Volume 213 Issue 3

Clinical record A 40‐year‐old woman of Karen ethnicity presented with 5 days of generalised abdominal pain. The pain was worsening and associated with vomiting in the 12 hours preceding presentation. She had been constipated for 5 weeks. There was no diarrhoea, no blood or mucous in the stool and no haematemesis. There were no sick family, friends or colleagues and no recent travel. She had an omnivorous diet, which had not changed recently, and worked casually at a vegetable farm. In the emergency department, vital signs were normal and the abdomen was mildly distended and tender. Initial blood tests showed a neutrophil count of 9.6 × 109/L (reference range [RR], 2.0–8.0 × 109/L), serum bicarbonate 22 mmol/L (RR, 22–32 mmol/L), normal renal function, and C‐reactive protein below 2.9 mg/L (RR, < 3.0 mg/L). Computed tomography of the abdomen and pelvis was consistent with colitis of the descending colon and ileus (Box 1). She was admitted for observation under the general surgical team. Five hours after admission, her condition rapidly deteriorated. Blood pressure was 80/40 mmHg, heart rate 129 beats per minute in sinus rhythm, and there was severe abdominal tenderness with generalised guarding. Repeat tests showed serum creatinine 175 μmol/L (RR, 60–110 μmol/L), bicarbonate below 10 mmol/L (RR, 22–32 mmol/L), blood pH 6.97 (RR, 7.35–7.45), and lactate 14.8 mmol/L (RR, < 1.5 mmol/L). At emergency surgery, colonoscopy and ileoscopy revealed mucosal inflammation affecting the distal 20 cm of terminal ileum, caecum, transverse and sigmoid colon, with patches of frank mucosal necrosis (Box 2). The bowel was grossly dilated, with small patches of full thickness caecal necrosis but no perforation. Subtotal colectomy, terminal ileectomy, and formation of an end ileostomy were performed, with resultant resolution of circulatory shock. Pathological examination demonstrated severe acute pancolitis and extensive mucosal necrosis (Box 3). Clostridium perfringens infection was suspected, due to a striking similarity to published cases.1,2C. perfringens was isolated from biopsy specimens of the necrotic colonic mucosa using selective culture media. The isolate expressed C. perfringens enterotoxin and α‐toxin, defined as toxinotype F.3 Postoperative management included vancomycin both orally and per rectum. Three months after the operation, she was pain‐free, with a normal appetite and functional state. Reversal of ileostomy is planned in coming months. Discussion C. perfringens is a gram‐positive bacillus that forms hardy spores, is ubiquitous in environmental soil and water, and can be part of normal bowel flora. Toxigenic strains commonly cause both foodborne and sporadic cases of acute, self‐limiting diarrhoea. The typical foodborne strain F produces C. perfringens enterotoxin and α‐toxin and was found in our patient.3 The organism exhibits the shortest known doubling time of any cell when grown at 42°C in cooked minced beef.4 Exposure to large inocula of toxigenic organisms may arise when meat is kept lukewarm before consumption. Enteric infections are characterised by adherence of organisms to small bowel mucosa before concurrent sporulation and release of toxin. This typically induces self‐limiting diarrhoea 10–12 hours after eating. Necrotising enterocolitis is a manifestation of C. perfringens enteric infection that is rare in high income countries. Some reported cases associate the condition with constipation, either pre‐existing due to medication side effects or induced by the high protein content of ingested contaminated meat. Constipation has been proposed to impair the usual expulsion of C. perfringens bacteria and spores, leading to mucosal necrosis and shock as opposed to the usual syndrome of transient diarrhoea. Mortality in case series is greater than 50%.1,2 Despite thorough assessment, the cause of our patient's constipation and means of exposure remain unclear. She most likely contracted the infection hours before the onset of her pain, 5 days before presentation. Exposure could have occurred during food preparation at home, meals with social groups, or via soil at her workplace. While rare in Australia, a type of C. perfringens necrotising enteritis was endemic throughout the 20th century in the Papua New Guinea highlands, caused by β‐toxin‐producing strains. Called “pigbel” in Tok Pisin, the disease is closely associated with traditional pig feasts. In the 1960s and 1970s, pigbel accounted for almost a quarter of paediatric deaths in highlands hospitals. Implementation of a β‐toxoid vaccine in 1979 resulted in an eightfold reduction in incidence and an even greater reduction in disease‐specific mortality.5 C. perfringens infection is an important differential diagnosis in cases of acute severe enteritis or colitis, particularly if accompanied by circulatory shock. Prompt operative intervention is necessary in such situations. In Papua New Guinea, toxoid vaccination has proven very successful. In Australia, food safety practices likely play the greatest role in controlling disease burden. Lessons from practice Toxigenic Clostridium perfringens type F commonly causes acute diarrhoea, with illness typically commencing hours after meat consumption. Cases are usually self‐limiting, and require symptomatic management only. Very rarely, toxigenic C. perfringens strains can cause fulminant bowel necrosis requiring emergency bowel resection, which may be associated with pre‐existing constipation. In the highlands of Papua New Guinea, necrotising enteritis has been a common cause of paediatric morbidity and mortality, where it is caused by a locally endemic strain of toxigenic C. perfringens. Box 1 – Coronal computed tomography image of the abdomen and pelvis with portal venous phase contrast, demonstrating mural thickening of the descending colon in the left lower quadrant and fluid‐filled distension of the transverse colon, ascending colon, and ileum Box 2 – Endoscopy images obtained immediately before laparotomy, showing mucosal necrosis of the ascending colon Box 3 – Macroscopic appearance of resected colon, demonstrating extensive mucosal necrosis and oedema

Harry N Walker · Kwee‐Chin Liew · Vicki Adams · Sarah Larcombe · Sonal S Nagra · Glenn Guest · Eugene Athan

The major impediments to control are lack of commitment, funding and coordination, not lack of knowledge It has been a long time coming, but Australia is starting to understand the tragedy and injustice of rheumatic heart disease (RHD) in Aboriginal and Torres Strait Islander people. No condition is more emblematic of “the gap”: in Australia, the burden of RHD is borne almost exclusively by Indigenous people, with rates among the highest in the world. It is a disease with social determinants, including poverty and overcrowded housing, it starts in childhood but stretches into adulthood, it kills people prematurely, and, most devastatingly, it is preventable. The major impediments to its being controlled or even eliminated are lack of commitment, funding and coordination, not lack of knowledge. Over the past five years, a network of researchers and service providers has come together in the National Health and Medical Research Council‐funded End Rheumatic Heart Disease Centre of Research Excellence. The Centre is about to publish The RHD Endgame Strategy: The blueprint to eliminate rheumatic heart disease in Australia by 2031. It has already modelled what will happen if we fail to alter course in RHD control: more than 10 000 Indigenous Australians will develop RHD over the next 11 years, of whom 563 will die and 1370 will require heart surgery as a direct consequence of RHD. More than $317 million would be needed for their medical care alone.1 Hearteningly, END RHD, a coalition of organisations led by the Aboriginal Community Controlled Health Organisation (ACCHO) sector, has formed to support communities at greatest risk of RHD, to advocate implementation of the Endgame Strategy, and to educate Australians about the role they can play in ending RHD. END RHD is co‐chaired by the chief executive officer of the National Aboriginal Community Controlled Health Organisation, Ms Pat Turner AM, and includes representatives from ACCHO peak bodies in each of the jurisdictions in which RHD is a major problem. END RHD embodies the essential elements of what is needed to rid Australia of this devastating disease: Indigenous leadership, community empowerment, and a primary focus on the social determinants of disease, in addition to strategies targeting streptococcal A skin and throat infections and care for people with established RHD. A study in this issue of the MJA2 highlights RHD care, other elements needed to implement the Endgame Strategy, and some of the challenges in doing so. Francis and colleagues report a cross‐sectional echocardiographic screening survey of children and young people in the remote Northern Territory community of Maningrida. They found an extraordinarily high prevalence of definite RHD (5.2% of screened people aged 5–20 years), of whom 62% had previously been undiagnosed and 25% had severe disease. This project had many admirable elements that could inform activities in other communities. The focus on education and health promotion in local languages, intense community engagement, and local leadership were exemplary, to which the very high participation rate is testament. However, a range of questions remain unanswered. Why, for instance, are the reported results so different from the findings of the gECHO study,3 conducted a decade earlier? In this study, in which almost 4000 Indigenous children aged 5–15 years in remote communities across northern and central Australia were screened, the prevalence of definite RHD was 0.86%; 53% of cases were previously undiagnosed, and only one in 18 new cases was severe. While the prevalence of definite RHD was highest in the Top End of the NT (1.5%), where Maningrida is located, the threefold difference in prevalence between the two studies is remarkable. A single community may not be representative of an entire region, but if the Maningrida findings are to stimulate consideration of more widespread screening, how one identifies communities in which it is warranted is critical. The difference in prevalence found by the two studies is difficult to explain. There is no evidence that socio‐economic determinants of group A streptococcal infections and RHD had dramatically worsened in this region over the past 10 years to a degree that would explain such discordance. However, four years prior to the study by Francis and colleagues, a large cluster of acute rheumatic fever (ARF) cases was identified in Maningrida: more than 1.5% of 5–14‐year‐old children developed ARF over a 6‐month period.4 As most people with RHD in the NT do not have known histories of ARF, and ARF can be very mild or even asymptomatic, it is likely that a substantially greater proportion of Maningrida residents had ARF at this time.5 Such a significant outbreak has rarely, if ever, been reported for an Indigenous community, and the study of Francis and colleagues may have included a number of RHD cases related the ARF outbreak four years earlier. Francis and his co‐authors also point out that auscultation is still used in child health checks in NT Indigenous communities. This approach, however, is less accurate than flipping a coin for diagnosing RHD, and should therefore be abandoned for this purpose.6 We commend the authors for the careful wording of their recommendations. They recognise that echocardiographic screening may have obvious benefits; besides detecting new cases of RHD and facilitating life‐saving treatment and secondary prevention, it is an excellent tool for motivating a community to focus on RHD, which, together with education about prevention and related activities, can enhance engagement. But it is also intensive and costly: hence the need to focus on more practical methods for implementation, as the authors point out, but also to ensure that communities are advised about a threshold for screening in accordance with established criteria. They must also be provided with adequate technical support and advice before embarking on such screening programs. Australia has a rare opportunity to eliminate RHD by implementing the Endgame Strategy. In so doing, we will make an important step towards closing the health gap between Indigenous and non‐Indigenous Australians, not only by reducing the burden of RHD but also the burdens of other diseases that share similar social determinants. But success depends on communities being supported to direct local strategies that comprehensively address streptococcal A infections, ARF and RHD at many levels. Maningrida is a perfect example.

Jonathan R Carapetis · Alex Brown

Objectives: Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD) in a remote Northern Territory town. Design: Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register. Setting, participants: People aged 5–20 years living in Maningrida, West Arnhem Land (population, 2610, including 2366 Indigenous Australians), March 2018 and November 2018. Intervention: Echocardiographic screening for RHD by an expert cardiologist or cardiac sonographer. Main outcome measures: Definite or borderline RHD, based on World Heart Federation criteria; history of acute rheumatic fever (ARF), based on Australian guidelines for diagnosing ARF. Results: The screening participation rate was 72%. The median age of the 613 participants was 11 years (interquartile range, 8–14 years); 298 (49%) were girls or women, and 592 (97%) were Aboriginal Australians. Definite RHD was detected in 32 screened participants (5.2%), including 20 not previously diagnosed with RHD; in five new cases, RHD was classified as severe, and three of the participants involved required cardiac surgery. Borderline RHD was diagnosed in 17 participants (2.8%). According to NT RHD register data at the end of the study period, 88 of 849 people in Maningrida and the surrounding homelands aged 5–20 years (10%) were receiving secondary prophylaxis following diagnoses of definite RHD or definite or probable ARF. Conclusion: Passive case finding for ARF and RHD is inadequate in some remote Australian communities with a very high burden of RHD, placing children and young people with undetected RHD at great risk of poor health outcomes. Active case finding by regular echocardiographic screening is required in such areas.

Joshua R Francis · Helen Fairhurst · Hilary Hardefeldt · Shannon Brown · Chelsea Ryan · Kurt Brown · Greg Smith · Roz Baartz · Ari Horton · Gillian Whalley · James Marangou · Alex Kaethner · Anthony DK Draper · Christian L James · Alice G Mitchell · Jennifer Yan · Anna Ralph · Bo Remenyi

Percutaneous coronary intervention with stent implantation (PCI‐S) has revolutionised the management of patients with coronary artery disease at high risk of myocardial infarction and stroke.1 Dual antiplatelet therapy (aspirin with clopidogrel, prasugrel or ticagrelor) is superior to aspirin alone for preventing atherothrombotic events, including stent thrombosis, in patients undergoing PCI‐S,2 and is recommended by Australian guidelines.3 We analysed de‐identified, linked Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) data for a 10% random sample of Medicare beneficiaries provided by the Australian Department of Health, to quantify rates of antiplatelet drug dispensing within 30 days of PCI‐S. We included all patients with MBS claims for PCI‐S (items 38306, 38312, 38318) between 1 January 2013 and 30 September 2014. MBS data on PCI‐S procedures are available only for private patients, who account for about 45% of PCI‐S procedures in Australia.4 The medicines of interest for our analysis were clopidogrel and clopidogrel/aspirin (Anatomical Therapeutic Chemical [ATC] codes B01AC04 and B01AC30), ticagrelor (ATC code B01AC24), and prasugrel (ATC code B01AC22). Aspirin alone was not examined because over‐the‐counter use is not captured in PBS claims data. We assessed the association of several factors with antiplatelet medication dispensing within 30 days of PCI‐S, expressed as odds ratios, by logistic regression modelling. The New South Wales Population and Health Services Research Ethics Committee approved the study (Cancer Institute NSW reference, 2013/11/494). Of 2869 patients who underwent PCI‐S during the study period, 2592 (90%) were dispensed antiplatelet drugs within 30 days of the procedure. Dispensing was more frequent for concessional PBS beneficiaries, patients who had not undergone PCI‐S in the preceding year, patients not dispensed antiplatelet drugs during the preceding six months, and patients dispensed proton pump inhibitors within 30 days of the procedure. Antiplatelet therapy was also more frequent among patients from Victoria or Tasmania, Queensland, and Western Australia than for those from NSW or the Australian Capital Territory (Box). Our findings indicate that 10% of patients undergoing PCI‐S did not receive guideline‐recommended dual antiplatelet therapy within 30 days of their procedure. Cost may have been a barrier, as antiplatelet therapy was less frequent among general than concessional PBS beneficiaries; the maximum out‐of‐pocket cost for any single PBS item in 2013 was $5.90 for concessional beneficiaries, but $36.10 for general beneficiaries, and general beneficiaries may have already experienced significant out‐of‐pocket costs for both health insurance and their procedure. In most states, the Public Hospitals Pharmaceutical Reform Agreement6 ensures that PBS‐subsidised medications can be dispensed to patients when they are discharged from hospital. NSW and the ACT, however, do not participate in this agreement; patients are discharged from public hospitals with unsubsidised medicines sufficient for only 2–7 days, after which they must visit a community doctor for prescribing of PBS‐subsidised medications. This inconvenience may contribute to the lower 30‐day dispensing rate in these jurisdictions. We were unable to evaluate the long term clinical effect of antiplatelet therapy as the analysed datasets do not include information about hospital admissions. The number of PCI‐S procedures in Australia increased from 24 500 MBS claims in 2013 to 29 000 in 2018 (http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp), and the number of patients at risk of early stent thrombosis may also have grown. Why some patients undergoing PCI‐S are not receiving dual antiplatelet therapy directly after their procedure should be further investigated. Box – Characteristics of patients undergoing percutaneous coronary intervention with stent implantation (PCI‐S) in Australia, and their association with dual antiplatelet therapy within 30 days of PCI‐S Number of patients Odds ratio (95% confidence interval) Underwent PCI‐S Antiplatelet therapy within 30 days Univariate models Multivariate model Total number of patients undergoing PCI‐S 2869 2592 (90%) Age (years) 18–54 351 (12%) 307 (87%) 1 1 55–64 711 (25%) 640 (90%) 1.29 (0.87–1.93) 1.26 (0.83–1.91) 65–74 965 (34%) 879 (91%) 1.47 (0.99–2.16) 1.17 (0.76–1.81) 75–84 660 (23%) 605 (92%) 1.58 (1.04–2.40) 1.09 (0.66–1.81) 85 or more 182 (6%) 161 (88%) 1.10 (0.63–1.91) 0.83 (0.66–1.60) Sex Women 670 (23%) 604 (90%) 1 1 Men 2199 (77%) 1988 (90%) 0.97 (0.73–1.30) 0.86 (0.63–1.18) State where PCI‐S was undertaken New South Wales/Australian Capital Territory 1121 (39%) 986 (88%) 1 1 Victoria/Tasmania 752 (26%) 694 (92%) 1.64 (1.19–2.26) 1.56 (1.12–2.17) South Australia/Northern Territory 147 (5%) 129 (88%) 0.98 (0.58–1.66) 0.94 (0.55–1.60) Queensland 549 (19%) 504 (92%) 1.53 (1.08–2.19) 1.47 (1.02–2.13) Western Australia 300 (10%) 279 (93%) 1.82 (1.13–2.94) 2.14 (1.28–3.59) PBS patient category General 1453 (51%) 1293 (89%) 1 1 Concessional 1404 (49%) 1299 (93%) 1.53 (1.18–1.98) 1.63 (1.18–2.26) Previous PCI‐S Preceding 12 months 234 (8%) 199 (85%) 1 1 None 2635 (92%) 2393 (91%) 1.74 (1.19–2.55) 1.41 (0.93–2.13) Previous antiplatelet therapy Preceding 6 months 1135 (40%) 995 (88%) 1 1 None 1734 (60%) 1597 (92%) 1.64 (1.28–2.10) 1.96 (1.45–2.64) Anticoagulant therapy within 30 days of PCI‐S No 84 (3%) 77 (92%) 1 1 Yes 2785 (97%) 2515 (90%) 1.18 (0.54–2.59) 1.04 (0.47–2.33) Proton pump inhibitor therapy within 30 days of PCI‐S No 1002 (35%) 931 (93%) 1 1 Yes 1867 (65%) 1661 (89%) 1.63 (1.23–2.16) 1.42 (1.05–1.92) Comorbid conditions (six months before PCI‐S) None 196 (7%) 169 (86%) 1 1 1 180 (6%) 165 (92%) 1.76 (0.90–3.42) 1.47 (0.72–3.01) 2 259 (9%) 234 (90%) 1.50 (0.84–2.67) 1.34 (0.71–2.56) 3 389 (14%) 356 (92%) 1.72 (1.00–2.96) 1.54 (0.84–2.82) 4 452 (16%) 395 (87%) 1.11 (0.68–1.81) 1.01 (0.57–1.79) 5 or more 1393 (49%) 1273 (91%) 1.70 (1.08–2.65) 1.56 (0.88–2.75) PBS = Pharmaceutical Benefits Scheme. *Patients were classified as concessional beneficiaries if all PBS dispensing was concessional during year preceding and the three months following the PCI‐S procedure. †Based on RxRisk comorbidity indices.5

Benjumin Hsu · Michael O Falster · Andrea L Schaffer · Sallie Pearson · Louisa Jorm · David B Brieger

Although infection risks posed by COVID-19 influence all aspects of adult cardiac arrest management, the basic principles of resuscitation remain the same

Simon Craig · Mya Cubitt · Ashish Jaison · Steven Troupakis · Natalie Hood · Christina Fong · Adnan Bilgrami · Peter Leman · Juan Carlos Ascencio‐Lane · Guruprasad Nagaraj · John Bonning · Gabriel Blecher · Rob Mitchell · Ellen Burkett · Sally M McCarthy · Amanda M Rojek · Kim Hansen · Helen Psihogios · Peter Allely · Simon Judkins · Lai Heng Foong · Stephen Bernard · Peter A Cameron

Australian clinicians need to be able to recognise, diagnose, manage and appropriately refer patients affected by COVID-19

Irani Thevarajan · Kirsty L Buising · Benjamin C Cowie

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic is placing increasing pressure on the health care resources of nations. Particular concern is held for supplies of N95 (or P2) masks and surgical masks — personal protective equipment designed to achieve close facial fit and protection from more than 95% of 0.3 μm test particles. These masks are recommended for routine care of patients on airborne precautions, with current guidelines indicating that N95 masks are single use.1 Further highlighting the importance of N95 masks in protecting health care workers during the COVID‐19 pandemic, a recent study of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infection rates among medical staff in Zhongnan Hospital of Wuhan University showed that none of the staff (0/278) who wore N95 masks and followed frequent disinfection and handwashing became infected during the period of 2–22 January 2020 compared with 4.7% (10/231) of staff who did not wear masks, despite the fact that the latter group worked in lower risk areas.2 Previous outbreaks of respiratory viruses, including the 2004 SARS outbreak and the 2009 H1N1 influenza pandemic, have highlighted the risks of shortages of N95 masks during these events.3 If demand for N95 masks outstrips the current supplies, what options will be available for health care workers in Australia and elsewhere? During the 2009 H1N1 pandemic, reusing masks was common practice in Californian hospitals in response to shortages.4 The reuse of masks involves health care workers donning the same mask for multiple close patient contacts and doffing it at the end of each patient contact before eventually discarding it.3 To support the reuse of masks, a growing number of studies have investigated decontamination practices.5,6,7,8 A comparison of decontamination methods has found that physical decontamination methods (eg, ultraviolet germicidal irradiation [UVGI]) are less destructive to the mask filter than chemical methods (eg, bleach).7 UVGI exposure at high doses has been shown to have only a very small impact on particle penetration, but it had a variable effect on mask structural integrity.6 It was suggested that the rate‐limiting step for repeated disinfection cycles would be the physical degradation of the mask material; however, this could also be used as a visual cue to determine when the mask should be discarded. A study into the efficacy of UVGI decontamination of H1N1 influenza‐contaminated N95 masks has also shown that significant reductions in influenza viability could be seen when N95 masks contaminated with viable H1N1 influenza virus and soiled with saliva or skin oils were treated with 1 J/cm2 UVGI for about one minute.5 In terms of useability, after UVGI treatment, differences in the fit, odour, discomfort, or increased difficulty in donning of masks were also found to be minimal.9 In the absence of equipment to perform effective UVGI‐irradiation, what other options are available? While steam appears to have some potential,10 it is safe to say that the answer is currently unclear and may need novel solutions. For example, could solar disinfection — a method that has been shown to be effective for decontaminating RNA virus‐contaminated water in polyethylene terephthalate bottles at high temperatures (eg, 40°C) — be an effective solution to disinfecting N95 masks for reuse in the Australian climate?11 Urgent research is needed to validate current methods and investigate novel solutions for the potential decontamination of N95 masks to protect health care workers and patients. Quality assurance systems to evaluate the performance of a decontaminated mask are an obvious concern. In terms of the efficiency of biological decontamination, available data show that indicator organisms such as Bacillus spores12 or influenza virus substitutes (eg, MS2 bacteriophage13) can be indicators of disinfection. Measuring filter performance, particular particle penetration is less straightforward and may require specialised equipment. In these circumstances, ensuring that published protocols are used only on the N95 masks they have been evaluated on may be important, given that different N95 masks are affected differently by the same decontamination method.8 Furthermore, avoiding the unnecessary use of N95 masks when the use of surgical masks is recommended and improving the potential for local production and sourcing of personal protective equipment will also assist in reducing Australia's reliance on dwindling international stockpiles during the COVID‐19 pandemic and in preparation for any future respiratory viral infection outbreaks.

James M Branley · Adam Polkinghorne · Gwendolyn L Gilbert

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has focused whole‐of‐government efforts on protecting Australia's health. Border closures, case quarantine, public health interventions and social distancing have controlled COVID‐19 case numbers, limiting community acquisition. Workplaces at particular risk of occupational exposure to COVID‐19 — hospitals, aged care facilities and, interestingly, abattoirs — require effective infection control. Presenteeism in this context refers to the occupational transmission risk that employees infected with severe acute respiratory syndrome coronavirus 2 pose by continuing to work despite being symptomatic. Such presenteeism may be an issue common to a number of industries.1 Occupational infection has occurred among Australian hospital staff, notably in North West Tasmania.2 Delayed recognition of COVID‐19 cases leading to infection control breaches, presenteeism with infected health care staff working for up to 7 days with respiratory symptoms, along with other factors all contributed to this hospital outbreak.2 In total, 73 of the 114 outbreak cases were hospital staff.2 Meat processing facility workers have been a notable at‐risk group in the United States, with over 4000 COVID‐19 cases reported, representing up to 3% of affected facility workforces and resulting in 20 COVID‐19 related deaths.3 In Australia, a COVID‐19 cluster was reported among abattoir workers in Melbourne.4 There are meat processing industry work practices that enhance COVID‐19 acquisition risks.4 Commonly, the layout of meat processing facilities challenges implementation of appropriate distancing between workers, who may be spaced as little as 30 cm from colleagues during routine operations. Compliance with wearing face masks is difficult given the pace and physical demands of work. Financial imperatives appear to motivate food processing employees to work even if unwell.3 Australian aged care workers and airline baggage handlers have also experienced COVID‐19 outbreaks. Despite concerns expressed by teachers and early childhood educators, as of 16 June 2020, no major outbreaks had occurred in schools and only one cluster had been reported in a NSW childcare centre.5 A NSW investigation of possible transmission in schools showed only two secondary cases in students.6 Some schools have been closed for deep cleaning after detection of community acquired cases of COVID‐19. Design and implementation of effective, industry specific, infection prevention policies are crucial for employer compliance with the Australian Work Health and Safety Strategy principle that “all workers, regardless of their occupation or how they are engaged, have the right to a healthy and safe working environment”.7 This requires strong, industry group, leadership. Recognition of workplace specific infection risks, provision of reliable personal protective equipment, redesign of work practices, discouragement of presenteeism, and improved access to sick leave must all be attended to for the sake of Australia's workforce.

Damon Eisen

To the Editor: The National Disability Insurance Scheme (NDIS) is one of the largest health reforms in Australia's history.1 The scheme aims to give people with a disability choice and control over their daily lives.2 It is designed to operate as nation‐wide disability “markets” from which services can be “purchased”.2 NDIS participants are allocated a budget from which they purchase the services they require. The NDIS is very different from our previous disability models, which saw people receiving standardised services from a more limited number of government and not‐for‐profit organisations, and a less decentralised workforce. The NDIS is a visionary reform; however, we are now seeing that it is also designed to spread an epidemic such as coronavirus disease 2019 (COVID‐19) to thousands of people with a disability. The NDIS has created a “gig economy” within the disability services sector. Individuals are paid for discrete services, from showering and feeding, to social support activities, to household tasks. This means as many as ten different carers entering a participant's home, performing a care service, and then moving on to another home. The workforce is now predominantly casual, and there are growing numbers of self‐employed.3 This structure is primed to spread infection because: large numbers of carers are moving between homes; carers are not paid if they do not perform care tasks, which deters people from self‐isolating; and much of the workforce is disparate and there is no central registry, which makes it difficult to provide new information such as hygiene practices to all people. Unfortunately, many people who are part of the NDIS have comorbidities,4 making them vulnerable to COVID‐19 by both physiology and system design. Previous research has raised concerns about the readiness of the workforce to handle complex disability under normal circumstances, let alone in the context of a pandemic.5 While government agencies are working to communicate hygiene practices with NDIS participants, challenges such as personal protective equipment shortages and high worker motility need to be addressed. Otherwise, the health care system will need to ready itself for a disproportionate number of people with disability.

Gemma Carey

To the Editor: Harms related to the inappropriate use of prescription drugs include fatal and non‐fatal overdose and are a significant public health concern in Australia.1 In response, Victoria recently introduced SafeScript (https://www2.health.vic.gov.au/safescript) — a system similar to the widely implemented real time prescription monitoring (RTPM) systems in the United States.2 The Victorian RTPM system is designed to help health professionals make safer decisions when supplying high risk medicines.3 RTPM systems have been associated with unintended consequences, such as a transition from pharmaceutical opioid use to illicit opioid use, which has been associated with an increased risk of overdose and spread of blood‐borne viruses.2,4 Indeed, a 2019 American study suggests that lowering prescription opioid supply through initiatives such as RTPM use will only have a modest effect on opioid‐related deaths, unless supported with a multipronged approach including increased access to pharmacotherapy and harm‐reduction services.5 In Victoria, the implementation of an RTPM system may be of more benefit than seen in the US since these services are widely available. We have begun to explore effects of the introduction of SafeScript through analysis of data collected through the Burnet Institute's SuperMIX study — a prospective cohort study of about 1300 people who inject drugs (https://www.burnet.edu.au/projects/89_supermix_the_melbourne_injecting_drug_user_cohort_study). We introduced questions related to RTPM use in March 2019, with a total of 387 interviews conducted since the implementation of SafeScript in Victoria. We found that 20% of participants (48/242) who used a medicine monitored by SafeScript reported being refused a prescription by a general practitioner. One‐third (16/44) of those who have been refused were requesting the prescriptions for the treatment of anxiety and 45% were refused two or more times by doctors. Three per cent of participants (8/245) reported having a prescription they had already been receiving withdrawn. In addition, six out of 241 participants were refused dispensing of a prescribed medicine by a pharmacist. One‐third of participants (15/47) who had been refused a prescription were told this was due to a risky combination of medicines or having multiple providers. A third of participants (14/45) who had been refused a prescription reported an intention to not seek medication from their doctors in the future. Most had moderate to severe anxiety (33/41) and depression (36/41) disorders measured through a self‐administered Patient Health Questionnaire (PHQ). In the case of refused prescriptions requested for the treatment of anxiety, ten out of 13 patients had moderate to severe anxiety disorder and 11/13 patients had severe depression disorder, suggesting unmet treatment needs in patients denied prescriptions. RTPM systems such as SafeScript may help prevent the inappropriate use of prescription medications. Our initial analysis provides early insights on the impacts of SafeScript on this cohort, indicating careful implementation is required, particularly for people who inject drugs living with concurrent mental illnesses. The use of RTPM systems may reduce medicine‐related harm if integrated mental health and drug treatment services are adequate. It is not clear whether this is the case in Victoria. It is important to understand what happens when people are refused prescriptions — what care they receive and whether this care is appropriate for their needs. Increased mortality following restrictions to prescribed medicines is reported elsewhere.2 Rigorous research should evaluate the impact of RTPM use in Australia to understand if similar outcomes are observed.

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

To the Editor: More Australians die of prescription medication overdose than of illicit drug use or motor vehicle accidents.1 Real time prescription monitoring systems have been recommended to track patients’ supply history for potentially high risk medicines, including strong opioids and benzodiazepines. These programs aim to assist in the early identification of high risk medicine use to inform clinical care, and have received broad support from pharmacy and medical professional groups. However, the use of prescription monitoring systems by prescribers and pharmacists is voluntary and uptake has been limited.1 From April 2020, Victoria will be the first state in Australia to mandate the use of its newly implemented real time prescription monitoring system, called SafeScript (https://www2.health.vic.gov.au/safescript). An automated algorithm will place a red, amber or green flag against a patient's profile to highlight medication‐related risk based on the patient's prescribing and dispensing history. All Victorian community prescribers and pharmacists will be required by law to check a patient's SafeScript profile before prescribing or dispensing monitored medications. Similar programs across North America led to decreases in prescription rates of monitored medicines and in reductions in multiple provider episodes or “doctor shopping”.1 Nevertheless, these programs have been associated with unintended harms, including increased use of and overdose deaths from more accessible, illicit substances (eg, heroin or fentanyl); refusal of health care; and undertreatment of pain resulting in significant physical and psychological patient distress.2,3 Perceived scrutiny from the monitoring systems has resulted in some prescribers’ and pharmacists’ refusing to supply potentially high risk medications despite appropriate clinical indication. The abrupt discontinuation of benzodiazepines and opioids carries a risk of seizure and overdose death, especially in chronic opioid therapy.3 Addiction elicits some of the highest stigma in health care4 and may undermine the quality of care for patients with chronic pain (a population that has historically relied heavily on these medicines), who report feeling abandoned by the health care system. The use of the traffic light algorithm may also have a strong impact on clinical decision making, a phenomenon known as “automation bias”, where health care professionals place more emphasis on the default settings of automated systems (eg, red, amber or green flag) at the expense of other relevant emotional and psychosocial patient information.5 With the introduction of mandatory implementation of SafeScript, the number of people identified as being at risk of medication‐related harm will increase.1 In the face of potential unintended harms, it is critical that specialist pain and alcohol and other drug treatment services are appropriately resourced and that there is affordable access to multimodal pain management and psychological services. Prescribers and dispensers need comprehensive training and resourcing so patients can access affordable services. Ongoing evaluations of SafeScript are required to examine the impact of the system on prescribers’ and pharmacists’ clinical practice, patient psychosocial wellbeing, stigma, clinical care, and patient–provider relationships. These evaluations would inform decisions around national implementation of real time prescription monitoring systems, practitioner training, and the provision of sufficient drug treatment services, and would help minimise any unexpected harms.

Sarah Haines · Michael Savic · Louisa Picco · Suzanne Nielsen · Adrian Carter

Foundation Professor of General Practice at Monash University and mentor to many, Neil Carson is farewelled

John Murtagh