Issues
Volume 213 Issue 1
Perspectives
Tracking, tracing, trust: contemplating mitigating the impact of COVID‐19 through technological interventions
A false impression of technological panacea may see much needed interventions overlooked and may introduce unintended consequences and risks In the face of coronavirus disease 2019 (COVID‐19) limiting free movement, experts are scrambling to mitigate the profound impact that the disease is having on our lives. For many countries, this approach involves increased testing, isolation, and education about hygiene practices until a vaccine is found. To varying degrees, without much evidence as to their efficacy, countries are turning to technology to solve some of the current challenges.1 Increasingly, smartphone applications (apps) are being contemplated for tracking proximity of people to determine possible sources of transmission, with elements of technological solutionism. Such technical solutions require trust, and without honest and clear information about the possibilities and limitations of technologies, an app's benefits may be undermined by low adoption, or conversely a false impression of a technological panacea may see much needed interventions overlooked. For example, the Australian Government's target of a 40% uptake of the COVIDSafe app may or may not be effective in helping to control the disease, while 60% uptake is supported by independent modelling from the United Kingdom.2 Furthermore, such summary statistics do not clarify to the public the wide range of other factors and assumptions that must be considered in predicting the app's efficacy. Much is being written about the different technological models and whether they trace, track and comply with privacy and human rights frameworks, including whether this information can, in fact, ever be anonymised.3 Fully effective anonymisation is unlikely when collecting data as granular as regular interaction with others in addition to age, gender and postcode demographics, as has been demonstrated by previous attempts to de‐anonymise data.4 If these data are accidentally or deliberately linked with other datasets, such as births in hospitals or the public Myki public transport dataset,5 anonymity is virtually impossible to guarantee. Successful uptake of new technologies requires trust. When adoption is insufficient, collective benefits are not guaranteed. Civil society in the United Kingdom called for clear and comprehensive primary legislation to regulate data processing in symptom tracking and digital contact tracing applications, including with a strict purpose, access and time limitations.6 Such regulation may improve trust. Technology embeds values Even when people are told of the limitations of technology, they may have magical thinking about its capabilities.7,8 In early May 2020, the Australian Government furthered this magical thinking by direct messaging Australians that downloading the COVIDSafe app would help to keep people safe and ease restrictions, linking the two directly and potentially conflating the capability of COVIDSafe. Contact tracing apps may assist in manual tracing, in turn slowing the virus’ spread, but usage of an app does not render the individual protected from infection nor does it guarantee successful tracking without intensive manual efforts. Yet statements by those in authority have made strained assertions about COVIDSafe, likening the use of the app to the use of sunscreen9 or a digital vaccine: “You could think about contact tracing as a digital vaccine with our contact data being the virtual antibodies”.10 Such statements are incorrect representations of the app's capabilities.11 Even the technical details of the app are not immune from false messaging. For example, the app records all Bluetooth contacts, not just those that last 15 minutes or that are within 1.5 m. The filtering occurs after contacts are uploaded. Furthermore, there are some inaccurate statements on the official COVIDSafe website; for example, the frequently asked questions section states that “all information that is stored on the phone is digitally encrypted;” however, metadata, such as the device make and model for each contact, are stored unencrypted.12 Communication must be fact‐based, transparent and consultative, any short term gains in support from the use of emotive and persuasive messaging may be undone when they are ultimately demonstrated to be false. Centralised versus decentralised data collection The fundamental difference between centralised versus decentralised tracking is in who learns what. In the centralised approach, the central authority learns who an infected person has interacted with, whereas this does not occur in the decentralised system. Decentralised systems are no more challenging to implement but they better protect privacy. In a centralised approach (Box 1), such as TraceTogether (Singapore) or COVIDSafe (Australia): encrypted identifiers are issued by the central authority to each device; devices broadcast the encrypted identifiers via Bluetooth, and nearby devices listen for such broadcasts and record any that they receive; if a person tests positive, they report to the central authority all the identifiers they have received within a predetermined timeframe; and the central authority decrypts the identifiers and maps them to the individuals they were issued to and duly notifies them if they are deemed to be at risk. The above is a very high level description and there are many technical challenges in implementing such a system securely.13 In a decentralised approach (Box 2), as proposed by decentralised privacy‐preserving proximity tracing (DP‐3T), Covid Watch, Apple and Google: devices generate random identifiers that are not linked to an individual; identifiers are broadcast via Bluetooth and recorded by nearby devices; a person who tests positive publishes a list of the identifiers they have broadcast; and all apps on user devices download such lists and check if they received positive identifiers so as to identify likely contacts. While there are variations in the details, in the decentralised approach, the central authority does not map identifiers to individuals. Although the distinction between centralised versus decentralised tracking may seem small, from a privacy perspective, there is a significant difference. In the case of COVIDSafe, the identifiers are generated and provided to the phone individually rather than as a daily batch: the central authority can monitor whether the app is being used in at least 2‐hourly increments, and possibly as frequently as every 9 minutes, due to regular checks for new identifiers. Models reflect differing societal priorities. In Germany, where there are legal protections for both individual and group privacy, the decentralised app has been chosen. In fact, it has been suggested that a decentralised smartphone contact tracing system — as contemplated by DP‐3T, Apple, Google, and governments across Europe — would be likely to comply with human rights and data protection laws. In contrast, a centralised smartphone system would pose a greater risk to fundamental rights and would require significantly greater justification to be lawful.6 Even when consent for central data collection has been sought, it is unclear what users are consenting to in the absence of fully open code that includes server‐side code, a clear regulatory framework, and with omissions, such as the COVIDSafe's Privacy Impact Assessment and Privacy Policy failing to mention the collection of the devices’ make and model.14 In comparison, Singapore's TraceTogether is based on the same codebase and its frequently asked questions section notifies of such data collection.15 Efficacy and risks of using Bluetooth Bluetooth Low Energy (BLE) is designed to be a low power communication technology, it was not designed to facilitate range finding. Accurately measuring the distance between two devices based only on the received signal strength is a challenge, with error margins often in the metres.16 The signal strength is relative not absolute, and thus, the scale of the reported values differ by manufacturer. Furthermore, the signal strength is influenced by many external factors, including the angle at which the device is held, whether it is in a pocket or a bag and any objects around or between it and the other device. Whether BLE can deliver the necessary accuracy remains an open question. While the use of Bluetooth avoids direct location tracking, many other risks remain. There are vast networks of Bluetooth beacons distributed around cities, which facilitate location tracking. Security advice is to disable Bluetooth when not in use. While the public might be expected to compromise for the common good, legislation could also move to limit Bluetooth beacons during the crisis. However, the Privacy Amendment (Public Health Contact Information) Act 202017 passed on 14 May provides no such protections.18 It provides an exemption to those accidentally collecting COVIDSafe data as part of a wider collection of non‐COVIDSafe data. This appears to be aimed at protecting commercial tracking, rather than protecting privacy. Legal and social implications are as important as the technical ones Given the many risks of using technology, the contemplation of any technological solutions to alleviate the impacts of COVID‐19 needs to be not only technical but also legal and social. Making the code open for audit provides some technical guard rails, much as providing open and transparent proof of test results ensures that no risks are overseen. But beyond technical questions there are also legal questions, including with whom the data may be shared. A recently published article refers to the multiple legal regimes potentially applicable to the app in Australia, as experts scramble to review the legal protections for individuals using COVIDSafe.19 Enacting emergency measures in the face of catastrophes is easy. Rolling back changes to technology, habits and even culture is far more difficult. If they are to be used, technological tracking solutions must have sunset clauses to ensure that human rights are protected. But even with sunset clauses, the large quantity of data collected are effectively out in the world, where they can be accessed and misused. Protections and limits for these data and their providers need to be contemplated before use, not only to protect individuals but also for group privacy. Increasingly, there is a risk of data being accessed by overseas agencies, which could have an impact on national security. It is vital that the technical, legal and social challenges are addressed in coordination. Any new legislation must be written within the context of existing technological practices, particularly around Bluetooth tracking. Likewise, where technical compromises are made, they must be justified to the public with clear, concise explanations, in a manner that is transparent and open to scrutiny. While many liberties have been curtailed during COVID‐19, all modifications to existing rights are required, under law, to be legal, necessary and proportionate. These same standards apply to the use of technology. Legal protections need to be in place to ensure that rights are protected, including the right to privacy. Without sound legal protections and safeguards, tracing apps will not only fail but will embed values that may not be those that represent the society we wish to be. Box 1 – The centralised approach of contact tracing wherein the central server learns user contact details Box 2 – The decentralised approach to contact tracing wherein no central authority learns user contact details
Kobi Leins · Christopher Culnane · Benjamin IP Rubinstein
Reducing stillbirth safely in Australia
Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm. There are five components of the Safer Baby Bundle: supporting women to stop smoking in pregnancy; improving awareness of a safe maternal sleeping position; improving decision making about timing of birth; improving the detection and management of fetal growth restriction (FGR); and raising awareness and improving care for women with decreased fetal movements (DFM). Of these five components, the latter two have the potential to increase early delivery. FGR is the strongest contributor to the burden of stillbirth. If detected and managed, the risk of stillbirth is 20‐fold lower than if FGR remains undetected.5 Improving the detection of FGR is central to any program aiming to reduce stillbirth. But increasing FGR detection may also cause harm. In a French population, half of the babies suspected of FGR antenatally had normal growth.6 In Victoria, a greater focus on improving the detection of FGR quadrupled the number of babies delivered early for suspected FGR, from 741 in 2000 to 2996 in 2017.5 The number and proportion of these babies with a birthweight in the 10th centile or greater increased from 307 (41%) to 1597 (53%).5 Striving to increase the sensitivity of FGR detection decreased specificity. This is a problem because unwarranted early delivery is harmful to both immediate perinatal5,6 and longer term developmental outcomes.7 Similar risks exist for increasing awareness of DFM. It has long been recognised that there is a relationship between DFM and stillbirth. Women who report DFM have a 2.4‐fold increased risk of stillbirth.8 However, translating this into an effective intervention has been challenging. Thirty years ago, it was shown that the use of formal fetal movement counting charts failed to reduce stillbirth.9 More recently, a large randomised controlled trial — the AFFIRM trial — assessed a care package for women presenting with DFM. In over 400 000 women attending 33 health services in the UK, increasing the awareness of DFM and standardising the care of those women presenting with DFM did not significantly reduce stillbirth.10 Moreover, there was evidence of harm to both mother and baby. Despite clear guidance for clinicians about what investigations to offer women with DFM and under what circumstances delivery was merited,11 there was an increase in the rates of induction of labour and caesarean delivery,10 with an additional 500 babies born between 32 and 34 weeks’ gestation and 5000 more born between 34 and 37 weeks’ gestation. The number of babies requiring admission to a neonatal unit also increased.10 The fact that most women with DFM will go on to give birth to a healthy baby suggests that the care package assessed by AFFIRM needs to be better targeted to women at risk. So what lessons can be drawn from these experiences for the Australian Safer Baby Bundle? Foremost, it is to be aware of the potential harm of any intervention and to look for this harm. This is possible with the use of balance performance measures12 —essentially, measures of unnecessary early delivery such as the proportion of babies delivered for suspected FGR but who were normally grown, or the number of neonatal unit admissions of term babies. Stillbirth programs elsewhere did not embed balance measures as part of their planned evaluation. Benefiting from the lessons learned by others, the Australian Safer Baby Bundle will include these measures to ensure that strategies designed to reduce stillbirth are targeted towards babies who are at most risk.1 The ultimate goal of balance measures is to reduce the unintended harm of our interventions. At present, no strategy has been shown to increase the sensitivity of FGR detection without causing harm. Neither is there a reliable tool to differentiate patterns of fetal movement that correspond to adverse outcome from those that are just a normal event. It is likely that more discriminatory screening tools reside in improved use of ultrasonography and biomarkers that assess fetoplacental function13 or in a better understanding of circadian patterns of fetal movements.14 Until then, caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies. It is crucial that the potential for unintended harm is made explicit and that measures of unnecessary early delivery are used to monitor progress of the Safer Baby Bundle implementation in Australia.
Roshan Selvaratnam · Mary‐Ann Davey · Euan M Wallace
Opening the lines of communication: towards shared decision making and improved end‐of‐life care in the Top End
Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.
Emma Spencer · Eswaran Waran
Medical education
Snakebite: an overlooked occupational hazard
A 52-year-old fireman presented to the hospital after being bitten by a white snake when demonstrating a snake handling technique to his colleagues
Kuang‐Ting Chen · Chien‐Ming Chiu
Editorials
Critically ill Indigenous Australians and mortality: a complex story
For most patients, life continues beyond the intensive care unit, and this is where action is needed
Paul J Secombe · Alex Brown · Michael J Bailey · David Pilcher
Hospital in the home: needed now more than ever
Changes in models of care elicited by COVID-19 may improve the quality of at- home care for patients
Hugh G Dickson
Research
Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care
Objectives: To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non‐electively to intensive care units (ICUs). Design: Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007–2016. Setting: All four university‐affiliated level 3 ICUs in South Australia. Main outcomes: Mortality (in‐hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. Results: 2035 of 39 784 non‐elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34–57 years) was lower than for non‐Indigenous ICU patients (64 years; IQR, 47–76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81–1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03–1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8–31.8 v 12.5; IQR, 0–22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75–0.80; non‐Indigenous, 0.77; 95% CI, 0.76–0.78). Conclusions: Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non‐Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.
William G Mitchell · Adam Deane · Alex Brown · Shailesh Bihari · Hao Wong · Rajaram Ramadoss · Mark Finnis
Home ward bound: features of hospital in the home use by major Australian hospitals, 2011–2017
Objective: To describe uptake of hospital in the home (HIH) by major Australian hospitals and the characteristics of patients and their HIH admissions; to assess change in HIH admission numbers relative to total hospital activity. Design: Descriptive, retrospective study of HIH activity, analysing previously collected census data for all multi‐day hospital inpatient admissions to included hospitals during the period 1 January 2011 – 31 December 2017. Setting, participants: Nineteen principal referrer hospital members of the Health Roundtable in Australia. Main outcome measures: HIH admissions by diagnosis‐related group (DRG); patient and admission characteristics. Results: 80 167 of 2 185 421 admissions to the 19 hospitals included HIH care, or 3.7% (95% CI, 3.6–3.7%) of all admissions. Median length of stay for admissions including HIH (7.3 days; IQR, 3.1–14 days) was longer than that for those that did not (2.7 days; IQR, 1.6–5.1 days). For HIH admissions, the proportion of men was higher (54.4% v 45.9%), the proportion of patients who died in hospital was lower (0.3% v 1.4%), and re‐admission within 28 days was less frequent (2.3% v 3.6%). The 50 DRGs with greatest HIH activity encompassed 65 811 HIH admissions (82.1%), or 8.4% (95% CI, 8.4–8.5%) of all admissions in these DRGs. HIH admission numbers grew more rapidly than non‐HIH admissions, but the difference was not statistically significant. Conclusions: HIH care is most frequently provided to patients requiring hospital treatment related to infections, venous thromboembolism, or post‐surgical care. Its use could be expanded in clinical areas where it is currently used, and extended to others where it is not. HIH activity is growing. It should be systematically monitored and reported to allow better overview of its use and outcomes.
Michael Montalto · Patrick McElduff · Kristy Hardy
Research letter
Presentations to emergency departments by children and young people with food allergy are increasing
The prevalence of food allergy among Victorian children is rising.1 In Victoria, children with suspected food allergies can be on hospital outpatient clinic waiting lists for months before being assessed.2 This may lead families to consider alternative avenues, which can lead to poor allergy management and the need for emergency care. Increasing numbers of Victorian children are presenting to emergency departments,3 but we do not know whether the number visiting with food allergy is also rising. We analysed Victorian Emergency Minimum Dataset (VEMD) data for the period 2005–06 to 2014–15. The VEMD is a statewide administrative dataset that includes non‐identifiable patient‐level data for all Victorian public emergency department encounters. We included all food allergy‐related presentations by children and young people aged 0–19 years, selected according to International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) codes: T78.0 (anaphylactic shock due to a food reaction), T78.1 (other adverse food reactions, not elsewhere classified), T78.4 (allergy, unspecified: includes non‐food‐related allergies), and L27.2 (dermatitis due to ingested food). Presentation rates by age group were calculated using Australian Bureau of Statistics (ABS) age‐stratified population data for Victorians aged 0–19 years;4 rates for regions were calculated using ABS population data for Statistical Areas 2 (SA2).5 The study was deemed exempt from the need for formal ethics approval by the Royal Children's Hospital Human Research Ethics Committee. The number of children presenting to emergency departments with food allergy‐related problems increased from 2368 in 2005–06 to 4263 in 2014–15; the presentation rate increased from 18 to 29 per 10 000 population (Box 1). About half the children who presented with food allergy‐related problems were aged 0–4 years, the rate for this age group increasing from 38 to 55 per 10 000 population (Box 2). The proportion of presentations triaged as being more urgent (triage categories 1–3) also increased, from 51% to 63% (Box 1). The rate of presentations to metropolitan hospitals increased more (from 18 per 10 000 in 2005–06 to 32 per 10 000 in 2014–15; 78% increase) than did the rate for rural hospitals (26 per 10 000 in 2005–06 to 36 per 10 000 in 2014–15; 38% increase) (Box 1). Hospitals in the North‐West Melbourne region received about one‐third of all allergy‐related emergency department visits, and the number in this region doubled over the study period (706 in 2005–06; 1536 in 2014–15) (Box 3). These data indicate that the demand for emergency services associated with food allergy‐related problems in children increased during 2005–15. The increase was particularly marked for children aged 0–4 years and for children and young people in the North‐West Melbourne and Southern Melbourne regions. While the reason for the increased burden is not clear — that is, whether the prevalence of allergy had increased (including because of a change in population composition), management plans had changed, or access to community services was reduced — the consequence is greater demand on emergency services across Melbourne. Box 1 – Presentations to Victorian public emergency departments by childen and young people (0–19 years) with food allergy‐related problems 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 All food allergy presentations Number 2368 2680 2754 2991 3082 3159 3185 3422 3881 4263 Rate (per 10 000 population)* 18 20 21 22 23 23 23 24 27 29 ICD‐10‐AM diagnostic codes T78.0 141 (6.0%) 152 (5.7%) 154 (5.6%) 168 (5.6%) 233 (7.6%) 283 (9.0%) 289 (9.1%) 339 (9.9%) 437 (11.3%) 501 (11.8%) T78.1 800 (33.8%) 948 (35.4%) 962 (34.9%) 1127 (37.7%) 1167 (37.9%) 1152 (36.5%) 1117 (35.1%) 1288 (37.6%) 1464 (37.7%) 1624 (38.1%) T78.4 1234 (52.1%) 1351 (50.4%) 1441 (52.3%) 1488 (49.8%) 1552 (50.4%) 1597 (50.6%) 1633 (51.3%) 1702 (49.7%) 1881 (48.5%) 2031 (47.6%) L27.2 193 (8.2%) 229 (8.5%) 197 (7.2%) 208 (7.0%) 130 (4.2%) 127 (4.0%) 146 (4.6%) 93 (2.7%) 99 (2.6%) 107 (2.5%) Age Number 0–4 years 1202 (50.8%) 1364 (50.9%) 1424 (51.7%) 1537 (51.4%) 1520 (49.3%) 1595 (50.5%) 1593 (50.0%) 1759 (51.4%) 2015 (51.9%) 2152 (50.5%) 5–9 years 466 (19.7%) 515 (19.2%) 521 (18.9%) 573 (19.2%) 673 (21.8%) 608 (19.3%) 660 (20.7%) 702 (20.5%) 813 (21.0%) 967 (22.7%) 10–14 years 305 (12.9%) 335 (12.5%) 355 (12.9%) 405 (13.5%) 403 (13.1%) 426 (13.5%) 383 (12.0%) 433 (12.7%) 515 (13.3%) 561 (13.2%) 15–19 years 395 (16.7%) 466 (17.4%) 454 (16.5%) 476 (15.9%) 486 (15.8%) 530 (16.8%) 549 (17.3%) 528 (15.4%) 538 (13.8%) 583 (13.7%) Rate (per 10 000 population)* 0–4 years 38 42 43 45 43 45 44 47 53 55 5–9 years 15 16 16 18 21 18 19 20 22 26 10–14 years 9 10 11 12 12 13 12 13 15 16 15–19 years 12 13 13 13 14 15 15 15 15 16 Sex Number Boys 1284 (54.2%) 1435 (53.5%) 1476 (53.6%) 1625 (54.3%) 1663 (54.0%) 1723 (54.5%) 1779 (55.9%) 1867 (54.6%) 2158 (55.6%) 2388 (56.0%) Girls 1084 (45.8%) 1245 (46.5%) 1278 (46.4%) 1366 (45.7%) 1419 (46.0%) 1436 (45.5%) 1406 (44.1%) 1555 (45.4%) 1723 (44.4%) 1875 (44.0%) Rate (per 10 000 population)* Boys 19 21 21 23 24 25 25 26 29 32 Girls 17 19 20 21 21 22 21 22 24 26 Hospital region Number Metropolitan† 1560 (65.9%) 1860 (69.4%) 1907 (69.2%) 2008 (67.1%) 2071 (67.2%) 2194 (69.5%) 2186 (68.6%) 2345 (68.5%) 2781 (71.7%) 3149 (73.9%) Rural‡ 808 (34.1%) 820 (30.6%) 847 (30.8%) 983 (32.9%) 1011 (32.8%) 965 (30.5%) 999 (31.4%) 1077 (31.5%) 1100 (28.3%) 1114 (26.1%) Rate (per 10 000 population)* Metropolitan† 18 22 22 23 23 25 24 25 29 32 Rural‡ 26 27 27 32 33 31 32 35 35 36 Triage category Categories 1–3 1198 (50.6%) 1429 (53.3%) 1568 (57.0%) 1707 (57.0%) 1830 (59.3%) 1861 (59.0%) 1807 (56.8%) 2047 (59.8%) 2365 (61.0%) 2694 (63.2%) Categories 4, 5 1170 (49.4%) 1251 (46.7%) 1186 (43.0%) 1284 (43.0%) 1252 (40.7%) 1298 (41.0%) 1378 (43.2%) 1375 (40.2%) 1516 (39.0%) 1569 (36.8%) ICD‐10‐AM = International Classification of Diseases, tenth revision, Australian modification. * All presentation rates are per 10 000 children in Victoria aged 0–19 years in the corresponding category. † Victorian Emergency Minimum Dataset (VEMD) regions: North‐West, Southern, and Eastern Melbourne. ‡ VEMD regions: Loddon Mallee, Gippsland, Barwon South West, Hume, Grampians. Box 2 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems: rates per 10 000 population, by age group Box 3 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems, by hospital campus region
Rachel O'Loughlin · Harriet Hiscock
Guidelines
Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines
The incidence of paediatric type 2 diabetes has increased in Australasia parallel to paediatric obesity and international guidelines available do not address the specifics for high risk ethnic groups
Alexia S Peña · Jacqueline A Curran · Michelle Fuery · Catherine George · Craig A Jefferies · Kristine Lobley · Karissa Ludwig · Ann M Maguire · Emily Papadimos · Aimee Peters · Fiona Sellars · Jane Speight · Angela Titmuss · Dyanne Wilson · Jencia Wong · Caroline Worth · Rachana Dahiya
Letters
COVID‐19 in Australian health care workers: early experience of the Royal Melbourne Hospital emphasises the importance of community acquisition
To the Editor: There is marked concern among health care workers in Australia regarding the safety of caring for patients with coronavirus disease 2019 (COVID‐19), which partly relates to highly publicised reports of health care workers dying from COVID‐19 overseas. The concern has caused high levels of anxiety in many health care workers, the use of personal protective equipment (PPE) outside of government guidelines, and many seeking exemptions from being involved in the care of patients with COVID‐19. The reports of health care worker deaths overseas generally do not explore whether the infection was contracted caring for patients or through community contact, or whether appropriate PPE was worn. In March 2020, a clinic was established to screen staff from Royal Melbourne Hospital and neighbouring hospitals who had developed a fever or new respiratory symptoms. A targeted history was taken and a swab was performed according to public health department recommendations at the time. In addition to this, a public screening clinic run by the hospital was also available for health care workers practising in the broader community, so those working in non‐hospital settings could be identified and tested. At 6 April 2020, 1160 symptomatic staff had been assessed in the staff clinic and the majority had been swabbed for COVID‐19, while a number of health care workers also attended the public clinic. Across both staff and public screening clinics, 11 health care workers were found to be positive for COVID‐19. Of these, eight had a history of travel or close contact with a COVID‐19 case in the community. The other three had no obvious COVID‐19 contact in the workplace, during a period when fewer than ten patients with COVID‐19 were treated at the hospital. Two of the staff, while identifying as health care workers, did not work in a clinical hospital setting and were judged to be at low risk of contracting infection from an unwell patient in their workplace. The other worked in a hospital ward where no known COVID‐19 infected patients had been managed. Although a dedicated service for screening and supporting staff may not be feasible in all settings, it does provide access to rapid testing which gives valuable reassurance for staff. Importantly, monitoring the data helps to contextualise our local experience. These data indicate that COVID‐19 is very uncommon in health care workers at present, and that the large majority who have contracted COVID‐19 have done so away from work. There is already intensive training in the use of appropriate PPE in the workplace, and we continue to reassure health care workers that this affords high level protection. Victorian census data in 2016 suggest that approximately 12% of adults identify as health care workers,1 which gives some context to the state‐wide data suggesting that 11% of positive cases to date have occurred in health care workers.2 This is not to trivialise the risk that frontline health care workers face, particularly when caring for unrecognised cases without using PPE. Our data show that currently, community acquisition of COVID‐19 is likely to be occurring in health care workers more often than work‐related acquisition. Health care workers should focus on taking measures (eg, social distancing and hand hygiene) to protect themselves from COVID‐19 when away from work. Ongoing monitoring of the epidemiology related to staff clinic presentations may help provide information on local risks.
Stephen Muhi · Louis B Irving · Kirsty L Buising
Emerging viral mutants in Australia suggest RNA recombination event in the SARS‐CoV‐2 genome
To the Editor: The coronavirus disease 2019 (COVID‐19) outbreak has become a public health emergency globally.1,2 Until 26 May 2020, there were 7126 confirmed cases reported in Australia (https://coronavirus.jhu.edu/map.html). However, specimens of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) independently isolated in Australia (in Sydney, the Gold Coast and Melbourne)3 exhibited very unusual mutations, which have not been identified in other countries (Box, A). Up to 29 April, 1319 sequences of the Australian SARS‐CoV‐2 isolates are available in the website of the Global Initiative on Sharing All Influenza Data (GISAID).3 Except for the NSW03 and NSW01 isolates, viral mutations are located at the stem‐loop II motif (s2m), an extremely conserved RNA element in the 3’ untranslated region (3’‐UTR) (Box, A). The NSW02 and VIC01 isolates have deletion of 41 and ten nucleotides respectively. All Queensland cases have single G‐to‐A substitution (nucleotides 29714/QLD01, 29736/QLD02, 29736/QLD04, and 29737/QLD03). Moreover, patients with NSW05, NSW06, NSW07, NSW15, NSW18, NSW19, NSW21, NSW24, NSW26, NSW28, or NSW31 (nucleotide 29696) have single G‐to‐U substitution at the same nucleotide. This substitution is only present in Australian patients and has not been found in SARS‐CoV‐2 isolates from other countries. Phylogenetic analysis showed that SARS and 30 other coronaviruses and astroviruses all possess the genetic element s2m, suggesting that this motif is conserved in both nucleotide sequence and secondary structure folding during evolution in an otherwise rapidly mutable RNA genome.3,5 The three‐dimensional crystal structure of the s2m RNA element of the SARS virus shows that guanosine (19), which is mutated in Australian isolates, is critical for tertiary contacts to form an RNA base quartet involving two adjacent G–C pairs (G19, C20, G28, and C31)4 (Box, B). Because s2m plays an essential role for the viral RNA to substitute host protein synthesis, we hypothesise that the disruption of s2m could alter the viral viability or infectivity dramatically. The s2m sequence of coronaviruses is highly conserved, and spontaneous mutations in this motif were not expected to have occurred during the apparent short period when SARS‐CoV‐2 has been present; therefore, it is highly likely that the changes are due to recombination.5 Because a high frequency of recombination events in coronaviruses occurs, RNA recombination could either enhance the adaptation process to its new host like humans or cause unpredictable changes in virulence during infection. Box – Mutations, deletions and recombination breakpoints in the stem‐loop II motif (s2m) of Australian severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) isolates Panel A: Deletions and mutations in the primary, secondary and tertiary structures of the coronavirus disease 2019 (COVID‐19) s2m RNA genetic element based on the three‐dimensional crystal structure of the SARS virus. Conventional RNA helical base pairings are indicated in italics. Sequence complements are indicated using colour‐coded brackets. The G19 mutation (arrowhead) of the Australian SARS‐CoV‐2 is shown with purple colour. Asterisks label the RNA recombination breakpoints based on analysis of 1319 Australia SARS‐CoV‐2 sequences using Recco algorithm (https://recco.bioinf.mpi-inf.mpg.de/) (P < 0.002). Panel B: Schematic representation of the s2m RNA secondary structure of the SARS virus, with tertiary structural interactions indicated as long range contacts.4
Ting‐Yu Yeh · Gregory P Contreras
Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes
To the Editor: We read the perspective by Weinstein and colleagues1 with interest and agree that treatment of snake envenoming in Australia is complex, and that clinicians should seek expert advice in cases of severe or unusual envenoming. There is 24‐hour specialist clinical toxicologist support available through the national Poisons Information Centre network (13 11 26), which takes 300 calls annually regarding snakebite. However, we are concerned that the authors argue for just one non‐evidenced‐based solution — higher doses of antivenom — despite the extensive evidence that this historical approach does not lead to better outcomes. They suggest that the reduction in antivenom doses is based on a study of snakebite data in Australia from 2005 to 2015,2 which concluded that as “the usual antivenom dose for all major snake groups has decreased to one vial, with no evidence of adverse consequences, this approach should be retained” (emphasis added).2 However, the evidence supporting the move to lower doses of antivenom was based on a series of around 15 earlier studies.2 Serial measurement of venom concentrations using enzyme immunoassays in patients with snake envenoming demonstrated complete neutralisation after any dose,2 and the time course of recovery was unaltered by antivenom dose. The evidence suggests benefits from earlier antivenom but not from higher doses.3 Weinstein and colleagues cite a study by O'Leary and colleagues4 when they state that using “samples from rodents injected with venom … inaccurately determines a true neutralising dose”. However, the cited study measured venom–antivenom complexes in vitro to determine the antivenom concentration at which every venom molecule is bound to at least one antivenom molecule, as a measure of efficacy.4 It showed that this was similar to the manufacturer's original recommendation of a dose of a single vial of antivenom. Weinstein and colleagues criticise the use of data from the large multicentre prospective cohort, the Australian Snakebite Project, which reports both clinical and laboratory outcomes and measures venom concentrations. They provide no citations to support their contentions, other than single cases and opinion (often citing their own previous views). A coroner's case in which a person died after three vials of antivenom is strangely cited as highlighting concerns that a single vial of antivenom is insufficient. They suggest two vials may be sufficient, or even larger doses, but offer no research or studies to support this, and no guidance as to when larger doses are required. They also do not provide a useful or practical alternative approach to the treatment of snake envenoming. Current national evidence‐based guidelines and Poisons Information Centres recommend that one vial of brown snake antivenom and one vial of tiger snake antivenom be given as soon as possible in most snake envenoming cases in Australia.5 This ensures that the most common snakes are covered, as snake venom detection kits are unreliable.2 It also means an equivalent of two vials of antivenom is administered, because Australian “monovalent” antivenoms are in fact polyvalent.6 Evidence‐based guidelines continuously evolve, and we believe the key to better outcomes is early identification of envenomed patients and prompt access to the latest evidence‐based advice by consulting a clinical toxicologist through the Poisons Information Centre.
Geoffrey K Isbister · Nicholas A Buckley
Risks and realities of single vial antivenom recommendations for envenoming by Australian elapid snakes
In reply
Scott A Weinstein · Peter J Mirtschin · Julian White
Careers
Happy Birthday Honours list
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COVID‐19 acute respiratory distress syndrome (ARDS): clinical features and differences from typical pre‐COVID‐19 ARDS
Peter G Gibson · Ling Qin · Ser Hon Puah
Challenges of diabetes management during the COVID‐19 pandemic
Emma S Scott · Alicia J Jenkins · Gregory R Fulcher
Reconsidering the immediate release of prisoners during COVID‐19 community restrictions
Stephane Shepherd · Benjamin L Spivak
COVID‐19: planning for the aftermath to manage the aftershocks
Steven G Faux · Kathy Eagar · Ian D Cameron · Christopher J Poulos
Helping infants through trauma
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From SARS to COVID‐19: the Singapore journey
Ray Junhao Lin · Tau Hong Lee · David CB Lye
Transfusion support in mass casualty events: lessons for hospital and pathology preparedness from the Bourke Street Mall incident
Linda Saravanan · Amanda Ormerod