Volume 214 Issue 3

The response to the largest institutional outbreak of COVID‐19 in health care workers in Australia to date needed to be multidimensional In many countries, high rates of health care workers with coronavirus disease 2019 (COVID‐19) have been associated with inadequate personal protective equipment (PPE), exposure to large numbers of patients with COVID‐19, worker fatigue, and limited access to diagnostic testing.1,2,3 In Australia, during the initial phase of the epidemic, infections in health care workers were largely attributable to international travel, corroborated by genomically distinct severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) lineages.4,5 At the Royal Melbourne Hospital, we observed a marked increase in staff infections during July and August 2020, concurrent with a statewide surge in COVID‐19 cases. To inform future responses in the Australian setting, we present a description of health care worker infections at our institution and the suite of interventions associated with outbreak control. Setting The Royal Melbourne Hospital City Campus is a 550‐bed university‐affiliated tertiary hospital with an additional 150 geriatric and rehabilitation beds at the Royal Park Campus, a large mental health service and four residential aged care facilities, employing about 10 000 staff. Throughout the pandemic, a rapid access COVID‐19 testing clinic was provided for symptomatic staff. To diagnose infection, deep nasal and throat swabs were sampled for nucleic acid testing (reverse transcriptase polymerase chain reaction [RT‐PCR] for SARS‐CoV2). SARS‐CoV‐2 RNA was detected using the Coronavirus Typing assay (AusDiagnostics).5 All positive COVID‐19 tests were notified to the Department of Health and Human Services, with staff members also being notified to the Royal Melbourne Hospital infection prevention services. Infected staff were interviewed by an infection prevention nurse consultant to identify any contacts and enquire about PPE use, work locations in the days before symptoms, nature of their work, characteristics of their patients, and any suspected acquisition events. Contacts with other staff outside work were also explored. Infected staff were required to isolate for 10 days or more after symptom onset and close contacts (≥ 15 minutes of face‐to‐face contact or ≥ 2 hours in a shared space in the 48 hours before symptom onset) were furloughed for 14 days and quarantined, according to state guidelines. Outbreaks (two or more epidemiologically and/or spatially linked staff and/or patients) were managed by a multidisciplinary incident management team. Data regarding health care worker infections were entered into a REDCap 10 (Research Electronic Data Capture) database, a secure web‐based platform, and were analysed using Stata 16. This study was approved by the Melbourne Health Human Research Ethics Committee (QA2020058). Overview Between 1 July and 31 August 2020, 262 cases of COVID‐19 were identified among Royal Melbourne Hospital staff (Box 1 and Box 2). Fifteen individuals (5.7%) required inpatient care and 13 (4.9%) received care by a hospital in the home service. Two were admitted to the intensive care unit (ICU), none requiring mechanical ventilation, with no deaths. Nurses were most commonly affected, followed by support staff (such as food and cleaning services) and doctors (17/21 of these being doctors‐in‐training) (Box 1). The trend in incidence of health care worker infections reflected the prevalence of inpatients with COVID‐19 (Box 3). The ICU had between zero and ten concurrent patients with COVID‐19 over the period (median, 7; interquartile range [IQR], 5.0–8.0), with four ICU staff acquiring COVID‐19. No operating theatre staff and no staff working in affiliated residential aged care facilities were infected. The median turnaround time for health care worker test results (from specimen collection to reporting) was 20.2 hours (IQR, 11.4–29.1 hours). Overt recognised PPE breaches were rarely reported. Contacts with known COVID‐19 cases outside the hospital were infrequent but did occur (eg, health care workers living together). Outbreak linked to geriatric and rehabilitation inpatient wards The Royal Park Campus had the highest number of staff with COVID‐19, making up 40.8% (n = 107) of health care worker infections at the Royal Melbourne Hospital, despite this campus constituting about 10% of the total staff workforce at the hospital (acknowledging that some staff move between sites). Between 12 and 18 July, the Royal Park Campus received a large number of patients from external residential aged care facilities, not affiliated with the Royal Melbourne Hospital, with COVID‐19 outbreaks. These residents were COVID‐19‐positive at admission and were managed with appropriate infection precautions throughout. COVID‐19 cases among staff rapidly escalated across all six wards at the campus after 16 July, peaking on 27 July. The peak number of patients with COVID‐19 at the Royal Park Campus was 60. At the Royal Park Campus there are a variety of buildings constructed from the 1970s to early 2000; most have central air conditioning plants, but one has a local split system. An engineering review of the wards revealed air exchanges met current requirements; however, a more detailed assessment of air movement suggested that some were not as well ventilated as others. Some patients were in single rooms, but many were in multibed spaces. Improved nurse to patient ratios were used to help manage patients. Despite this, because of large numbers of staff furloughs, the remaining staff experienced high workloads. A decision was made on 3 August to close four wards at the Royal Park Campus. Fifteen patients were moved to other health services, while the remaining 45 were moved to single rooms in wards with more modern infrastructure. Outbreaks linked to “hot wards” At the Royal Melbourne Hospital City Campus, most affected staff were working in wards with patients with suspected or confirmed COVID‐19 (“hot wards”) (Box 1). These staff were highly trained in PPE use, PPE was always readily available (ie, gowns, gloves, eye protection, and masks), and use was checked by a PPE “buddy” (usually a colleague) before patient room entry and at doffing. Staff noted that particular behaviour in infected patients appeared to be linked to transmission events (patients shouting, vigorous coughing). The peak combined prevalence of inpatients at the Royal Park and City campuses was 99 on 5 August 2020. As increasing numbers of staff infections were recognised, the density of patients on the COVID‐19 wards was reduced by closing beds in shared rooms and moving each patient to a single room where possible. On 21 July, use of N95 (or P2) masks by all staff at all times on COVID‐19 wards at both campuses was instituted. “Spotters” (supernumerary staff) were deployed to observe PPE donning and doffing, and senior staff ward walk‐arounds and additional cleaning with monitoring were implemented. Staff working on “hot wards” were offered weekly asymptomatic testing to detect any infections early. Outbreaks on “cold wards” On three occasions, clusters occurred outside the designated “hot wards”; that is, in wards not allocated to caring for patients with suspected or confirmed COVID‐19 infection. In some staff, having previously worked at the Royal Park Campus was identified as a potential risk factor. A management plan for these wards was deployed, including closure to new admissions, moving patients to separate rooms (where possible), managing the whole ward using increased precautions, deep cleaning, and voluntary testing of all patients and staff every 3–4 days. Hospital‐wide asymptomatic staff testing was instituted (> 600 staff tested) and whole hospital inpatient testing occurred as a point prevalence activity in late July, with no additional cases identified outside the affected wards. Institutional responses Responses were multifactorial and iterative, with daily review of emerging evidence that informed ongoing decisions. Importantly, a hierarchy of controls was used to manage these outbreaks (Box 4). A proactive approach was used to support infected and furloughed staff wellbeing, with dedicated nursing and medical staff monitoring physical and mental health as well as providing practical supports. This service managed over 680 staff during the outbreak period. Discussion We describe the largest institutional outbreak of SARS‐CoV‐2 health care worker infections reported in Australia to date. Our response was necessarily iterative and pragmatic and advice often pre‐dated formal state and federal recommendations. During these outbreaks, a number of key factors emerged that shaped our responses, extending well beyond a focus on PPE alone. First, the concept of a “critical burden” of infection framed our responses to patient movement and ward closures. Concurrent with large numbers of cases in the hospital and the community, the number of staff who acquired infection rose rapidly. Based on overseas experience,6,7 we hypothesised that large numbers of patients in confined spaces may have created a high density of droplets, aerosols and environmental contamination. This triggered a detailed assessment of ward physical layout, including the possible role of patient placement and air circulation. We elected to use single rooms wherever possible and to physically space infected patients by closing beds on the ward. The intensity of transmission in some wards led to a decision to close wards and move some patients to other health care services. Further, we adopted the use of N95 masks for staff working in areas with large numbers of patients with confirmed or suspected COVID‐19. While use of N95 masks for all COVID‐19 care was not recommended in state or federal guidelines at that time,8,9 this organisational decision was based on our local epidemiology and a need to trial any reasonably available strategy to contain health care worker infections. Second, the availability of rapid and accessible testing for staff was critical to informing real‐time outbreak management, highlighted by international studies.10,11 Rapid availability of data informed our daily incident management meetings and enabled prompt decision making using the best possible information. Finally, the importance of staff communication and wellbeing cannot be understated. Similar to other studies,3,12 many staff reported physical and mental fatigue and stress during these outbreaks. In addition, workforce shortages meant that staff were taking on extra shifts at short notice and working in unfamiliar roles. Accordingly, access to employee support programs was an important element of this response. Box 1 – Demographic characteristics of health care workers with coronavirus disease 2019 (COVID‐19), confirmed by polymerase chain reaction (PCR) testing, at the Royal Melbourne Hospital (1 July – 31 August 2020) Characteristic Number of confirmed cases
(%) Total number of confirmed cases 262 Sex Male 57 (21.8%) Female 205 (78.2%) Median age at diagnosis (IQR), years 32.7 (26.8–44.9) Employee type Nurse 179 (68.3%) Doctor 21 (8.0%) Allied health practitioner 9 (3.4%) Support staff (food services, environmental services) 38 (14.5%) Administrative staff 6 (2.3%) Student 4 (1.5%) Security staff 4 (1.5%) Laboratory staff 1 (0.4%) Location Royal Park Campus (rehabilitation, geriatric rehabilitation) 107 (40.8%) Hot wards* (COVID‐19 wards,† ED, ICU) 57 (21.8%) Cold wards‡ with recognised COVID‐19 outbreaks (3 wards) 20 (7.6%) Cold wards‡ with no outbreaks (1 or 2 unlinked cases; 6 wards) 7 (2.7%) Mental health ward§ 8 (3.1%) Not ward‐based (eg, non‐clinical) 31 (11.8%) Unknown (no campus/ward stated, includes both campuses) 32 (12.2%) ED = emergency department; ICU = intensive care unit; IQR = interquartile range. * Hot wards are wards dedicated to managing patients with confirmed or suspected COVID‐19. † COVID‐19 wards are wards where patients with confirmed or suspected COVID‐19 were managed. ‡ Cold wards are all other wards. § Mental health wards were situated at the City Campus and at other sites. Box 2 – Epidemic curve of health care worker infections at the Royal Melbourne Hospital (1 July – 31 August 2020) RPC = Royal Park Campus. * “Other” includes non‐clinical not ward‐based staff, staff working across several campuses, or ward not known. Mental health wards include off‐site facilities. Box 3 – Prevalence of inpatients with coronavirus disease 2019 (COVID‐19) at both the Royal Melbourne Hospital City Campus and the Royal Park Campus over time (13 July – 31 August 2020)* * Data start on 13 July 2020. Box 4 – Hierarchy of controls used to guide interventions to address health care worker infection with coronavirus disease 2019 (COVID‐19) at Royal Melbourne Hospital Elimination* Public health restrictions to reduce community incidence Testing availability in the community (and for staff) to identify and isolate cases early Rapid turnaround time for test results to identify and isolate cases early Frequent testing of staff and patients in wards with outbreaks for early recognition and management of cases Symptomatic staff furloughed until test results available Furlough asymptomatic staff who are contacts of COVID‐19 cases Work from home policies for staff Telehealth consultations rather than in‐person visits to hospital Visitor restrictions to hospitals (use of phone/iPad to liaise with family) Early discharge of patients not requiring inpatient care, use of hospital in the home services Use of remote meeting technology Engineering controls Attention to ventilation and air circulation in all clinical and non‐clinical areas Availability of negative pressure rooms Physical separation of patient groups (access to single rooms, wards with doors to separate from other wards) Equipment to improve turnaround times for microbiologic testing to enable rapid identification of cases Adequate space for staff to safely don and doff PPE Provision of break rooms with increased space enabling adequate physical separation Physical barriers for public facing non‐clinical staff (eg, perspex barriers) Appropriate cleaning (correct equipment to enable this) Administrative controls Existing policies, procedures and subcommittees (with appropriate governance) in place before the COVID‐19 pandemic regarding infection prevention, PPE, hand hygiene, transmission‐based precautions, cleaning, outbreak management, management of contact tracing, pandemic plan Appropriate governance (Emergency Operations Centre with multidisciplinary representation from all areas) during pandemic Use of national and state guidelines to inform development of hospital COVID‐19 guidelines Regular meetings of key stakeholders to discuss emerging issues Regular communications to staff via email, social media, and remote meetings by hospital executive and managers Policies to encourage physical distancing between staff (staggered breaks, start/stop times, roster redesign) Workflow changes to encourage distancing between staff and patients where possible Use of dedicated “COVID teams” in wards to minimise staff moving between wards Resourcing of staff in “COVID‐19 wards” to ensure manageable workload, improved nurse to patient ratios Bed allocation (avoidance of high density of COVID‐19-positive patients in wards, minimise use of shared rooms) Management of COVID‐19-positive patients in separate wards from COVID‐19‐negative patients Training (baseline and refreshers) and monitoring of PPE use (spotters) for all clinical and non‐clinical staff Increased resourcing of cleaning services and ongoing training in cleaning, using in‐house and not agency staff Monitoring of cleaning (eg, ongoing fluorescent marking programs, spotters) Hand hygiene training and auditing, including development of videos and posters specific to COVID‐19 PPE Universal pandemic precautions (surgical mask and face shields all staff all the time) Masks on patients where possible for source control Use of PPE appropriate to the circumstance (gowns, gloves, surgical masks, N95/P2 masks, eye protection) PPE = personal protective equipment. * Actions to remove or minimise the number of infected people on site.

Kirsty L Buising · Deborah Williamson · Benjamin C Cowie · Jennifer MacLachlan · Elizabeth Orr · Christopher MacIsaac · Eloise Williams · Katherine Bond · Stephen Muhi · James McCarthy · Andrea B Maier · Louis Irving · Denise Heinjus · Cate Kelly · Caroline Marshall

Posts can provide valuable feedback during public consultation for health guidelines

Benjamin C Riordan · Daniel T Winter · Paul S Haber · Carolyn A Day · Kirsten C Morley

Current regulations address product safety, but they do not adequately ensure accuracy of formula preparation and provision Breastmilk is the optimum source of nutrition for most infants born at full term. When breastmilk is unavailable or unsuitable, the only safe and nutritious substitutes are commercial infant formulas.1 Infant formula — predominantly powdered infant formula — makes a major contribution to infant nutrition in Australia, with the 2010 Australian National Infant Feeding Survey reporting that 34% of infants had been introduced formula in their first month of life, 45% by 2 months and 69% by 6 months of age.2 In Australia, infant formula products are regulated under Standard 2.9.1 — Infant Formula Products in the Australia New Zealand Food Standards Code (Std2.9.1IFPANZC).3 All commercially produced infant formula products available in Australia and New Zealand must comply with the composition and safety requirements outlined in the Code. Std2.9.1IFPANZC specifies the mandatory nutrient content for infant formula and follow‐on formula to ensure that nutrition requirements are met. The standard includes labelling requirements, specifically prohibiting various claims, images and symbols. While these regulations address product safety, they do not adequately ensure accuracy of formula preparation and provision. In particular, potential for error remains around formula powder reconstitution, given multiple differing brands with variable scoop to water ratios, and volume of feed for differing ages and body weights. In this article, we discuss the infant formula range available in Australia, the infant formula powder reconstitution variability and the potential impacts, and the variability of manufacturer feeding guides compared with recognised recommendations and potential implications. Formula brands and types In Australia, there are more than ten brands of infant formula from which to choose. Within each brand there are often minor variations, from standard formulas meeting basic Food Standards Australia New Zealand (FSANZ) formula composition guidelines through to manufacturer‐specified gold formulas and condition‐specific formulas (Supporting information, table 1). FSANZ guidelines describe the purpose of infant formula labelling as providing information to caregivers to make informed choices, as well as information about appropriate preparation and safe use of infant formula products. Under FSANZ guidelines, all infant formulas must meet essential nutrient requirements. Specific nutrient content and health claims are prohibited in Clause 3 of Standard 1.2.7.4 Despite regulation, there are often misleading names or ingredient claims on infant formulas which construe a health claim or benefit and create doubt or sway opinion in consumers. For example, “[trade name] constipation”, as a name of a formula may be assumed by a consumer to be a superior formula for babies with constipation. Similarly, a statement of “fish oil to help support brain and eye development” could potentially be interpreted by a consumer as a health claim. There is currently no unbiased, freely available source of information to help parents choose a formula and this is often the first point of confusion. The authors frequently encounter parents swapping formulas in response to their infant's behaviour, believing that another formula may offer benefit. Typical examples in clinical practice are changing from a standard term formula to a colic, antireflux, or casein‐predominant formula when there is irritability or spilling. Powdered formula reconstitution While infant formulas are made in liquid ready‐to‐feed and in powdered forms, the latter is predominantly used in the home. Under Std2.9.1IFPANZC, the labelling of a powdered formula product must include the powder to water reconstitution ratio to achieve the specified nutritional composition, and the weight of powder in one scoop. However, the Standard does not dictate scoop size and, consequently, the scoop to water reconstitution ratio is determined by the manufacturer, although the powder weight to water ratio is relatively constant between manufacturers. In Australia, there is significant variation in reconstitution ratios across brands. Australian infant formula dilution reconstitution ratios are most commonly either one scoop per 30 mL water, per 50 mL water or per 60 mL water. The choice between a smaller or larger ratio is manufacturer‐specific. Explanations company representatives have provided for choosing a smaller scoop to water ratio include being able to make up smaller quantities of formula, greater accuracy, and a reconstitution method that yields rounded number volumes of 100 mL. In contrast, companies with larger scoop to water ratios propose reduced risk of error in sleep‐deprived parents who might lose count of scoops. However, none of these justifications are evidenced‐based. While there is a general expectation that parents use the formula label instructions or community advice, brand changes enhance potential for parental miscalculation of formula concentration. Under Std2.9.1IFPANZC, all powdered infant formula products must carry a warning stating, “Warning — follow instructions exactly. Prepare bottles and teats as directed. Do not change proportions of powder except on medical advice. Incorrect preparation can make your baby very ill”.3 This warning is often not obvious, and in practice, we have observed parents swapping between formulas and either assuming that the scoop to water reconstitution ratio is the same, confusing the ratios between brands, or using the incorrect scoop with a different manufacturer's powder, resulting in incorrect formula concentration. A systematic review of five studies supports this observation, finding that significant errors may be made when reconstituting formulas.5 Incorrect dilution ratio results in a formula strength that is either too dilute, increasing risks of nutrient deficiencies and faltering growth, or too concentrated, risking hypernatraemic dehydration or excessive weight gain. A review of reconstitution recipes of the major brands of standard infant formulas reveals a formula powder to water ratio of 0.142–0.15 g/mL (Supporting information, table 2) and a narrow caloric strength range of 4.8–5.2 Kcal/g. Clearly, a standardised reconstitution recipe is possible. We propose that standardisation of reconstitution ratio of powdered infant formula to water would minimise error and risk while providing clarity for parents and health professionals. Formula feeding guides Infant feeding guidelines for health workers1 state that as a formula is designed to remain at a constant strength, it is the amount of formula that should increase as the infant grows. The guidelines outline approximate formula requirements for infants (Supporting information, table 3), which correlate appropriately with the estimated energy requirements of infants as outlined in the National Health and Medical Research Council (NHMRC) Nutrient reference values for Australia and New Zealand.6 The infant feeding guidelines also note that feeding guidelines on formula packaging recommending certain amounts for various ages are guides only and do not necessarily suit every infant.1 Manufacturers of commercial infant formulas usually include a feeding guideline on the formula packaging that outlines the number and volume of feeds recommended for the corresponding ages. This is not a requirement under the Food Standards Code. There is substantial inconsistency in the feeding guidelines for volume and frequency of feed by age printed on the containers (Box), both from one manufacturer to another and also compared with the NHMRC‐recommended volumes by age and weight. The lack of weight standardisation means that the caregivers of a small infant may overfeed, while a genetically larger infant might be underfed. Greater consistency or standardisation of manufacturer feeding guides that correlate appropriately with the NHMRC feeding guidelines may help reduce both over‐ and underfeeding as well as alleviate parental confusion and anxiety around feeding volumes. While both under‐ and overfeeding may have negative clinical consequences, there are no published data to support adverse outcomes as a common consequence of parental misunderstanding. The absence of published evidence, however, should be considered in the light of anecdotal experience of health professionals within our health service, who report spilling and irritability from overfeeding and parental anxiety when their baby does not achieve volumes stated on the formula tin. Expert opinion concurs with our own clinical experience, as shown by the 2018 guideline on gastroesophageal reflux issued jointly by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPAGHAN), where the first step in management of an infant presenting with excess vomiting is to ensure that overfeeding is avoided.7 However, there is clearly a need for further study in the area of parental interpretation and use of the feeding guides provided on formula tins to determine the impact of variation in product labelling on health outcomes. Conclusion Infant formula is commonly used with a choice of brands and types of formula. There is limited access to unbiased advice on formula selection for parents, caregivers and health professionals who encounter feeding‐related problems in daily practice. In addition, there is a wide variation in reconstitution ratios of powdered infant formula due to differences in scoop sizes between manufacturers, which may contribute to error in formula concentration. Standardisation of reconstitution ratios is an opportunity to minimise error. Lastly, formula feeding guides provided on formula tins vary between companies and, by not accounting for weight, differ from NHMRC recommendations, which may lead to over‐ or underfeeding. Standardisation of formula feeding guides in line with NHMRC feeding guidelines, with clearer warning statements, may help reduce these risks. The absence of evidence as to the effectiveness and risks of current food and nutrition policy with respect to infant formula feeding is a significant gap in ensuring the safe care of infants both in our community and worldwide. We propose that this area becomes a future focus of public health research and advocacy for child health. Box – Standard infant formulas — manufacturer-suggested feeding volume(mL) and number of feeds per day juxtaposed as mL/kg/day for a 3rd centile female infant, 50th centile female infant and 97th centile male infant (World Health Organization growth data)

Shelley Farrent · Brian Coppin · Scott Morris

The disability burden of non-fatal disease is not reflected in allocation of grants

Stephen E Gilbert · Rachelle Buchbinder · Ian A Harris · Christopher G Maher

An 81-year-old woman presented with subacute chorea as a paraneoplastic neurological syndrome

Rebecca Nothrop · Will Lee · Denise Lee · Amanda K Gilligan

Guidelines for reporting results from randomised trials have long underscored the importance of confidence intervals

Karla Hemming · Monica Taljaard

A 58-year-old man presented with shortness of breath on exertion and cough.

Mike M Nguyen · Melissa M Moore

There are legal considerations for both clinicians and patients when recording health care consultations Studies show that patients often have inaccurate recall of health care events and diagnoses.1 Concentration during a medical consultation may be “hampered by unspoken anxieties or pain, making it difficult to recall detail”.2 Audio recordings of consultations can be useful for patients and clinicians to assist memory and understanding. They have mainly been evaluated in oncology and paediatrics.3,4 Patients report that listening to their consultation recording increases knowledge and understanding of their illness, and recordings can assist with treatment decision making, increasing a sense of empowerment.5 Sharing recordings with family can facilitate support and understanding. Clinicians likewise recognise recordings’ benefits for patients and for improving the quality and efficiency of their care.6 Research in the United Kingdom found that 69% of patients wish to record consultations.7 Increasingly, patients are using smartphones to record consultations, either with permission or covertly.7,8 Recording systems have been developed by health services themselves, transformed by the ubiquitous use of smartphones and other flexible technologies.9,10,11 Examples include the Open Recording Automated Logging System (ORALS) software in the United States9 and telephone‐based digital recording in Denmark.11 In Australia, the Second Ears smartphone app, developed at the Victorian Comprehensive Cancer Centre in 2018, is designed to make recordings available to both the patient and the hospital health information management service.6,10 Patients can choose whether to download and use the app (either before their appointment or in the clinic), access the recordings on their smartphone, and share them with family and friends.6,10 Common design features of such health service‐led recordings address data security, file storage and patient consent. Whether the clinician or the patient controls the recording process may differ across technology platforms; for instance, in the Danish example above, the clinician initiated the recordings, whereas with Second Ears the patient would do so. The use of consultation recordings often raises legal questions.5,7,10,12 In this article, we compare the legal implications of overt and covert recordings of health care consultations and address key concerns identified by clinicians, notably the requirement for consent to record and share the recording, and the use of recordings in negligence claims.8,13,14,15 We distinguish between three recording types: Overt patient‐led recordings: for example, a patient recording a consultation with the clinician's consent. These recordings are akin to a patient's handwritten notes. Overt health service‐led recordings: for example, the Second Ears app, where both clinician and patient consent (actively or impliedly) to the recording; the app is facilitated by the health service and the primary version of the recording stored on their system. Covert patient‐led recordings: for example, a patient recording without the clinician's knowledge or consent. As each legal question is identified, we consider the law in the context of the Second Ears app. This article is general in nature and does not constitute legal advice. References to legislation are current at 13 October 2020. References to state or territory laws relate to the location of the recording or the place at which the sharing of the recording originated. We do not address the issue of intentional recording of private conversations by third parties, either overtly or covertly. Consent to record a consultation Clinician consent to patient‐led recordings Clinicians consider that their consent to be recorded is a key issue. Perhaps surprisingly, at law in many Australian jurisdictions, the patient need not obtain explicit consent from the clinician. In Victoria, Queensland and the Northern Territory, the law does not consider a recording of a conversation that is made by one of the parties (as opposed to a third party). In New South Wales, Tasmania and the Australian Capital Territory, patients can record their consultation without the clinician's consent (or, by extension, their knowledge) if the recording is only for the patient's own use (ie, to listen back to the recording later), or to protect their lawful interests (such as in a negligence claim). In South Australia and Western Australia, clinician consent is required (ie, two‐party consent) for recording a consultation for later listening‐back by the patient (Box 1). Patient consent to health service‐led recordings Where the recording is made on an app like Second Ears with data stored by the health service, this is an act of health information collection about an individual that requires the patient's express or implied consent. The patient's decision to download and install the app can act as implied consent; the app's terms and conditions could also include a clear statement about patient consent. Consent of other people captured incidentally in any overt recording A consultation recording — whether patient‐led or health service‐led — might accidentally capture another conversation, for instance from the clinic's reception desk. No consent of the third party is needed in this case, because they are not a party to the recorded conversation. Typically, Australian surveillance device laws do not regulate recordings of conversations occurring in circumstances in which the parties ought reasonably to expect to be overheard, such as in public or an open hospital ward. This means that if a patient is overtly recording their own consultation while in a curtained cubicle, their inadvertent capture of another clearly heard conversation in the next cubicle would not require the consent of those having that conversation. Consent when someone else joins any overt recording If another person, such as the patient's relative or another clinician, enters a room where a consultation is being recorded, but does not join in the conversation, the new person is not a party to it and that person's consent is therefore not needed. However, if the new person does join the conversation, they become a party to it. Box 1 indicates when that new party's consent to be recorded is required. In SA and WA it is usually required. In NSW, the ACT and Tasmania it is required if the patient makes the recording intending to share it with anyone else, but not if the recording is intended only for the patient to listen to. Consent, when required, can be either express or implied. An example of how this situation might be addressed could be a health service policy to have a door sign stating prominently that a recording is in progress and that by entering the room the new participant consents to be recorded. A person entering the room could then signal their non‐consent by verbally requesting the recording be stopped. This applies to health service‐led and patient‐led recordings. Covert recordings by patients Covert recording by patients is not uncommon; a survey conducted in the UK found that 15% of respondents self‐reported recording clinical encounters without permission. A further 35% of respondents would consider covert recordings in the future.7 In the US, a similar survey found that far fewer respondents recorded covertly (2.7%);8 possibly because some health services routinely provided permission for recording. Currently, the proportion of Australian patients who record covertly is unknown; anecdotally, however, clinicians report that it is occurring.16 Covert recording has been described as a topic of “significant legal ambiguity”.17 In Australia, as noted above, the law varies significantly by jurisdiction. Only SA and WA require two‐party consent and thus prohibit patients covertly recording for their own use (Box 1). Covert recordings: legal penalties Not all consultation recordings require consent. In SA and WA, where two‐party consent is required, a person making a covert recording for their own use is subject to legal penalties; for example, in SA, fines of up to $15 000 or imprisonment for up to 3 years. In Toth v DPP (NSW) [2014] NSWCA 133, a case concerning a patient's illegal covert recording, the magistrate imposed an 18‐month good behaviour bond. Dealing with unwanted recording If their consent is legally required but the clinician does not want to be recorded, they can simply ask the patient to discontinue the recording. Regardless of whether the act of recording legally requires their consent, a clinician's refusal to be recorded, or the exposure of covert recording by a patient, may lead to breakdown of the therapeutic relationship,14 necessitating transfer of care to another clinician as per the Medical Board of Australia's code of conduct (https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx). While discontinuing a relationship may be appropriate in the context of misuse of an audio recording or its use with malicious intent, it would be a drastic response to a simple request by the patient to record, given the benefits of doing so. Health service‐led systems such as Second Ears may overcome this problem by incorporating clear frameworks around participation, consent and sharing. Sharing recordings with others Health care organisations sharing recordings Recordings made by the health service with the patient's consent (eg, via the Second Ears app) form part of the medical record and the organisation can lawfully share the recording in various ways, which are broadly similar across Australian states and territories. These include: with the person's consent; without the person's consent for a directly related purpose as long as the person would “reasonably expect” the disclosure (eg, in transferring care to another provider at the same service: F v Medical Specialist [2009] PrivCmrA 8); to defend a legal claim; for research in the public interest (if certain privacy guidelines are met, such as those set out by the National Health and Medical Research Council18); and with an immediate family member of the patient for compassionate reasons or to provide the patient with care when the patient is incapable of providing consent. This mirrors other parts of the medical record such as written notes and scans. If the recording is de‐identified (which may be difficult because voice patterns are distinctive and health information discussed during consultations is often reasonably identifiable), it can usually be used without patient consent for communication training within the health service. Consent may provide a more appropriate legal basis for such use. Patients sharing recordings Apps such as Second Ears facilitate patients’ sharing of recordings with family and others for treatment decision making and care. The law relating to such sharing of recordings with third parties varies between jurisdictions and also turns upon the question of whether the original recording was overt or covert. Separate legislative provisions address the act of recording compared with the recordings’ subsequent use. Two‐party consent is generally, but not always, required for patients to lawfully share recordings with third parties (Box 2). In Queensland, Tasmania and the ACT, there is a distinction between patients sharing a recording with immediate family (which can be done without the clinician's consent to share) and sharing with the wider world (which requires the clinician's consent). In NSW, unusually, a recording that is originally lawfully made with only one party's consent but with no intention to share can be subsequently shared without restriction (eg, on social media) (Surveillance Devices Act 2007 (NSW), section 11). Clear communication and consent remain the most desirable mechanisms to frame patients’ expectations and choices around the sharing of recordings with others, even where consent is not legally required. For the avoidance of doubt, an agreement to create a recording — whether a clinician's oral agreement for a patient to record on their smartphone, or the terms and conditions built into an app — should explicitly address the extent to which a patient can share the recording with others. Such an agreement might, for instance, permit the patient to share the recording with family but not publish it at large, for example, on public social media. This could override any legislative entitlement to share a recording openly. If a patient distributed the recording in violation of the terms and conditions, the health service could pursue a legal claim for breach of contract. We are not aware of previous such claims. Health services would need to weigh up the financial and reputational costs of pursuing such a claim. The use of recordings in legal proceedings Recording the consultation does not change clinicians’ medico‐legal obligations to patients. Such recordings provide transparency of the discussion and could be used as evidence of appropriate information sharing with patients, thus meeting the clinician's required standard of care. Clinicians have a duty to provide sufficient information on inherent risks of treatment and alternative treatments, to enable patients to exercise a meaningful choice. A claim may lie in negligence if the patient can demonstrate a “failure to warn”, where the clinician did not meet the appropriate standard of care and the patient consequently made an uninformed choice about treatment which resulted in harm. The importance of patient‐centred communication was highlighted in the UK decision of Montgomery v Lanarkshire [2015] UKSC 11 and the Australian case Rogers v Whitaker [1992] HCA 58. In a claim for negligent non‐disclosure, where the patient states that the clinician did not provide information concerning material risks about the proposed procedure, the recording could be used to provide evidence of the consultation. In most states and territories, whether the recording itself was taken with both parties’ consent or by one party covertly does not affect its admissibility in court. In jurisdictions where covert recording is not lawful (Box 1), an exception typically exists permitting a person to covertly record a private conversation to protect their lawful interests. An example is where there is a serious dispute between two parties regarding different versions of an arrangement (Georgiou Building v Perrinepod [2012] WASC 72). The relevant lawful interest must exist at the time of the recording (Marsden v Amalgamated Television Services [2000] NSWSC 465). The recording's lawfulness is a separate issue to its admissibility. It has been established that tape recordings are admissible to provide primary evidence of the conversation or sounds recorded on the tape. In the case of Butera v Director of Public Prosecutions (Vic) [1987] HCA 58, it was held that the tape is “a part of the machinery by which the evidence is produced”. It would follow that the recording on an app such as Second Ears provides evidence of the conversation that took place between the clinician and patient. Such a recording is admissible in court if the content is relevant and otherwise admissible, the voices are properly identified, and the recording has provenance — it is authentic, accurate and has not been tampered with. In this instance, the voices recorded would fall within the category of hearsay evidence — that is, representations made out of court that are led as evidence of the truth of the fact. As audio recordings fall within the definition of “document” in the Evidence Act 1995 (Cth) (which is uniform with most state and territory Acts), they may be admissible if they conform to the statutory requirements. As an example, in Victoria courts have the discretion to admit recordings as evidence if the evidence is relevant (Evidence Act 2008 (Vic), sections 55 and 56) and if the desirability of admitting the evidence outweighs the undesirability of doing so (Evidence Act, section 138). The recording will form only part of the record of information flow between clinician and patient. Contemporaneous notes and other non‐recorded conversations will also be relevant to determine if the standard of care has been met. There is no evidence that audio or video recordings of consultations increase litigation.19,20 A study evaluating the provision of consultation video recordings to patients found that in the high risk specialty of neurosurgery, none of the 2807 patients recorded used the video in a legal action.19 Recordings might actually reduce conflict and litigation because they overcome differences in recollection between two parties.21 Ownership of recordings Traditionally, the law has not conceived of information as property (Boardman v Phipps [1967] 2 AC 46). In Australia, patients have no proprietary interest in a doctor's medical notes (Breen v Williams [1996] HCA 57) (although legislation provides a right to access them). Nor do doctors have any proprietary interest in a patient's handwritten notes, or by extension, an overt patient‐led recording. However, a health service‐led recording such as one made using the Second Ears app could be said to be jointly created. As there are two copies of it, one held by the patient and one by the health service, it could be argued that each has some proprietary interest. A recent exploration of this position posited that there may be multiple rights holders of health data.22 This view has yet to be tested in the courts. It is appropriate to focus instead on the obligations of the different parties to protect and store the recording data. Data security and storage of overt recordings A recording made on a system such as Second Ears forms part of the medical record and the organisation must take reasonable steps to protect it from misuse, loss and unauthorised access or disclosure. Any contract with a third‐party organisation (eg, a cloud storage provider) should also reflect these requirements and address issues of security and access. Health records must be retained for a specified period; in Victoria, NSW and the ACT, this is 7 years after the patient last received care from the organisation, after which the records should be destroyed if they are no longer needed. By comparison, patients need neither keep nor protect their own copy of a recording. If the recording is made using a third‐party app, the terms and conditions of that app are relevant, adding further complexity in relation to custodianship and data protection. Conclusion Health service‐led recording technologies, of which Second Ears is an example, can draw on a framework that makes explicit all parties’ rights and responsibilities, and ensure that an authenticated version of the recording is maintained securely. Such an approach promotes shared expectations between patients and clinicians and is likely to reduce miscommunication. Our analysis found surprising diversity in Australian legislation pertaining to consultation recording, leading us to conclude that, to avoid confusion, expressly articulated permissions around the act of recording and the extent of sharing recordings are desirable. While covert recording is not uniformly unlawful in Australia, transparency promotes trust and enhances the clinician–patient relationship. There is some evidence that concerns about a heightened litigation risk as a consequence of recording are unfounded; rather, the existence of a recording should minimise conflicting recollections and enhance a sense of collaboration. While the act of recording does not alter a clinician's duty to disclose relevant information to a patient, communication skills training may be a way to alleviate concerns about being recorded.10 Box 1 – Patient‐led recordings: when is consent from the other party required for the act of recording? Jurisdiction Patient makes recording for unspecified purpose Patient makes recording intending it for personal use only Patient makes recording that is reasonably necessary for the protection of their own lawful interests Legislation Victoria, Queensland, Northern Territory Consent not required Consent not required Consent not required Surveillance Devices Act 1999 (Vic): no relevant provision Invasion of Privacy Act 1971 (Qld), s 43(2)(a) Surveillance Devices Act 2007 (NT): no relevant provision New South Wales, Australian Capital Territory, Tasmania Consent required Consent not required Consent not required Surveillance Devices Act 2007 (NSW), s 7(3) Listening Devices Act 1992 (ACT), s 4(1)(b), (3) Listening Devices Act 1991 (Tas), s 5(1)(b), (3)(b) South Australia, Western Australia Consent required Consent required Consent not required Surveillance Devices Act 2016 (SA), s 4 Surveillance Devices Act 1998 (WA), s 5 Box 2 – Can a patient share their lawfully made recording with third parties for general purposes* without the clinician's consent for the sharing? Jurisdiction Sharing with immediate family and friends† Sharing with public at large Legislation Victoria, Northern Territory No (clinician consent for sharing required) No (clinician consent for sharing required) Surveillance Devices Act 1999 (Vic), s 11(2)(a) Surveillance Devices Act 2007 (NT), s 15(2)(a) Western Australia No (clinician consent for sharing required) No (not even with clinician consent) Surveillance Devices Act 1998 (WA), s 9(2)(a)(ii), (3) Queensland, Tasmania, Australian Capital Territory Yes‡ No (clinician consent for sharing required) Invasion of Privacy Act 1971 (Qld), s 45(2)(a), (d) Listening Devices Act 1991 (Tas), s 10(2)(a), (d) Listening Devices Act 1992 (ACT), s 5(2)(b), (e) New South Wales, South Australia Yes§ Yes§ Surveillance Devices Act 2007 (NSW), ss 7(3)(b), 11(1). Surveillance Devices Act 2016 (SA), ss 4(2)(a)(i), 12(1). * Legislation usually deals separately with the sharing of recordings for different purposes, such as “in the public interest”, for protecting the “lawful interests” of the person who is sharing the recording, “in the course of legal proceedings”, “in the performance of a duty”, or as authorised by law. This table solely addresses when clinician consent is required for the sharing of a recording with a family member or with the public at large when the purpose of the sharing is not specified. This may include for the patient's health and wellbeing. It does not address sharing for other purposes. † This is typically expressed in legislation as: persons who have, or are believed on reasonable grounds by the person who is communicating or publishing the recording to have, such an interest in the private conversation (ie, the health care consultation) as to make the sharing reasonable under the circumstances. ‡ In these jurisdictions, the original recording may be lawfully made covertly by the patient for their own use, and then shared with family, without the clinician's consent. § Section 11 of the Surveillance Devices Act 2007 (NSW) is silent about the sharing (publication or communication) of recordings that were made lawfully. A recording that is made by one party without an original intention that the recording be published or otherwise disseminated is lawful in NSW: section 7(3)(b)(ii). Section 12 of the Surveillance Devices Act 2016 (SA) is silent about the sharing of recordings that were made lawfully, such as a recording made with the consent of both parties under section 4(2)(a)(i).

Megan Prictor · Carolyn Johnston · Amelia Hyatt

While apparently non-inferior to originator biologics, other factors need to be considered before switching

Gregory T Moore · Charlotte Keung

We need more robust strategies with targeted, customised approaches, and increased funding for evidence-based interventions

Michael J Dudley · Ping-I Lin

Objective: To examine whether non‐medical switching of patients with inflammatory bowel disease (IBD) from originator infliximab to a biosimilar (CT‐P13, Inflectra) is safe and clinically non‐inferior to continued treatment with originator infliximab. Design: Prospective, open label, multicentre, parallel cohort, non‐inferiority study in seven Australian hospitals over 48 weeks, May 2017 – October 2019. Participants: Adults (18 years or older) with IBD receiving maintenance originator infliximab (Remicade) who had been in steroid‐free clinical remission for at least 12 weeks. Intervention: Managed program for switching patients in four hospitals from originator to biosimilar infliximab (CT‐P13); patients in three other hospitals continued to receive originator infliximab (control). Main outcome measures: Clinical disease worsening requiring infliximab dose escalation or change in therapy. Results: The switch group included 204 patients, the control group 141 patients with IBD. Ten patients in the control group (7%) and 16 patients switched to CT‐P13 (8%) experienced clinical deterioration; the adjusted risk difference (control v switch group) was –1.1 percentage points (95% CI, –6.1 to 8.2 percentage points), within our pre‐specified non‐inferiority margin of 15 percentage points. Serious adverse events leading to infliximab discontinuation were infrequent in both the switch (six, 3%) and control (six, 4%) groups. Conclusion: Switching patients with IBD from originator to biosimilar infliximab is safe and non‐inferior to continuing treatment with originator infliximab. Moreover, the introduction of biosimilar infliximab, by increasing market competition, has resulted in substantial cost savings for the Pharmaceutical Benefits Scheme.

Craig Haifer · Ashish Srinivasan · Yoon‐Kyo An · Sherman Picardo · Daniel Langenberg · Shankar Menon · Jakob Begun · Simon Ghaly · Lena Thin

Objective: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. Design: Retrospective analysis of National Coronial Information System (NCIS) data. Setting, participants: People aged 10–24 years who died by suicide in Australia during 2006–2015. Main outcome measures: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. Results: 3365 young people died of suicide during 2006–2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio‐economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self‐harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). Conclusions: Three‐quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

Nicole TM Hill · Katrina Witt · Gowri Rajaram · Patrick D McGorry · Jo Robinson

Complementary medicines are used by more than half the people in Australia, incurring out‐of‐pocket health expenses of about $5.2 billion in 2019.1 Information about their use by older adults in Australia is more than a decade old.2 Given subsequent demographic changes and doubling in sales of vitamins and supplements,1 we should update our knowledge in this area. We analysed data from the ASPirin in Reducing Events in the Elderly (ASPREE) Longitudinal Study of Older Persons (ALSOP) to assess self‐reported use (every day, occasionally, never) of complementary medicines (fish oil, glucosamine, ginkgo, coenzyme Q10, calcium, zinc, vitamins B, C, D and E, multivitamins, Chinese or herbal) by healthy people over 70 years of age residing in metropolitan or regional Victoria, South Australia, Tasmania, the Australian Capital Territory or southern New South Wales, recruited through their usual general practitioners.3 We summarised data as descriptive statistics; we assessed differences between groups in χ2 tests (categorical variables). Analyses were conducted in SPSS Statistics 23 (IBM). ALSOP was approved by the Monash University Human Research Ethics Committee (reference, CF11/1100). During January 2012 – July 2015, 14 757 of 16 703 ASPREE participants returned ALSOP Baseline Medical Questionnaires3 with at least partial responses to the questions on complementary medicines (response rate, 88%); their mean age was 75.2 years (standard deviation, 4.3 years), and 8068 (55%) were women). A total of 10 961 respondents (74.3%) reported using them either daily or occasionally; fish oil (6563 of 14 757 respondents, 44.5%), vitamin D (4995, 33.8%), glucosamine (3940, 26.7%), and calcium supplements (3652, 24.7%) were the most frequently reported items (Supporting Information, table 1). Complementary medicines were used by larger proportions of women (6637 of 8068, 82.3%) than of men (4324 of 6689, 64.6%; P < 0.001), and of people with more than 12 years of education (4418 of 5838, 75.7%) than of people with less education (6542 of 8918, 73.3%; P = 0.001). The proportions of complementary medicine users who reported a history of depression (987 of 4053, 24.4%) or osteoarthritis (3060 of 5240, 58.4%) were larger than for non‐users (depression, 264 of 1347, 19.6%; P = 0.002; osteoarthritis, 705 of 1598, 44.1%; P < 0.001); self‐reported diabetes was more common among non‐users (363 of 3790, 9.6%) than among complementary medicine users (815 of 10 944, 7.4%; P < 0.001) (Box; Supporting Information, tables 2 and 3). Almost three‐quarters of people in our sample of community‐dwelling older adults in south‐eastern Australia used complementary medicines, with fish oil the most common product. While proprietary complementary medicines are generally regarded as safe, their widespread use by older people, who generally have a greater burden of disease, higher medical expenses, and low or fixed incomes, raises questions about their marketing and promotion.5 Our study population represents Australians over 70 who regularly visit general practitioners, and we included participants from geographically and socio‐economically diverse backgrounds.3 As we pre‐specified a limited number of products, our use estimates may be conservative. In our study, complementary medicine use was defined differently to some earlier studies; for example, the Australian Health Survey which asked about complementary medicine use in the previous 24‐hour period.6 This difference may account for our estimates being slightly higher. Our findings provide the most comprehensive information to date on complementary medicine use by Australians over 70 years of age. Box – Characteristics of respondents to survey of community‐dwelling Australians over 70 years of age on their use of complementary medicine

for the ALSOP Complementary Medicine Research Group*

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen

To the Editor: Elasticated straps — also known as “octopus” straps or bungee cords — are used to secure loads of various shapes and sizes. Unexpected release of the potential energy stored in these straps can cause catastrophic injuries. The Royal Victorian Eye and Ear Hospital (RVEEH) is the largest eye hospital in Australia and is well positioned to assess and treat a variety of ocular injuries. We explored trends in presentations to the RVEEH emergency department (ED) for such injuries between 2007 and 2018, using the ED triage database and information relating to total numbers of ocular trauma presentations. This study was approved by the RVEEH Ethics Committee (09/886H). Between 2007 and 2018, there were 169 presentations involving an elasticated strap‐related eye injury (145 male and 24 female; mean age, 43.4 years). While most patients had multiple injuries, the most common primary diagnosis was traumatic hyphaema, followed by corneal abrasion and open globe (full‐thickness wounds) injuries (Box). There were 23 admissions, of which 21 required surgical intervention, with vitrectomy, orbital wound exploration and closure, and lensectomy being the most common procedures. The final visual acuity measurements of the 17 patients who were admitted and able to be followed up were 6/36 or better for nine patients and 6/60 or worse for eight patients. While males presented more frequently than females, the absolute number of yearly presentations by gender was stable. Elasticated strap‐related injuries accounted for 0.23% of the total 72 663 ocular trauma presentations in the period. While it is problematic to compare incidence with previous studies, due to factors such as growth of the RVEEH ED, growth of other hospitals around Melbourne, and population growth, elasticated strap‐related eye injuries remain a significant contributor to presentations at the RVEEH. These straps were a known danger in the early to mid‐1990s1 and they remain dangerous more than 20 years later, causing severe ocular damage and requiring operative intervention in 12.4% of patients. Although the total number of elasticated strap‐related eye presentations does not appear to be dramatically rising, the continued presence of severe eye injuries necessitating admission for surgical intervention is cause for concern. Multiple steps can be taken to address the continued challenge of elasticated strap‐related injuries. Thorough assessment of the patient remains crucial to facilitate prompt treatment of vision‐threatening diagnoses. In addition, preventive measures should be undertaken to lessen the likelihood of visual loss caused by these devices. This includes patient education and encouraging the use of alternative devices that are functionally similar but pose no risks to eyesight, such as non‐elasticated straps that can be gradually tightened, braided metal locking straps, or even self‐contained soft roof rack and strap combinations. Regulators should also consider whether the convenience of elasticated straps justifies the danger they continue to pose to eyesight almost half a century after they were first introduced to Australia and the first eye‐related injury was reported.2 Box – Primary diagnoses of elasticated strap‐related eye injury sequelae table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Primary diagnosis* Total cases Traumatic hyphaema 63 (3.3%) Corneal abrasion 42 (24.9%) Open globe injury 11 6.5%) Conjunctival/lid/canalicular laceration 7 (4.1%) Commotio retinae 8 (4.7%) Traumatic iritis/mydriasis/uveitis 7 (4.1%) Periorbital haematoma 3 (1.8%) Corneal foreign body 2 (1.2%) Subconjunctival haemorrhage 2 (1.2%) Traumatic glaucoma 2 (1.2%) Conjunctival abrasion 1 (0.6%) Vitreous haemorrhage 1 (0.6%) Posterior vitreous detachment 1 (0.6%) Retinal detachment 1 (0.6%) Lens dislocation 1 (0.6%) Other injury 5 (3.0%) No abnormality detected 7 (4.1%) Patient did not wait to be seen 5 (3.0%) Total 169

Philip Rothschild · Peter Meagher · Thomas G Campbell

To the Editor: We congratulate Hill and colleagues1 for their timely research on the performance of symptom assessment smartphone applications (apps) in Australia. The apps in the study were selected using structured criteria2 to identify those featuring most prominently in internet search engines and app stores. However, we note that this strategy is biased against an important class of symptom checkers. Because the app store search included “medical diagnosis” and “health symptom diagnosis”, the authors’ approach was less likely to identify many symptom checkers regulated in Europe under the CE (Conformité Européene) Marking system. Specifically, these apps must not describe themselves as “diagnostic tools”, as diagnosis is a function carried out by a doctor. We believe this to be the reason why the CE‐marked Ada health assessment app was not identified or selected by the authors.1 This represents a missed opportunity for analysis, as Ada has been freely available in Australia since 2016,3 and was downloaded at least 200 times more frequently in Australia between November 2018 and January 2019 than either Symptomate or Symcat, which were included in the study (App Annie [www.appannie.com] download data; viewed June 2020). Other studies have found that the Ada app performs well when compared with the other apps assessed, as recently published.4

Stephen Gilbert · Paul Wicks · Claire Novorol

In reply

Michella G Hill · Moira Sim · Brennen Mills

To the Editor: In 1996, two articles showed that bowel cancer screening in subjects aged 45–741 and 45–752 years, recruited in the early 1980s, led to a significant reduction in mortality; since then, the age range in Australia’s screening program remains at 50–74 years. Between 1981 and 2015–2017, the mean life expectancy at birth for men and women in Australia rose by 9.3 and 6.3 years respectively.3 In 2016–2018, the mean life expectancy at 75 years was 12.3 and 14.3 years for men and women respectively, and even at 80 years, the mean life expectancy was 9.1 and 10.6 years respectively,3 suggesting a reduction in morbidity in the 75–79 years cohort over the 1981–2017 period. In 2015, the estimated bowel cancer incidence and mortality rates for Australians in the 75–79 years range were 28% and 82% higher than in the 70–74 years range.4 In the United States, in adults aged 65 years and older, the prevalence of screening was higher than 80% in nine states.5 In Australia, mean participation in the National Bowel Cancer Screening Program (NBCSP) increased with age cohort6 (Box). Although there is an increased risk of complications from colonoscopy with increasing age, a prospective observational study compared the risks in the 75–79 with the 70–74 years range and found no increase in perforation rates.7 A US study found that colorectal cancer screening was cost‐effective at ages 79 and 80 years even in persons with severe comorbid conditions.8 A recent Australian microsimulation study9 suggested that the cost‐effectiveness of screening the 50–79 and 50–74 year groups would be almost identical, although the advantage of a likely high participation in the 75–79 age range was not addressed. It found that the number of immunochemical faecal occult blood tests and colonoscopies would increase by 10–16% and 21–30% respectively if the screening cessation age were extended to 79 years, both of which should be welcomed. Facilities in Australia can cope with such an increase in colonoscopies. In view of the above, the NBCSP age range should be extended to 79 years. At a minimum, a pilot study of such an extension should be undertaken. Box – Australian National Bowel Cancer Screening Program participation Age (years) Participation rates (%) 2014–2015 2015–2016 2016–2017 2017–2018 Mean 50–54 28.5 28.1 29.8 31.9 29.6 55–59 36.8 35.5 35.5 37.3 36.3 60–64 43.2 42.7 43.1 43.7 43.2 65–69 43.5 44.2 47.5 49.6 46.2 70–74 52.5 52.5 52.6 53.1 52.7

Donald J Frommer