Pager Receiver (BE1230) that can be used all over the home. The Bellman Flash Receiver (BE1442) and Bellman Portable Receiver (audible alerts – BE1033) both have battery backup, so can be easily unplugged and moved around the home or outside as needed. With regard to placement in wet areas, the Bellman Visit range has no Ingress Rating, and should be protected from direct contact with water. It would be acceptable to place the receivers in a bathroom on a shelf, or outside if they are protected from the weather.

4. Responses from Brooks Australia

a) Is there an option for a signal repeater/range extender that can be purchased and used to improve the Radio Frequency signals used by Brooks products

There is a product to extend the range to overcome perceived interference and improve radio frequency performance to EN 300220-3. Part number EIB420RF

b) Are you aware of any common problems with Brooks products, including, but not limited to:

i) Reliability of the radio frequency system used to connect transmitters and receivers/components?

The Brooks radio frequency system is a proprietary radio link using multi-path, multi repeater mesh architecture on the 926 Mhz radiolink protocol which is a very reliable system.

ii) Reliability of power sources, either primary and/or backup sources.

The Brooks alarms are either 240v mains powered and have battery backup or are battery powered only. The products that we have supplied to the deaf and hearing impaired are 10 year lithium battery powered alarms which are guaranteed for life of the alarm.

iii) If so, what are the common solutions that they might suggest for each problem a person might commonly experience?

If the customer maintains the alarms as per guidelines the probability of failure is greatly diminished and is almost non-existent.

iv) Fragility of the strobe lights (if there used to be an issue, has this changed, if so when)

The strobe light fitted with the vibration patrice are plugged into a 240v mains powered product with an SLA battery and is very robust and if maintained will last for the life of the product.

v) Reliability of the bed shaker to alert the person to the triggering of the fire alarm during sleep.

The vibration patrice is an additional pad designed for use with alarms for the hearing impaired and provides additional warning and will activate awakening the occupant.

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vi) Can any receivers be worn or placed for visibility from outdoor and wet areas, if not, any additional comments.

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All of the Brooks alarms and ancillary products are for indoor use only however your local electrician maybe be able to help with connecting alarms with other Brooks products for visibility from outside.

5. References

| [1] | Classification of Buildings and Structures. Queensland Fire & Emergency Services, https://www.qfes.qld.gov.au/community-safety/smokealarms/Documents/QFES-IS- SABuildingClassification.pdf. Accessed 6 Oct. 2020. | | — | — | | [2] | Queensland Government, Queensland Fire & Emergency Services, For Existing Dwellings, https://www.qfes.qld.gov.au/community-safety/smokealarms/Pages/existing- properties.aspx. Accessed 10 June 2020. | | [3] | Queensland Government, Queensland Fire & Emergency Services, New dwellings and dwellings being renovated, https://www.qfes.qld.gov.au/community- safety/smokealarms/Pages/new-properties.aspx. Accessed 10 June 2020. |

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DOCUMENT 8 FOI 25/26-0555

Research Request – Medicinal Cannabis

| Brief | Provide research on Medicinal Cannabis in Australia with a focus on :

What conditions can medical cannabis be used to treat?
Evidence of efficacy
How is the medication prescribed?
Does prescription and access differ between states?
What access schemes are available in each state?
Clinical guidelines. | | Date | 03 March 2020 | | Date of review | | | Requester | Karyn M redacted: s22(1)(a)(ii) - ir (Director – TAB) | | Researcher | Craig O redacted: s22(1)(a) (Tactical Research Advisor – TAB/AAT) | | Reviewer | Stephanie P redacted: s22(1)(a)(ii) - irreleva |

Research Summary …………………………………………………………………………………………………………….. 2 What is Medicinal Cannabis? ……………………………………………………………………………………………….. 3 Current Status of Medicinal Cannabis in Australia ………………………………………………………………….. 3 Clinical Guidelines ………………………………………………………………………………………………………………. 4 Overview Documents ………………………………………………………………………………………………….. 4 Guidelines for Health Care Professionals ……………………………………………………………………… 4 Evidence of Efficacy ……………………………………………………………………………………………………………. 4 Epilepsy - in paediatric and young adult patients ……………………………………………………….. 4 Multiple Sclerosis (MS) ………………………………………………………………………………………………….. 5 Chronic Non-Cancer Pain …………………………………………………………………………………………………. 6 Chemotherapy - induced nausea and vomiting in cancer …………………………………………………….. 7 Palliative Care……………………………………………………………………………………………………………….. 8 Confirmed and Potential Conditions for Treatment ……………………………………………………….. 8 Prescription of Medicinal Cannabis …………………………………………………………………………………….. 10 Accessing Treatment ………………………………………………………………………………………………….. 10 Prescription Guidelines by State ……………………………………………………………………………………. 11 Specialised Cannabis Access Clinics …………………………………………………………………………………. 13 Treatment Guidelines ……………………………………………………………………………………………………….. 14 TGA Registered Cannabis Medicines in Australia ………………………………………………………………….. 14

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Cost of Treatment ………………………………………………………………………………………………….. 15 Monthly Cost Analysis ………………………………………………………………………………………………….. 15 Consultation/Assessment Costs ……………………………………………………………………… 15 Private Health Insurance ………………………………………………………………………………………………. 16 Conclusions ………………………………………………………………………………………………………………… 16 References ………………………………………………………………………………………………………………… 16

Please note:

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

Research Summary

Developments and research into this subject is steadily gathering momentum. Users of this document will need to acknowledge the date of this research paper.
This paper concludes that given the available information on the subject, there is insufficient research measuring the effectiveness of medicinal cannabis for the management of different medical conditions as a first-line treatment.
The Commonwealth Department of Health has researched the efficacy of Medicinal Cannabis for the treatment of various health conditions and has provided guideline documents for several health conditions including multiple sclerosis, epilepsy, chronic pain, palliative care and chemotherapy induced nausea and vomiting.
Most medicinal cannabis products are ‘unregistered products’ and therefore do not appear on the Australian Register of Therapeutic Goods (ARTG).
Patients wanting to access the treatment must do so via the ‘unregistered medicines’ regulatory route, which can be a complicated process, however there are recent trends to fast track the process which mainly involves access via specialist clinics.
Medicinal cannabis can be prescribed by medical practitioners. Currently, there are no limits to the symptoms and conditions for which a cannabis medicine may be prescribed. Prescription and dispensing may vary slightly in each Australian state or territory.

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Medical cannabis products are not listed on the Pharmaceutical Benefits Scheme (PBS). Annual treatment costs must be met by the patient or a third party and can be considerably high.

What is Medicinal Cannabis?

Medicinal cannabis products are legal, high quality medicines that can be prescribed for people by their doctor. Medicinal cannabis is derived from cannabis plants and can be used to treat the symptoms of certain medical conditions, and the side effects of some treatments.

There are different medicinal cannabis products available to treat different conditions.

The active ingredients in medicinal cannabis are called ‘cannabinoids’. There are between 80 and 100 cannabinoids in medicinal cannabis.

Currently, most medicinal cannabis products contain the cannabinoids cannabidiol (CBD) and tetrahydrocannabinol (THC). [1]

THC and CBD have different pharmacological actions and therapeutic application: THC influences pain, spasticity, sedation, appetite and mood while CBD has anxiolytic, anti-convulsant and anti- inflammatory effects reported (MacPhail et al, 2022).

Evidence of efficacy of medicinal cannabis is continuing to build with increasing randomised controlled trials and preclinical research, however there is still minimal or ambiguous evidence for many conditions (MacPhail et al, 2022).

Current Status of Medicinal Cannabis in Australia

In 2017 the Commonwealth Department of Health, with financial support from several state governments, commissioned a team from the Universities of New South Wales, Sydney and Queensland under the coordination of the National Drug and Alcohol Research Centre (NDARC) to review the available evidence for the use of medicinal cannabis in palliative care, chemotherapy-induced nausea and vomiting, chronic pain, multiple sclerosis and epilepsy.
A series of guidance documents have been developed for palliative care, epilepsy, chemotherapy-induced nausea and vomiting (CINV), multiple sclerosis (MS) and chronic pain.
The guidance documents are based on evidence available at the time of publication and will be regularly updated as new evidence emerges.
Working groups have been established for the five different settings and will meet yearly to review evidence and make updates where required.
It is hoped that sufficient data on the safety and efficacy will emerge in coming years to enable registration of more medicinal cannabis products on the Australian Register of

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Therapeutic Goods (ARTG). [2]

Clinical Guidelines

Resulting from the review for clinical evidence the Commonwealth Department of Health has developed a series of guidance documents to assist health professionals and patients, especially medical practitioners, who choose to prescribe medicinal cannabis in Australia under current access schemes. [2]

The scope of the guidance is broad, and not specific with regard to the use of medicinal cannabis for particular symptom clusters, but includes some suggestions for the use of single products or mixtures of cannabinoids and their routes of administration. [3]

There are five guidance documents for health care professionals for each of: multiple sclerosis, epilepsy, chronic pain, palliative care and chemotherapy induced nausea and vomiting, as well as an overview document for prescribers. There is also a consumer-oriented brochure intended for patients and their carers.

Overview Documents

Medicinal cannabis products: Patient information
Guidance for the use of medicinal cannabis in Australia: Patient information
Guidance for the use of medicinal cannabis in Australia: Overview

Guidelines for Health Care Professionals

Guidance for the use of medicinal cannabis in the treatment of multiple sclerosis in Australia
Guidance for the use of medicinal cannabis in the treatment of palliative care patients in Australia
Guidance for the use of medicinal cannabis in the treatment of epilepsy in paediatric and young adult patients in Australia
Guidance for the use of medicinal cannabis for the prevention or management of nausea and vomiting in Australia
Guidance for the use of medicinal cannabis in the treatment of chronic non-cancer pain in Australia

Evidence of Efficacy

Currently there is only limited evidence about the effectiveness of medicinal cannabis for use in different medical conditions. There is also little known about the most suitable doses of individual cannabis products.

Following are the Commonwealth Department of Health’s findings of evidence of efficacy, and its recommendations for the use of medicinal cannabis placement in the therapeutic hierarchy. [3]

Epilepsy - in paediatric and young adult patients

In patients with paediatric-onset drug-resistant epilepsy, cannabidiol products reduced seizure frequency by 50 per cent or more in up to half of the patients and achieved seizure freedom in a

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small number of patients. This is when cannabidiol products are used as an add-on to current treatments in drug-resistant epilepsy in children and young adults. There are few studies of whether cannabidiol is effective in treating adult epilepsy.

General Recommendations Summary

Epilepsy treatment with medicinal cannabis or cannabinoids is only recommended as an adjunctive treatment - that is, in addition to existing anti-epileptic drugs.
Patients and prescribing clinicians should be aware of likely adverse events such as diarrhoea, drowsiness, and changes to appetite. Adverse events such as a worsening of seizures, convulsions, severe diarrhoea or behavioural difficulties may affect the aims of the epilepsy treatment and increase the likelihood of treatment withdrawal, and should be evaluated on a case by case basis. If treatment is likely to be long-term, it is important that any side-effects from medicinal cannabis are not greater than side effects experienced with other AEDs, and that their response to treatment is regularly assessed.
In the absence of strong evidence for dosing and specific preparations of cannabis or cannabinoids in epilepsy treatment, it is recommended that should the treating physician elect to initiate medicinal cannabis therapy in epilepsy patients, patients should be re- evaluated after 12 weeks for evidence of response to treatment.
In the absence of strong evidence for dosing and specific preparations of medicinal cannabis in epilepsy treatment, it is recommended that CBD be used and re-evaluated after twelve weeks of therapy, to ascertain whether there has been any benefit from its introduction.
Prescribing clinicians should also be aware of the potential drug-drug interactions with CBD and anti-epileptic drugs.

For more specific information on the recommendation please see the research summary.

Multiple Sclerosis (MS)

There is some evidence to suggest that medicinal cannabis products may be effective for treating the pain symptoms of MS although this is inconsistent. Studies differ as to whether medicinal cannabis products can help improve bladder function, sleep, quality of life, ataxia/tremor and disability/disease progression. There are currently no studies that compare medicinal cannabis products with commonly-used medications for MS pain and spasticity, so medical cannabis products are more suitable for those who have not responded adequately to other anti-spasticity medication.

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General Recommendations Summary

There is some evidence that dronabinol or THC extracts may be effective at reducing pain associated with multiple sclerosis. There is also some evidence (although inconsistent) that nabiximols and other THC:CBD extracts may reduce muscle spasticity and improve patient quality of life.
Recommendations are limited by lack of quality evidence. Currently available studies demonstrate no evidence of an effect of cannabinoids on MS disease activity or disability progression. There have been no studies comparing cannabinoids against current standard treatments for multiple sclerosis.
In the absence of evidence comparing cannabinoids to first line treatments for pain and spasticity in MS, including baclofen, dantrolene, and benzodiazepines, there is no basis for using cannabinoids as a monotherapy or first line treatment. If pain and spasticity are not properly controlled by standard therapies, doctors may discuss with their patients the use of nabiximols or dronabinol as an adjunctive therapy.
In the absence of strong evidence for dosing and particular preparations of cannabis or cannabinoids in the treatment of symptoms of multiple sclerosis (other than nabixomols), it is recommended that any treating physician who elects to initiate cannabinoid therapy should re-evaluate patients after four to six weeks for evidence of response to treatment.
For patients who may benefit from the use of cannabinoids in treating pain or spasticity from multiple sclerosis, it is recommended that a physician who elects to initiate cannabinoid therapy use standardised products, and pharmaceutical-grade nabiximols, dronabinol, or THC extract produced with GMP (good manufacturing practice) which have the greatest evidence for efficacy based on the review.
If treatment is likely to be long term, it is important that any side-effects from cannabinoids are not greater than the side effects experienced with other medications. This requires their response to treatment to be regularly assessed. Measures of tolerability include experience of adverse event and patient assessment of treatment efficacy.

For more specific information on the recommendation please see the research summary.

Chronic Non-Cancer Pain

There is some evidence that the delta-9 tetrahydrocannabinol (THC) extract of cannabis can reduce pain in both MS-related neuropathic pain and other forms of neuropathic pain, but for many people the reduction in pain may be modest. There is, however, insufficient information to make a conclusion about cannabinoids for the treatment of pain associated with arthritis and fibromyalgia. While some individuals with pain have reported that their use of opioids has been reduced when they also use medicinal cannabis, clinical studies in this area are still ongoing.

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General Recommendations Summary

A comprehensive sociopsychobiomedical assessment of the patient with CNCP is appropriate; The use of medications, including medicinal cannabis, is not the core component of therapy for CNCP; Patient education is a critical component of therapy for CNCP, particularly with respect to expectations of drug therapy; and
There is a need for larger trials of sufficient quality, size and duration to examine the safety and efficacy of medicinal cannabis use in CNCP.
In terms of mode of delivery there are concerns about the safety of smoked or vapourised cannabinoids. Delivery of pharmaceutical grade products such as nabiximols, dronabinol or THC extracts is safer.
Most evidence on medicinal cannabis use in CNCP is derived from studies where cannabinoids were adjuvant interventions. Cannabinoids should not replace current approved first-line treatments for pain and there is significant potential for drug interactions which needs further study.
Adverse effects of long term medicinal cannabis use is poorly understood. Long term studies are required to explore this issue.
In the absence of strong evidence for dosing and specific preparations of cannabis or cannabinoids in the treatment of CNCP, it is recommended that any treating physician who elects to initiate cannabinoid therapy should assess response to treatment, effectiveness and adverse effects after 1 month. This is best achieved as part of a research project or clinical audit.
Pain patients and their prescribing clinicians should be aware of common adverse events such as dizziness, nausea, drowsiness, effects upon mood, cognition and attention. Clinicians considering medicinal cannabis therapy for CNCP patients should consider the individual’s risks in using these products for long periods of time.

For more specific information on the recommendation please see the research summary.

Chemotherapy-induced nausea and vomiting in cancer

High-THC medicinal cannabis products were as effective as many of the prescription medicines they were compared with when most of the studies were carried out (1980s/90s). In recent years, much more effective prescription medicines for nausea and vomiting have become available but there have been very few comparisons of medicinal cannabis products with these medicines. Therefore, medicinal cannabis products should only be prescribed only after newer standard approved treatments have failed.

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General Recommendations Summary

High-THC medicinal cannabis products can sometimes be effective for nausea and vomiting and should only be prescribed only after newer standard approved treatments have failed and where otherwise not contraindicated.

For more specific information on the recommendation please see the research summary.

Palliative Care

There was little evidence of benefit to advanced cancer patients with chronic pain. The published studies also showed little effect on appetite, nausea/vomiting, pain, dizziness, mental health or sleep problems. There is no evidence that medicinal cannabis has any anti-cancer activity in human studies or that it can slow the progression of these conditions.

General Recommendations Summary

As there are very few studies on medicinal cannabis treatment in palliative care, it should be used only after standard treatments have failed. It is possible that medicinal cannabis will interact with chemotherapy and other medications used in palliative care. More studies are needed to better understand this.
Patients and prescribing clinicians should be aware of possible adverse events such as somnolence, nausea and dizziness. Adverse events such as confusion, pain, diarrhoea or hallucinations may impact the overall aims of the palliative medicine and reduce quality of life, and should be evaluated on a case-by-case basis.

For more specific information on the recommendation please see the research summary.

Confirmed and Potential Conditions for Treatment

Below is a summary of the confirmed and potential conditions which current research shows that medical cannabis could assist with, as detailed by the white paper developed by the University of Sydney. [4]

The tables summarise the conditions which THC and CBD are known to be able to treat. This list is neither exhaustive nor definitive. It is here only to provide a snapshot of the current state of cannabis research.

Confirmed Conditions for Treatment

NOTE: Sativex® (nabiximols) is the only medicine currently registered in Australia on the ARTG.

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Potential Conditions for Treatment

NOTE: Sativex® (nabiximols) is the only medicine currently registered in Australia on the ARTG.

Condition	Treatment	Source of Treatment (CBD)	Source of Treatment (THC)	Source of Treatment (Both)	Strength of evidence
Arthritis	Symptomatic relief of joint pain	Oral			Moderate
Chronic non-cancer pain	Pain reduction			Oral mucosal cannabis spray	Moderate

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Condition	Treatment	Source of Treatment (CBD)	Source of Treatment (THC)	Source of Treatment (Both)	Strength of evidence
Epilepsy	Reduction in seizure frequency	CBD-enriched cannabis oil			Moderate
Glaucoma	Ocular therapeutic support			Orally, intravenously, or inhalation	Moderate
Schizophrenia	Reduced psychotic symptoms	Oral			Low
Tourette syndrome	Improvement in tic severity		Capsules: Dronabinol and Nabilone	Sativex	Moderate
Inflammatory bowel disease (including Crohn’s disease)	Decrease Crohn’s disease Activity Index (CDAI) scores		Smokeable		Low
Sleep disorders	Improvement in insomnia		Nabilone	Sativex	Moderate

Prescription of Medicinal Cannabis

Currently, there are no limits to the symptoms and conditions for which a cannabis medicine may be prescribed. The body of clinical evidence continues to grow daily, meaning a variety of other conditions may be recognized to have positive associated outcomes with cannabinoid medications. [13]

Accessing Treatment

Australia’s Therapeutic Goods Administration (TGA) regulates the supply of medicinal cannabis. Most medicinal cannabis products are ‘unregistered products’ and therefore do not appear on the Australian Register of Therapeutic Goods (ARTG).

Access to other medicinal cannabis products must be done via the ‘unregistered medicines’ regulatory route. To access unregistered medicines a doctor must lead an application to the TGA on a patient’s behalf. In addition to TGA approval, a separate permission will need to be obtained by doctors from the Health Department of the State or Territory in which the patient resides. This requirement varies depending on what type of medicinal cannabis product the doctor is looking to prescribe. [5]

Someone can gain access to medicinal cannabis by either of the following:

Authorised Prescriber Scheme (AP). APs are medical practitioners that can prescribe drugs such as medicinal cannabis for the treatment of conditions without the need for approval from the Therapeutic Goods Administration (TGA). [6]

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As an Authorised Prescriber the medical practitioner must have the training and expertise appropriate for the condition being treated and the proposed use of the product, be able to best determine the needs of the patient, and be able to monitor the outcome of therapy. An Authorised Prescriber is allowed to supply the product directly to specified patients under their immediate care. [9].

Special Access Scheme (SAS). SAS is available to medical practitioners who wish to treat patients with drugs such as medicinal cannabis that is not currently in the Australian Register of Therapeutic Goods (ARTG). [6]

Health practitioners who are considering treating a patient with an unapproved therapeutic good need to acknowledge that it has not been evaluated for quality, safety or efficacy and it has not been approved by the TGA. The prescribing health practitioner is best placed to determine the needs of the patient, including whether or not treatment with a particular unapproved good is required. Health practitioners are expected to be up to date with all relevant and available information about the unapproved good before choosing to prescribe it for their patient. [10]

Clinical trials. Participation in Clinical trials.

Clinical trials conducted in Australia are subject to various regulatory controls to ensure the safety of participants. The TGA regulates the use of therapeutic goods supplied in clinical trials in Australia under the therapeutic goods legislation. [11]

Prescription Guidelines by State

Prescription and dispensing of medicinal cannabis may vary depending on each Australian state or territory. The table below summarizes variations. [13]

STATE	Who can prescribe?	State Approval	State Approval Times	Physician Information	Patient Information
WA	Specialist Medical Practitioners and General Practitioners can make an application for their patients under the Special Access or Authorised Prescriber Scheme.	No state-based approval required for Schedule 4 CBD products. THC Schedule 8 drugs still require a State Approval for WA Practitioners.	Less than a week	Western Australia Department of Health	Western Australia FAQ Sheet
NT	Specialist Medical Practitioners and General Practitioners can make an application for their patients under the Special Access or Authorised Prescriber Scheme.	No state-based approval required for Schedule 4 CBD or Schedule 8 THC products.	Usually a few days unless more information is required	Northern Territory Department of Health	Nil
QLD	Australian Registered Specialist Medical Practitioners (including Specialist General Practitioners) can make an application for their patients under the Special Access or Authorised Prescriber Scheme.	No state-based approval required for Schedule 4 CBD products. Doctors who do not hold a specialist registration need approval from Queensland Health if prescribing a Schedule 8 medicinal cannabis product that is not	Two business days unless more information is required.	Queensland Department of Health	Queensland Patient Information

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STATE	Who can prescribe?	State Approval	State Approval Times	Physician Information	Patient Information
		registered on the ARTG. All Queensland doctors can prescribe Schedule 4 (CBD only) products without a State Approval.
NSW	Any Australian Registered doctor who is authorised under the Special Access or Authorised Prescriber Scheme can make an application for their patient.	No state-based approval required for Schedule 4 CBD products. Schedule 8 products require a State Approval for children under the age of 16 and for patients with drug dependencies or a history of drug use.	Up to one week unless more information is required	Centre for Medicinal Cannabis Research and Innovation	New South Wales Department of Health
ACT	Australian Registered Medical Practitioners must have approval from the ACT Chief Health Officer (CHO) to prescribe cannabis as a controlled substance as a single patient prescriber. A Category Approval states you may only apply to prescribe medicinal cannabis for patients with the following conditions: Spasticity in multiple sclerosis / Nausea and vomiting related to cancer chemotherapy / Pain and/or anxiety in patients with active malignancy of a life-limiting disease where (in either case) the prognosis might reasonably be expected to be 12 months or less / Refractory paediatric epilepsy / Prescribers may also apply for approval to prescribe medicinal cannabis for other indications.		Less than one week unless more information is required	ACT Health – Medicinal Cannabis	ACT Health – Medicinal Cannabis
VIC	Australian Registered Specialist Medical Practitioners and General Practitioners can make an application for their patients under the Special Access or Authorised Prescriber Scheme.	No state-based approval required for Schedule 4 CBD products. Schedule 8 medicinal cannabis products require a Schedule 8 Treatment Permit under the Victorian Drugs Poisons and Controlled Substances Act.	Less than a week unless more information is required	Victorian Department of Health – Medicinal Cannabis Schedule 8 Treatment Permit	Victoria Patient Information
TAS	General Practitioners (GPs) are unable to prescribe in Tasmania; referral to a relevant medical specialist is required who then applies to the Department of Health and Human Services for a legal authorisation to prescribe under the Cannabis Access Scheme (CAS).	All applications are reviewed by a delegate of the secretary of the Tasmanian Department of Health and Human Services in accordance with the usual pathways for Schedule 8 substances under Section 59E of the Act or for Schedule 4	Not available	Department of Health and Human Services – Medicinal cannabis	Department of Health and Human Services – Medicinal cannabis

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STATE	Who can prescribe?	State Approval	State Approval Times	Physician Information	Patient Information
		to prescribe a Schedule 8 medicinal cannabis product where it is being prescribed for longer than 2 months, or to patient already prescribed a Schedule 8 drug for a period exceeding 2 months, for any person the medical practitioner reasonably believes to be dependent on drugs. Exemptions apply in South Australia for patients aged over 70 years of age, and terminally ill patients whose doctors have notified the Drugs of Dependence Unit (Notified Palliative Care Patients).’
		cannabidiol under Regulation 70 of the Poisons Regulations 2008. The Tasmanian Access and Advisory Committee review applications and communicate reasons for rejected applications directly to patients and the prescribing doctor.
SA	Australian Registered Specialist Medical Practitioners and General Practitioners can make an application for their patients under the Special Access or Authorised Prescriber Scheme.	No state-based approval required for Schedule 4 CBD products. In South Australia a section 18A authority is ‘required to prescribe a Schedule 8 medicinal cannabis product where it is being prescribed for longer than 2 months, or	Less than one week unless more information is required.	South Australia Department of Health	South Australia Department of Health

Specialised Cannabis Access Clinics

Specialised Cannabis Access Clinics exist to streamline the often-complex process surrounding access to medicinal cannabis for people who experience conditions that have shown benefit from use of the drug.

The process starts with a patient making an application to access medicinal cannabis that is then reviewed by the clinic.
To be eligible, a patient must be an Australian resident and have been diagnosed with a condition that conventional treatments have failed to improve.
A letter from a GP or specialist backing the application is also required.

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If a face-to-face or telehealth consultation with the clinic’s doctors is successful and the treatment deemed beneficial for the condition then a medicinal cannabis prescription can be dispensed easily from a pharmacy. [12]

Following are examples of specialised clinics:

Cannabis Doctors Australia
CA Clinics
Cannvalate

Treatment Guidelines

The Department of Health’s guide for use of medicinal cannabis [2], suggests that :

Appropriate state or territory regulatory frameworks for access to medicinal cannabis need to be considered.
Specialist review or reports may need to be included with Special Access Scheme applications to the TGA.
A medical practitioner should complete a comprehensive clinical assessment of the patient that identifies risk factors that will need to be addressed before applying for access to medicinal cannabis.
An accurate and thorough history of the patient be taken by the medical practitioner.
A Treatment Plan should be implemented indicating that the medicinal cannabis product be used for a one-month trial to determine the effectiveness of the medication for the patient’s condition/symptoms.

TGA Registered Cannabis Medicines in Australia

Australia currently has access to two brands of medicinal cannabis, Sativex and Epidyolex (MacPhail et al, 2022). Sativex is an oromucosal spray with equal amounts of THC and CBD, and Epidyolex is a 100mg/ml CBD solution.

The cannabis medicine Sativex® (nabiximols) is plant-derived, and is the only cannabis medicine currently registered in Australia on the ARTG, approved for the treatment of moderate to severe spasticity in multiple sclerosis.

Other cannabis medicines that have been registered by regulators outside of Australia, but are not registered in Australia, include:

Marinol® (dronabinol) synthetically manufactured, and registered in the US by the Food and Drug Administration (FDA) for the treatment of anorexia in patients with AIDS, and for the management of chemotherapy-induced nausea and vomiting where standard anti-nausea treatments have failed.

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Cesamet® (nabilone) synthetically manufactured, and registered in the US by the FDA for the management of chemotherapy-induced nausea and vomiting.
Epidiolex® (cannabidiol) plant-derived, and registered in the US by the FDA for the management of Dravet and Lennox-Gastaut syndromes. [7]

Cost of Treatment

Medical cannabis products are not listed on the Pharmaceutical Benefits Scheme (PBS). Annual treatment costs must be met by the patient or a third party. [2]

Monthly Cost Analysis

A doctor’s prescription is often based on the patient starting on a low dose and increasing dose until an optimal outcome is achieved. The effective dosage a patient achieves can vary significantly by patient, but also varies significantly by the condition being treated. It is important to note that not all patients see benefit from medicinal cannabis treatments.

In 2018, Cannabis Access Clinics has analyzed patient costs, based on the actual monthly dosage patients took, across three treatment areas: [8]

Chronic Pain - the most common condition for patients receiving medicinal cannabis prescriptions. Analysis showed that patients paid $353 per month on average for legal medicinal cannabis in Q3 2018.

Epilepsy - Often cited as an example of the high costs of medicinal cannabis, patients with epilepsy require much higher dosage prescriptions in order to see benefits. In the period analyzed patients spent an average of $992 per month on treatment.

Other indications: A range of other indications we analyzed including insomnia, fibromyalgia, anxiety, and multiple sclerosis. The average product costs for these patients as a group was $212 per month.

Consultation/Assessment Costs

Where patients may approach a specialised clinic to access treatment, various fees may apply including initial consultation, TGA applications, and prescription consulting. Below is a brief outline of potential fees from several clinics taken from the Cannvalate website:

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	Screening	Initial Consult	TGA Application	Prescription Consult	Checkups
Cannabis Access Clinics	$25	$200	$250	$80	$80
Cannabis Doctors Australia	NA	$199	$35*	NA	$59
Cannadoc	NA	$250	Varies	$47~	$47“
Cannvalate	NA	$95	NA	$25***	$75
Emerald Clinics	NA	$380	NA	$30	$180

fee only applies if more than 1 application submitted ** usual cost, however price may vary *** first is free, $26 thereafter to see pharmacist 6)

Private Health Insurance

There is only one medicinal cannabis product listed on the ARTG which is nabiximols. Normally, drugs that are approved by the TGA but are not yet included on the Pharmaceutical Benefits Scheme (PBS), can be claimed on health insurance if the person has extras policy which covers pharmacy for non-PBS items.

However, since further research needs to be done into the efficacy of medicinal cannabis as a first- line therapy, private health insurance won’t cover the costs resulting in the person having to pay out-of-pocket. [6]

Conclusions

Given the available information on the subject, there is insufficient research measuring the effectiveness of medicinal cannabis for the management of different medical conditions as a first- line treatment.

References

(1) Services, Department of Health &. Human. Medicinal Cannabis.

[2] Services, Department of Health &. Human. Guidance for the Use of Medicinal Cannabis in

Australia Overview. Dec. 2017, https://www.tga.gov.au/sites/default/files/zuidance-use- medicinal-cannabis-australia-overview.pdf.

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[3] Administration, Australian Government Department of Health Therapeutic Goods. “Medicinal Cannabis - Guidance Documents.” Therapeutic Goods Administration (TGA), 29 May 2018, https://www.tga.gov.au/medicinal-cannabis-guidance-documents.

[4] University of Sydney. Medicinal Cannabis in Australia: Science, Regulation & Industry: A White Paper Developed by The University of Sydney Community Placement Program in Partnership with MGC Pharmaceuticals. 2016, https://mgcpharma.com.au/wp- content/uploads/2016/03/mgc whitepaper final-sml.pdf

[5] “How to Get Medicinal Cannabis.” The University of Sydney, https://sydney.edu.au/lambert/how-to-get-medicinal-cannabis.html. Accessed 2 Mar. 2020.

[6] Laycock, Richard. “Medical Cannabis in Australia.” Finder.Com.Au, 4 Jan. 2018, https://www.finder.com.au/medical-marijuana-australia

[7] Cannabis Medicines. https://www.health.nsw.gov.au/pharmaceutical/cannabismedicines/Pages/default.aspx. Accessed 2 Mar. 2020.

[8] Cannabis Access Clinics. Australian Medicinal Cannabis Pricing Analysis. 2018, https://cannabisaccessclinics.com.au/wpcontent/uploads/2019/06/CAC MedicinalCanna bisPricingAnalysis Online.pdf

[9] Administration, Australian Government Department of Health Therapeutic Goods. “Authorised Prescribers.” Therapeutic Goods Administration (TGA), 18 Sept. 2019, https://www.tga.gov.au/form/authorised-prescribers

[10] Administration, Australian Government Department of Health Therapeutic Goods. “Information for Health Practitioners.” Therapeutic Goods Administration (TGA), 5 Jan. 2018, https://www.tga.gov.au/book-page/information-health-practitioners

[11] Administration, Australian Government Department of Health Therapeutic Goods. “Clinical Trials.” Therapeutic Goods Administration (TGA), 21 June 2018, https://www.tga.gov.au/clinical-trials

[12] Staff, ANMJ. “Medicinal Cannabis Clinics Rolled Out.” ANMJ, 31 July 2018, https://anmj.org.au/medicinal-cannabis-clinics-rolled-out

[13] tetrahealth. “Medical Cannabis in Australia: A State-by-State Guide for Patients and Prescribers.” Tetra Health, 20 Nov. 2019, https://www.tetrahealth.com.au/2019/11/20/medical-cannabis-in-australia-a-state-by- state-guide-for-patients-and-prescribers

MacPhail, S. L., Bedoya-Perez, M. A., Cohen, R., Kotsirilos, V., McGregor, I. S., & Cairns, E. A. (2022). Medicinal cannabis prescribing in Australia: an analysis of

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trends over the first five years. Frontiers in Pharmacology, 13. https://doi.org/10.3389/fphar.2022.885655

Version Control

Version No.	Date	Drafting Officer/Author	Approved/Received	Description of change	Date of review
V0.1		Craig O `redacted: s22(1)(a)`	Karyn M `redacted: s22(1)(a)`	Nil	Nil

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DOCUMENT 9 FOI 25/26-0555

Research Request – Learner Driver in Australia

| Brief | Statistics and research to support the development of an NDIS funding position or at least and advice position. For a Learner (Class C – car) driver in Australia – What are the percentage of learners who access driving lessons (as opposed to learning from family/friends)? 1.) For Learner (Class C – car) driver’s doing the log book system – How many driving lessons do they usually require? 2.) For a Learner (Class C – car) driver, not doing a log book system but instead the state on-road licensing test - How many driving lessons do they usually require? 3.) Are there any differences (patterns) between different Australian states regarding driving instructor usage? 4.) Is there any evidence regarding the number of lessons an adult usually requires to learn to drive with a left accelerator in auto car as a new driver? 5.) Is there any evidence regarding the number of lessons an adult usually requires to re-learn to drive with a left accelerator in auto car (rather than a right one) as an existing driver? 6.) Is there any evidence regarding the maximum number of driving lessons funded by other funding agencies (eg TAC, Lifetime support scheme, DVA etc…) prior to them requiring further evidence ( - if so what is the required evidence - ? a Driver Trained OT on -road assessment review) 7.) Is there any evidence regarding the position in regard to funding Learner driving lessons for other funding agencies (eg TAC, Lifetime support scheme, DVA etc…). Do they consider whether some or all of this is an everyday cost for consumers and therefore not cover it. | | Date | July, 2020 | | Requester | Shannon A redacted: s22(1)(a) (Assistant Director – TAB) | | Researcher | Craig O redacted: s22(1)(a) (Tactical Research Advisor – TAB/AAT) |

Please note:

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

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Contents

Australia’s National Driver Licensing Scheme …………………………………………………………………………….. 2 Australia’s standard graduated licensing system (GLS) for cars ……………………………………………………. 2 Learners who access driving lessons with professional instructors as opposed to family/friends …….. 3 Number of Lessons: Log Book System/State on-road Licensing Test and Driving Instructor Usage …… 4 Number of Lessons: Adults learning to drive with a left accelerator in auto car as a new driver ………. 7 Number of Lessons: Adults re-learning to drive with a left accelerator in auto car (rather than a right one) as an existing driver ………………………………………………………………………………………………………… 8 Number of Lessons: maximum number of driving lessons funded by other funding agencies …………. 8 Traffic Accident Commission L2P Program …………………………………………………………………………….. 8 Funding learner driving lessons for other funding agencies …………………………………………………………. 9 Traffic Accident commission TAC ………………………………………………………………………………………….. 9 Department of Veteran Affairs (DVA) ………………………………………………………………………………….. 10 Lifetime Support Scheme …………………………………………………………………………………………………… 10 Cohorts ……………………………………………………………………………………………………………………………….. 10 References ………………………………………………………………………………………………………………………….. 11

Australia’s National Driver Licensing Scheme

In 1997, Australia implemented a National Driver Licensing Scheme (NDLS), establishing a single driver licence classification structure, eligibility criteria and a uniform set of requirements for key driver licensing transactions including the issue, variation, renewal, suspension and cancellation of licences.

Although Australia operates a federated licensing scheme (administered by the individual states and territories), the NDLS has been adopted by all Australian jurisdictions and, as a result, facilitates the mutual recognition between Australian jurisdictions of driver licences when transferring between jurisdictions. [1]

Australia’s standard graduated licensing system (GLS) for cars

All Australian jurisdictions have introduced a GLS for novice drivers. The fundamental components of Australia’s standard GLS policy framework are outlined below. All Australian jurisdictions currently meet or exceed these requirements. [1]

GLS requirements:

•   Learner permit at 16 years – supervised driving required

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•  12 months minimum holding of learner permit
•  Requirement to undertake at least 50 hours supervised driving recorded in a log book
•  Practical on-road test to achieve solo unsupervised licence
•  Hazard Perception Test as part of GLS
•  Solo licensing from 17 years
•  Zero Blood Alcohol Content (BAC) and no hand held mobiles during entire
    learner/provisional period
•  Lower demerit point threshold for novice drivers
•  Community education about risks associated with:
 o  Novice drivers and late night driving and carrying multiple passengers
 o  Young drivers on a full licence and drink driving
•   Support programs to assist disadvantaged drivers to progress.

Learners who access driving lessons with professional instructors as opposed to family/friends

No research or statistics could be sourced indicating learners who access driving lessons with professional instructors as opposed to family/friends. In 2013 The Centre for Accident Research & Road Safety – Queensland, published a series of three reports which examined education and training for novice drivers. The third and final report [2] provided an overview of the graduated driver licensing (GDL) system and outlines the expert opinion of four international novice driver experts about the potential road safety impacts of different training approaches if applied to the GDL system in place within Queensland.

In looking at supervised on road practice the report indicated that “All of the experts were in agreement that this is an effective way for the learner to gain experience and that there is strong potential for positive road safety effects in particular because of the potential to extend the learner phase using a mandated hours requirement. It was recognised that a certain amount of practice will be necessary before road safety effects can be realised, however, experts noted that there is no clear consensus in the literature as to how many hours this should be”.

The report also looked at the advantages and disadvantages of professional instructor lessons as opposed to supervision by family/friends with the following observations:

Advantages

•   Exposes learners to practice driving under supervision which has a low crash risk.
•   Allows gradual progression of practice from low crash risk (e.g. car parks) to higher risk
    conditions (e.g. night time driving).
•   Allows parents to judge if the novice is ready to take their test.
•   Increasing quantity of private supervision during learner phase is the most investigated and
  promoted way to reduce P1 crashes and has been shown to be effective at reducing crash
     risk in the first 2 unsupervised years.

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•  Without private supervision learners would likely rely on professional lessons, which often
    lack variety.
•   Research suggests bad habits picked up from private supervisors does not outweigh the
    overall benefits, and likely could be addressed by good professional instruction.
•   Required 100+ hours has potential to delay licensing which has safety benefits.

Disadvantages

•   Parents do not always have sufficient tools to assist them as supervisors.
•  Not all parents are good drivers or good teachers. Learners may adopt poor/unsafe/risky
    driving from a private supervisor.
•    It is not clear from research the extent to which supervised driving experience translates
    into safer driving when unsupervised.
•   Effects are only found if supervised practice is for a longer rather than shorter time/distance
     travelled.
•   Required 100+ hours results in more practice of novices but puts a strain on some families.

Number of Lessons: Log Book System/State on-road Licensing Test and Driving Instructor Usage

•  No state stipulates the number of driving lessons required. Instead, most states stipulate the
  minimum number of hours of supervised driving which needs to be recorded in a log book.

•    It appears to be recognized that the number of lessons required depends on the individual
     driver’s skills, confidence and other factors.

•  The number of hours required varies from state to state and varies according the age of the
     driver. In some states a log book does not need to be completed if the driver is over a
    certain age.

•   For all states, it appears there are no requirements regarding number of driving lessons for
   Learner Drivers not doing a log book system but instead the state on-road licensing test.

•   In all states anyone holding an appropriate licence can supervise/instruct the learning driver.
  No states stipulate the use a professional driving instructor. Only one state (NSW) gives an
    incentive to drivers to use a professional instructor by offering bonus log book hours.

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Below is table summarizing the general requirements per state for log book systems and driver

instructor usage.

Australian State & Link to authority responsible for driver licensing functions	LOG BOOK SYSTEM	Driving Instructor Usage
NSW: Roads and Maritime Services New South Wales	AGE: Under the age of 25 must complete a minimum of 120 hours of supervised driving experience (including at least 20 hours at night). Aged 25 or older doesn’t need to fill out a log book or complete any minimum amount of supervised driving. LOG BOOK: Hours must be recorded in a paper log book or log book app. Exemptions to the 120 hours include Previously held a NSW or interstate driver licence, other than a learner licence Previously held an overseas licence, other than a learner licence Hold an overseas licence, other than a learner licence, and are issued with a learner licence after failing one driving test Are specifically exempted by Roads and Maritime Services.	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor. There is a 3 for1 bonus hours incentive: If Lerner has lessons with a professional driving instructor: for every 1 hour structured driving lesson, Lerner can record 3 hours driving experience in their log book.
VIC: VicRoads	AGE: Under the age of 21 must complete a minimum of 120 hours of supervised driving experience (including at least 20 hours at night). Aged 21 or older doesn’t need to fill out a log book or complete any minimum amount of supervised driving. LOG BOOK: Hours must be recorded in a paper log book or log book app. Exemptions to the 120 hours include: If the nature of your essential activities, occupation, employment or family circumstances means that 120 hours of supervised driving would cause you or your family undue hardship. If you have sufficient previous driving experience (interstate and overseas experience will be considered).	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor
QLD: Department of Transport and Main Roads Queensland	AGE: Under the age of 25 must complete a minimum of 100 hours of supervised driving experience (including at least 10 hours at night).	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor

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Australian State & Link to authority responsible for driver licensing functions	LOG BOOK SYSTEM	Driving Instructor Usage
QLD (cont.)	Aged 25 or older doesn’t need to fill out a log book or complete any minimum amount of supervised driving. LOG BOOK: Hours must be recorded in a paper log book or log book app. Exemptions to the 100 hours: Will need to prove that at least one of the following circumstances applies to you: No car available, No supervisor available. Limited access to a road network. Source>	No stipulation to use a professional driving instructor
WA: Department of Transport Western Australia	AGE: Under the age of 25 must complete a minimum of 50 hours of supervised driving experience (including at least 5 hours at night). Aged 25 or older doesn’t need to fill out a log book or complete any minimum amount of supervised driving. LOG BOOK: Hours must be recorded in an app log book only. No paper log book. Exemptions: none sourced	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor
SA: Department of Planning, Transport and Infrastructure South Australia	AGE: Any age must complete a minimum of 75 hours of supervised driving experience (including at least 15 hours at night). Any age required to fill out a log book or complete any minimum amount of supervised driving LOG BOOK: Hours must be recorded in a paper log book or log book app Exemptions: Exemption to hours of supervised driving may be granted if learner_has driving experience from other states.	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor
TAS: Department of State Growth Tasmania	At least 80 hours of supervised driving experience (including at least 15 hours at night). Two stages to learner Driving: L1 Stage: No log book required, Supervisory Driver required. L2 Stage: Includes Driving Assessment, then Supervisory Driver required, and completion of log book (no app log) Source>	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor

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Australian State & Link to authority responsible for driver licensing functions	LOG BOOK SYSTEM	Driving Instructor Usage
NT: Department of Transport Northern Territory	AGE: If under 25 years old need to hold provisional licence for at least two years before upgrading to a full licence. If you are 25 or older provisional licence needs to be held for at least one year. No minimum driving hours required. LOG BOOK: None required	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor No stipulation to use a professional driving instructor
ACT: Road Transport Authority Australian Capital Territory	AGE: Under the age of 25 must complete a minimum of 100 hours of supervised driving experience (including at least 10 hours at night). Aged 25 or older required to complete 50 supervised driving hours including 5 at night. LOG BOOK: Hours must be recorded in the paper log book only. There is no app log. Exemptions: none sourced	Anyone holding an appropriate licence can supervise/instruct the learning driver. Professional Driving Instructor For the first 10 hours, 3 hours of supervised driving hours will be applied for each singular hour driven whilst supervised by an ACT Accredited Driving Instructor.

Number of Lessons: Adults learning to drive with a left accelerator in auto car as a new driver

No research or statistics could be sourced indicating the number of lessons required for adults learning to drive with a left foot accelerator in auto car as a new driver.

Below is table summarizing the general requirements per state for adults learning to drive with a left accelerator in auto car.

Australian State & Link to information regarding the left accelerator requirement	Summary of requirement
NSW: Roads and Maritime Services New South Wales Driving with a disability: Leg disabilities	In an automatic vehicle, the accelerator and brake can be used by either the right or left leg, or both (one for each pedal). If you only use your left leg, the accelerator should be fitted to the left of the brake pedal (unless Roads and Maritime approves operation with the pedals in their normal position).
VIC: VicRoads Guidelines for Occupational Therapy (OT) Driver Assessors.	A person who has no functional use of their right foot or leg needs to use a left foot accelerator unless they can demonstrate appropriate control by use of prosthesis (if relevant). VicRoads will not test an applicant if the left foot is used to operate an accelerator fitted to the right of the brake pedal. Where an additional accelerator pedal is fitted to the left of the existing brake pedal, both the right and left accelerator pedal must be independently capable of being rendered inoperable.
QLD: Department of Transport and Main Roads	While there are no requirements which specifically cover the location of a left foot brake or accelerator pedal, attention should be paid to the

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Australian State & Link to information regarding the left accelerator requirement	Summary of requirement
Queensland Code of Practice Vehicle Modifications Version 4.2	February 2020
Australian Capital Territory	Not found
WA: Department of Transport Western Australia	Not found
SA: Department of Planning, Transport and Infrastructure South Australia	Not found
TAS: Department of State Growth Tasmania	Not found
NT: Department of Transport Northern Territory	Not found
ACT: Road Transport Authority	Not found

Number of Lessons: Adults re-learning to drive with a left accelerator in auto car (rather than a right one) as an existing driver

No research or statistics could be sourced indicating the number of lessons required for adults re- learning to drive with a left foot accelerator in auto car as an existing driver.

Number of Lessons: maximum number of driving lessons funded by other funding agencies

Other than a Victorian program funded by TAC, no evidence from other funding agencies could be found indicating a maximum number of driving lessons.

Traffic Accident Commission L2P Program

The TAC L2P Program is a state wide program funded by the TAC that matches young learner drivers with supervising driver mentors. The purpose of the program is to enable the learner driver to meet the mandated 120 hours of driving practice required to gain a probationary licence.

Participants are eligible for up to 7 professional driving lessons from a registered driving instructor. [3]

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Funding learner driving lessons for other funding agencies

Traffic Accident commission TAC

TAC do not indicate the number of lessons or hours of instruction they will fund.

TAC pay the reasonable cost of a driving program, when recommended by an occupational therapist and overseen by a qualified driving instructor, in the following circumstances:

•   The transport accident injury imposes physical, psychological or cognitive restrictions on
    your client, and

•   Driving and participation will enable your client to commence, or return to, safe and
    competent driving.

TAC can pay for:

•   driving instructor fees.
•   lessons and training on how to use adaptations in modified vehicles.
•   travel for a specialised driving instructor when:
    o your client with special needs requires a suitably modified vehicle, and
    o an instructor with the necessary skills and experience is not located near your
       client’s home.

TAC will not pay for:

•   driving lessons for your client if their driver’s licence or learner permit is under suspension or
    has been cancelled for reasons which are not directly related to their transport accident
    injuries
•   driving permit and licence fees
•   driving programs that are not conducted safely
•   driving programs conducted by an occupational therapist with no specialist training in driver
    assessment [4]

TAC Driving assessment (Instructor) services provided on or after 1 July 2020 [5]

Service Description	TAC Item Number	Maximum Payment Rate
Driving Assessment By Driving School - Driving Instructor Fees
For 30 Minutes	EDO015*	$51.70
For 45 Minutes	EDOO15*	$77.55
For 60 Minutes	EDO015*	$103.39
Pro-Rata For Longer Periods

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Department of Veteran Affairs (DVA)

No evidence could be found with regard to funding for learner driving lessons.

Lifetime Support Scheme

No specific evidence could be found regarding learner driving lessons other than an indication that the scheme “facilitated driving lessons and modifications to a vehicle” for a SCI participant [6], and that another participant is “is undergoing lessons to learn how to drive a modified vehicle”. [7]

Cohorts

Although an extensive search was not carried out with regard to particular disability cohorts and driving education, there appears to be some research available in this area on learning methods, which may give insight into the number of hours/lesson requirements.

For example a study on learner drivers with cerebral palsy suggested a need for better methods for teaching CP learners search strategies, as problems increased for CP learners in those parts of training where high demands are set on visual search abilities. [8]

A 2017 study set out to explore the facilitators or barriers to driving education experienced by individuals with ASD or ADHD who obtained a learner’s permit, from the perspective of the learner drivers and their driving instructors. It found that driving license theory was more challenging for individuals with ADHD, whilst individuals with ASD found translating theory into practice and adjusting to “unfamiliar” driving situations to be the greatest challenges. [9]

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References

[1] Australian Driver Licensing. https://austroads.com.au/drivers-and-vehicles/registration- and-licensing/australian-driver-licensing. Accessed 9 July 2020. https://austroads.com.au/drivers-and-vehicles/registration-and-licensing/australian- driver-licensing

[2] The Centre for Accident Research & Road Safety Queensland(CARRS), How would changing driver training in the Queensland licensing system affect road safety?: Deliverable 3: Evidence-based driver education policy options, 2013, https://www.tmr.qld.gov.au/-/media/Safety/roadsafety/Road-safety-research- reports/report-3-evidence.pdf?la=en

[3] TAC. VicRoads and TAC Win Health Award for Learner Driver Mentor Program. http://www.tac.vic.gov.au/about-the-tac/media-and-events/news-and-events/2013- media-releases/vicroads-and-tac-win-health-award-for-learner-driver-mentor-program. Accessed 14 July 2020.

[4] TAC. Driving Instructor Guidelines. http://www.tac.vic.gov.au/providers/working-with- tac-clients/guidelines/provider-guidelines/driving-instructor-guideline. Accessed 14 July 2020.

[5] TAC. Driving Assessment (Instructor) Fees. http://www.tac.vic.gov.au/providers/invoicing-and-fees/fee-schedule/driving- assessment-instructor. Accessed 14 July 2020.

[6] Richard Davis | Lifetime Support Authority – South Australia. https://lifetimesupport.sa.gov.au/participants/participant-stories/richard-davis/. Accessed 15 July 2020.

[7] Peter Norde | Lifetime Support Authority – South Australia. https://lifetimesupport.sa.gov.au/participants/participant-stories/peter-norde/. Accessed 15 July 2020.

[8] Falkmer, Torbjörn, and Nils Petter Gregersen. “Fixation Patterns of Learner Drivers with and without Cerebral Palsy (CP) When Driving in Real Traffic Environments.” Transportation Research Part F: Traffic Psychology and Behaviour, vol. 4, no. 3, Sept. 2001, pp. 171–85. ScienceDirect, https://www.sciencedirect.com/science/article/abs/pii/S1369847801000213

[9] “Experiences of Facilitators or Barriers in Driving Education from Learner and Novice Drivers with ADHD or ASD and Their Driving Instructors.” Autism CRC, 29 July 2015, https://www.autismcrc.com.au/knowledge-centre/publications/experiences-facilitators- or-barriers-driving-education-learner-and

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