Volume 215 Issue 1

Bacteria‐infected mosquitoes could help control dengue fever Researchers from Monash University in collaboration with Indonesia’s Gadjah Mada University may have found a way to control dengue fever by releasing mosquitoes infected with the wMel strain of Wolbachia pipientis bacteria. The researchers released infected mosquitoes to control dengue in 12 clusters in Indonesia, and compared this to 12 clusters where they released no mosquitoes. The team found that introducing wMel mosquitoes into the wild populations reduced symptomatic dengue, and resulted in a reduction in hospitalisations for dengue among study participants by 86%. wMel has “virus‐blocking” properties, and affects mosquito reproduction to make sure that all baby mosquitoes are also infected with the bacteria — which researchers say could help control the population and the spread of the virus. Co‐Principal Investigator, Professor Cameron Simmons from Monash University said: “This trial result shows the significant impact the Wolbachia method can have in reducing dengue in urban populations. This result demonstrates what an exciting breakthrough Wolbachia can be — a safe, durable and efficacious new product class for dengue control is just what the global community needs.” The study was published in the New England Journal of Medicine. https://www.nejm.org/doi/10.1056/NEJMoa2030243 UQ develops quantum microscope that can see the impossible University of Queensland researchers have created a quantum microscope that can reveal biological structures that would otherwise be impossible to see. The microscope is powered by the science of quantum entanglement, an effect Einstein described as “spooky interactions at a distance”. Professor Warwick Bowen, from UQ’s Quantum Optics Lab and the ARC Centre of Excellence for Engineered Quantum Systems, said it was the first entanglement‐based sensor with performance beyond the best possible existing technology. “This breakthrough will spark all sorts of new technologies — from better navigation systems to better MRI machines,” Professor Bowen said. “Entanglement is thought to lie at the heart of a quantum revolution. We’ve finally demonstrated that sensors that use it can supersede existing, non‐quantum technology. It’s the first proof of the paradigm‐changing potential of entanglement for sensing.” A major success of the team’s quantum microscope was its ability to catapult over a “hard barrier” in traditional light‐based microscopy. “The best light microscopes use bright lasers that are billions of times brighter than the sun,” Professor Bowen said. “Fragile biological systems like a human cell can only survive a short time in them and this is a major roadblock. The quantum entanglement in our microscope provides 35% improved clarity without destroying the cell, allowing us to see minute biological structures that would otherwise be invisible.” The research was published in Nature. https://www.nature.com/articles/s41586-021-03528-w

Overlooking the potential for airborne transmission of SARS-CoV-2 leaves Australia vulnerable to outbreaks

Zoë Hyde · David Berger · Andrew Miller

Understanding the mental shortcuts people make and the values they bring to weighing risks is critical to informing effective risk communication

Julie Leask · Samantha J Carlson · Katie Attwell · Katrina K Clark · Jessica Kaufman · Catherine Hughes · Jane Frawley · Patrick Cashman · Holly Seal · Kerrie Wiley · Katarzyna Bolsewicz · Maryke Steffens · Margie H Danchin

New measures are designed to improve health outcomes for workers in the coal mining, artificial stone and other dust‐generating industries In Australia, there has recently been a worrying resurgence of dust‐related lung diseases (pneumoconioses) previously assumed to be obsolete. Pneumoconioses are chronic fibrotic lung diseases produced by inhaling mineral dust or dusts (pneumon = lung; konis = dust [Greek]). Conditions include coal workers’ pneumoconiosis (black lung disease) and silicosis.1,2,3,4 Many cases of these diseases have been described in Australia for the first time in over 40 years, including a new type of accelerated silicosis caused by cutting and polishing engineered (artificial) stone seen in kitchen and bathroom benchtop workers.5,6 The latter has occurred in men, often at the height of their working lives, producing much disability and distress and resulting in completely preventable deaths. Artificial stone silicosis differs from other types of silicosis in that it progresses more rapidly and is also associated with a higher rate of development of autoimmunity than classical silicosis. Pneumoconiosis has recurred primarily due to a widespread failure of regulatory controls in a situation where the medical evidence for efficacy of surveillance and prevention is very well established.7,8,9 This has included deficiencies in dust monitoring and control, even in industries where lung health is notoriously at risk (eg, mining), as well as potential changes in dust exposure due to increases in length of shifts and changes in mining technologies.9,10,11 New technologies may have altered the types and characteristics of respirable dust particles as well as the total dust levels.4,12 In some industries, new products like artificial stone have been introduced without adequate awareness of likely hazards, alongside lack of labelling, inadequate respiratory protection, and widespread complacency about dust control measures.13 Dry cutting of stone is notoriously dangerous,7,8 yet was occurring frequently and is still not banned throughout Australia. Many employers (often in small businesses without access to any occupational medical advice) did not appreciate the potential hazards of products they were using, and were not warned by the regulators. Thus, they failed to assess the type or levels of respirable dusts, implement any health surveillance, or use even basic dust control measures.7,8 Because symptoms occur only very late in these diseases, workers were often unaware of any adverse effects. Many workplaces were non‐unionised and workers came from non‐English speaking backgrounds, and did not have access to information about dust hazards and ways to find help. Workers were reluctant to be identified because of job insecurity and financial concerns. Even after a respiratory abnormality had been identified, there was sometimes a failure to identify the disease as occupational in origin.10,11 It was only after cases of severe disease were described by the medical profession, and after several cases had been referred for lung transplantation, that the resurgence of pneumoconiosis was identified.3,4,5 These events are a stark reminder that occupational lung diseases are still a real issue in Australia and that we as health professionals need to maintain vigilance to prevent them in the future. As health professionals, we also need to be aware of the full range of health effects resulting from dust exposures. Inhaled dusts have been shown to cause a broader range of disorders than was originally understood.7,8,14 Pneumoconiosis is only one of several lung disorders which can arise from dust inhalation. In general, high dust levels are needed to produce lung fibrosis; however, other diseases have different, often lower, dose–response profiles. There is now convincing evidence that coal and silica/silicate dust inhalation also produces chronic bronchitis, emphysema and diffuse dust‐related pulmonary fibrosis,7,8,14 and that these effects are additive and not only attributable to tobacco smoking. It is also underappreciated that lung cancer and tuberculosis risk rises in a dose‐related manner after silica exposure, and particularly with silicosis itself.7,14,15 Dust exposure is a factor related to several systemic connective tissue diseases,16,17 including Sjögren’s syndrome, rheumatoid arthritis and mixed connective tissue disorder,18 and renal dysfunction has also been described.7,8 Positive auto‐antibodies are particularly common after artificial stone exposure.16 Clinicians must therefore be aware that inhaled dust produces a broader spectrum of disease than just pneumoconiosis. The primary management of pneumoconiosis has always been to reduce or stop dust exposure. This slows the rate of progression of disease and increases time from exposure to development of symptoms (or disease latency).7,8,19 This has been the rationale for respiratory surveillance programs, which involve regular assessment of a worker’s respiratory health in the workplace every few years, and usually include a questionnaire, spirometry and chest x‐ray, with reduction or removal from exposure once a threshold for early disease diagnosis has been reached. These programs have been the cornerstone of the reductions in incidence of pneumoconiosis worldwide19,20 and are compulsory for workers exposed to several dusts in most Australian states and territories. General practitioners often become involved in these programs either as examining doctors or after an abnormal result has been detected, and are key players in ensuring disease recognition, implementing appropriate work plans, and referring for support. It was because of serious concerns about disease resurgence that members of the Thoracic Society of Australia and New Zealand (TSANZ), Australia’s primary organisation representing respiratory health, developed recommendations in June 2016 aimed at controlling coal mine lung dust diseases.3 The TSANZ suggested standardisation of coal mine dust exposure limits throughout Australia, and alignment to international standards (which were generally lower levels than those in Australia). It also suggested a standardised national surveillance program for at‐risk workers and highlighted the need for better education regarding occupational hazards.3 Following media interest and political support, the federal government established a National Dust Disease Taskforce21 to establish a national approach to the prevention, early identification, control and management of occupational dust diseases. It supported establishing a National Dust Disease Register and provided some funds for new research.21 To assist with the forthcoming recommendations of this Taskforce, the TSANZ has reviewed the evidence and developed a position statement22 in light of advances in knowledge and new techniques available for diagnosing respiratory disease. Respiratory surveillance programs for pneumoconioses22 have been mainly based on the World Health Organization recommendations from the late 1970s,19 but respiratory medicine has advanced since those times, enabling detection of much earlier disease. Modern computed tomography scans provide excellent visualisation of lung anatomy at much lower radiation doses than before, and global initiatives have standardised lung function measurement and reporting.23 The gathering, storage and analysis of data have been revolutionised. In its position statement, the TSANZ recommends enhanced methods for respiratory surveillance of dust‐exposed workers using contemporary methods22 (Box 1). Despite legislated reductions in exposure limits,24,25,26,27 dust levels may not always achieve these limits, and workplace exposure data need to be collected and made available in a central repository to enable improved assessment of a worker’s likelihood of developing disease. This would also significantly improve existing understanding of dose–response relationships, especially with artificial stone. Periodic assessments of respiratory health need to involve a standardised format and high quality, standardised imaging and full lung function assessments. Workers with early abnormalities need to be optimally clinically assessed, treated where possible, and protected by suitable legislation from loss or downgrading of employment.22 Implementing such recommendations will inevitably involve detection of other lung disorders, including those which are non‐occupational in origin, and workers will be referred back to their GP for advice. It is therefore important that GPs understand the possible spectrum of diseases induced by dusts and other toxins, and obtain adequate and ongoing training in occupational lung disorders, including local support systems and when to refer for specialist advice (Box 2). The Royal Australian College of General Practitioners has a training resource for GPs which is a useful tool.28 Ultimately, such a system should prove beneficial to the health of both the individual and the community. However, it will require support and careful implementation in its initial stages. Early disease is difficult to distinguish in clinical practice from other lung pathologies, but difficulties in diagnosis can be overcome using modern techniques. International standards for diagnosis are available and new treatments are under evaluation. Multidisciplinary team meetings in hospitals have been established for respiratory disease diagnosis for many years and are now embedded nationally, and a similar system for occupational lung diseases would be a valuable addition to improving the diagnostic process. An occupational multidisciplinary team in each jurisdiction would bring together a wide range of specialties (primary care, occupational and respiratory medicine, occupational hygiene, radiology, pathology and allied health) and could assist hugely in improving diagnostic standards, improving expertise and disseminating information. This would be best advanced using new virtual technologies, which would also enhance involvement by community and rural physicians. The TSANZ recommendations represent best practice on the basis of existing information and need to evolve with new evidence. The TSANZ has also recommended careful evaluation of the efficacy of new measures using prospective studies, and updating in the light of new research. Changing the system would inevitably require increased resources. However, long term costs are likely to eventually decrease for health services and the economy, given the chronic debilitating nature of these preventable diseases. The TSANZ recommendations are a start in the process of re‐engaging industry and regulator, workers, doctors and politicians; hopefully, they will lead Australia towards a future where preventable death and disablement from occupational lung diseases does not occur. [Corrections added on 22 June 2021 after first online publication: the article title was amended and a footnote was added to Box 1.] Box 1 – Thoracic Society of Australia and New Zealand (TSANZ) proposed improvements to periodic health surveillance in the coal mining and artificial stone industries22 Regular training of staff in accordance with international standards of respiratory surveillance (including quality control and assurance). Plain chest radiographs to be performed using International Labour Organization recommended techniques, technically acceptable, with classification only by qualified thoracic radiologists, and compared with previous images. Individual spirometry to be performed according to American Thoracic Society/European Respiratory Society standards; results to be interpreted using reference values of the Global Lung Initiative. Serial data to be compared with longitudinal predicted values using the lower limit of normal to define lung function abnormality, and spirometry longitudinal data analysis software (SPIROLA). Dust monitoring to be performed under typical working conditions (≥ 75% capacity) and recorded using an accredited facility, with individualised data available for periodic surveillance. Extending surveillance methods for artificial stone exposure to potentially include low dose CT. Careful evaluation of the role of ultra low dose CT for coal miners and artificial stone workers in longitudinal prospective studies. Extending surveillance methods for all workers to include lung diffusing capacity (DLCO) at intervals of 3years or less; careful evaluation of such surveillance within longitudinal prospective studies. A flexible, individualised approach to the timing of surveillance of coal mine dust workers, including annual spirometry and DLCO if results are abnormal but do not yet fulfil diagnostic criteria for disease. Active case finding for artificial stone workers previously exposed to high respirable crystalline silica levels using conventional high resolution CT/spirometry/DLCO performed at accredited respiratory laboratories and radiological facilities using recommended protocols; follow‐up by expert treating specialists/teams, preferably at occupational respiratory disorder multidisciplinary team meetings. For artificial stone workers, pre‐employment plain chest radiographs to exclude major abnormalities. For artificial stone workers undergoing active case finding without abnormal chest x‐ray or high resolution CT, annual spirometry/DLCO and imaging 3‐yearly or more often depending on individual factors and test results. Chest x‐ray imaging to be complemented with high resolution CT scans in high risk groups (eg, borderline fibrosis found on plain chest radiographs and/or discrepancy with lung function findings). Improving existing medical databases to allow capacity to compare serial lung function data, occupational exposure history, imaging findings and dust measurements over time. Early evaluation of the diagnostic utility of best available tests (low dose CT, ultra low dose CT and DLCO) using data collected prospectively with consent from workers, ideally in a research setting. CT = computed tomography; DLCO = diffusing capacity of the lung for carbon monoxide. Adapted from: Perret et al. Respiratory surveillance for coal mine dust and artificial stone exposed workers in Australia and New Zealand: a position statement from the Thoracic Society of Australia and New Zealand. https://doi.org/10.1111/resp.13952. Licence at http://creativecommons.org/licenses/by/4.0. Box 2 – How to manage a case of possible pneumoconiosis in primary care: first steps Be aware that many dusts, fumes and vapours can cause lung diseases. The time between exposure and disease occurrence (latency period) can be very long, usually years. Take time to go through a patient’s full occupational history in detail, from leaving school to retirement. A chronological table of jobs may help (www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf). If the patient uses technical descriptions of a particular job, make sure you know exactly what they mean. Ask them to describe exactly what was done. Ask about conditions in the job, including dust controls like ventilation, use of personal protective equipment, dust measurements and any workplace respiratory health surveillance. Ask about shifts, including length of time worked and any improvements in symptoms when away from work (especially on holidays). Ask whether any other workers were affected. Ask if the patient has access to any safety data sheets. These are information sheets which are meant to be made available from the employer if a worker is exposed to a potentially hazardous exposure (www.safeworkaustralia.gov.au/sds). If unavailable, search the internet for the suspected agent of concern, or contact the Australasian Faculty of Occupational and Environmental Medicine to find a suitable occupational physician and obtain advice (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine). Make contact with an occupational health practitioner if possible (an occupational physician and/or occupational health nurse and/or occupational hygienist). Small employers may not employ such specialists, but a local occupational health practitioner may be a local GP. Be careful not to contact a patient’s employer without obtaining permission first! Your local WorkSafe or similar government agency may be helpful in identifying a potential hazard and can often provide anonymous advice (ACT: www.worksafe.act.gov.au; New South Wales: www.icare.nsw.gov.au; Northern Territory: worksafe.nt.gov.au; Queensland: www.business.qld.gov.au/industries/mining-energy-water/resources/safety-health/mining; South Australia: www.safework.sa.gov.au; Tasmania: worksafe.tas.gov.au; Victoria: www.worksafe.vic.gov.au; Western Australia: www.workcover.wa.gov.au). Keep careful records of all the above. Negative information is also useful. Ensure that a complete history of the patient’s other risk factors (eg, tobacco use, other inhaled substance usage) is recorded. Obtain relevant investigations performed to recommended standards (spirometry, chest x‐ray, computed tomography scan if indicated). If there is reasonable suspicion of an occupational disease, refer to an occupational physician and/or a respiratory physician with occupational lung expertise (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine; www.thoracic.org.au). Costs of care may be covered by WorkCover if a link with employment is established, but this may take time to confirm. Standards for accepting an occupational disease vary in different jurisdictions and do not always accord with medical diagnoses. Other support is available to workers via their local SafeWork or similar government agency.

Deborah H Yates · Jennifer L Perret · Margaret Davidson · Susan E Miles · AW Musk

Transferable strategies and actions for increasing health assessments for people with an intellectual disability

Jodie Bailie · Alison Laycock · Veronica Matthews · Ross S Bailie

Clinical record A 44‐year‐old male health care worker presented with fevers, fatigue and head “fogginess” with abdominal discomfort and increased bowel frequency 8 days after receiving his first dose of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) (AstraZeneca). He was previously well, with a past history of depression and was only taking escitalopram. He had no prior thrombosis or exposure to heparin. The low platelet count, 70 × 109/L (reference range, 150–400 × 109/L), and markedly elevated D‐dimer, 114 mg/L (upper limit of normal, 0.5 mg/L), with vague abdominal pains prompted a computed tomography (CT) venogram of the abdomen, which demonstrated thrombosis with complete occlusion of the portal and splenic veins and protrusion of a tongue of thrombus into the superior mesenteric vein (Box 1). CT venogram of the head did not show central venous sinus thrombosis. The rest of the full blood count and the blood film showed no features of microangiopathic haemolytic anaemia. The prothrombin time, activated partial thromboplastin and fibrinogen levels, liver and renal function tests were all normal. Antiphospholipid antibodies were negative and a heterozygous prothrombin G20210A mutation was identified. Antibodies to the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) nucleocapsid protein and the respiratory polymerase chain reaction (PCR) test for coronavirus disease 2019 (COVID‐19) were negative, ruling out active COVID‐19 infection as a potential thrombosis aetiology. Antibodies to the heparin–platelet factor 4 (PF4) complex in the patient’s plasma was strongly positive (optical density, 1.94) by enzyme‐linked immunosorbent assay (ELISA)‐based test (Asserachrom HPIA IgG; Stago). Three functional assays, including serotonin release assay (SRA; Hidex 300 SL, Hydex), multiple electrode aggregometry (MEA; Roche Diagnostics) and flow cytometry (BD Fortessa, ETH Zürich; procoagulant assay) all detected heparin‐independent PF4 antibody complexes that activated donor platelets.1 Immediate anticoagulation was started with the anti‐factor Xa agent fondaparinux 10 mg (weight, 105 kg) subcutaneously every 24 hours and intravenous immunoglobulin (1 g/kg) administered on days 2 and 3, and repeated on days 7 and 8 after admission. Despite achieving the anti‐factor Xa fondaparinux level 6 hours after receiving a dose of 0.94 U/mL (target range, 0.50–1.20 U/mL), the platelets remained between 6 × 109/L and 20 × 109/L for the initial 6 days. The patient subsequently developed an acute abdomen clinically and a repeat CT scan showed extension and occlusive thrombus into the superior mesenteric vein with venous outlet obstruction and bowel ischaemic features. He underwent an immediate laparotomy with resection of 1.8 m of ischaemic bowel. Contemporaneously, given clot extension had occurred on fondaparinux, anticoagulation was changed to thrombin inhibitor bivalirudin, which had a short half‐life (25 minutes) that allowed for titratable perioperative anticoagulation and an intravenous pulse of methylprednisolone 1 g administered to augment PF4 antibody immunosuppression. The patient returned to the theatre 48 hours after the first laparotomy, where further compromised bowel was resected. Methylprednisolone 1 g daily was reinstituted for 4 days, with an immediate platelet peak to 385 × 109/L at completion of this 4‐day pulse. He was discharged after 34 days without further complications. He has transitioned to warfarin and continues to be well while monitored in the haematology outpatient clinic. Box 2 summarises the time course of treatment and response. Discussion In March 2021, Australia began the roll‐out of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) to combat the COVID‐19 pandemic. In Europe, where more than 20 million doses of this vaccine had been administered by mid‐March 2021, there were case reports of thrombosis at unusual sites associated with thrombocytopenia, which occurred at day 4–28 after vaccination and had a mortality rate of up to 25%, at an estimated rate of 1:100 000.2 In Australia, the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) was initially offered to people working in high risk professions without age restrictions. By the end of March 2021, about 350 000 first doses of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) had been administered Australia‐wide. This is the first reported case of thrombosis at an unusual site with thrombocytopenia following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) in Australia. The temporal association, the detection of anti‐PF4 antibodies with platelet activation in the absence of heparin, which is neutralised at high dose heparin, is consistent with the most recent reports.3 This entity, currently labelled as vaccine‐induced thrombotic thrombocytopenia (VITT) — also known as thrombosis with thrombocytopenia syndrome (TTS) — has pathological similarity to autoimmune heparin‐induced thrombocytopenia but without prior heparin exposure. More evidence is needed to demonstrate if the serum of patients with VITT contains antibodies that can bind to PF4 independent of heparin following vaccination for COVID‐19. Furthermore, the mechanism responsible for profound platelet activation following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]), as evidenced by ELISA high optical densities, remains to be established.3 While the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) is delivered via adenovirus vector, to the best of our knowledge, there are no reported VITT cases associated with mRNA COVID‐19 vaccines. It is doctrine in the management of heparin‐induced thrombocytopenia that, in addition to immediate cessation of all heparins, a non‐heparin anticoagulant is commenced to prevent (further) thrombosis. Given the pathogenic similarities of VITT cases to heparin‐induced thrombocytopenia, we initially used fondaparinux, as our patient was clinically stable with normal renal function at presentation. It is unclear if the clinical deterioration in our patient, despite achieving favourable therapeutic fondaparinux drug level, was resultant of anti‐factor Xa drugs non‐efficacy and/or because of the severity of the venous outflow obstruction with compromised ischaemic small bowel. In principle, the surgical removal of any ischaemic tissue would be associated with clinical improvement. The benefit of intravenous immunoglobulin remains debatable, but in vitro spiking experiments and observation of platelet increment after its administration suggest that there may be a role.3,4 It is possible that intravenous immunoglobulin displaces the binding of anti‐PF4 antibody complex to FcgammaRIIA (an Fc receptor for IgG) receptors on platelets.5 In our patient, it is difficult to ascribe a specific clinical and platelet recovery to intravenous immunoglobulin solely given the simultaneous timing of surgical removal of ischaemic intestine, the commencement of alternate anticoagulation with bivalirudin, and pulsed high dose steroids. It is noted that pulsed methylprednisolone was prescribed in the majority of recently reported cases.3 In line with evolving guidance documents, clinicians assessing patients who present with organ‐specific thrombotic symptoms 4–28 days following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) should look for any combination of thrombocytopenia and elevated D‐dimer, and/or low fibrinogen, with a low threshold for requesting imaging of the appropriate organ — in particular, the brain central venous sinus and abdominal splanchnic venous systems — for thrombosis plus anti‐PF4 ELISA testing in consultation with haematology. Lessons from practice Vaccine‐induced immune thrombotic thrombocytopenia (VITT) is rare but potentially life‐threatening. VITT should be considered when patients present at day 4–28 after vaccination with unusual site thrombosis: splanchnic and/or central venous sinus thrombosis, or thrombocytopenia (or falling platelets) and markedly elevated D‐dimer. Specific testing to detect anti‐platelet factor 4 (PF4) antibody is needed to support VITT. Treat with non‐heparin anticoagulation, intravenous immunoglobulin, and consider pulsed methylprednisolone. Avoid platelet transfusions. Box 1 – Computed tomography venogram at presentation showing (A) a filling defect of portal vein, contrast in superior mesenteric vein and its tributaries (arrow, coronal plane) and (B) a thrombus in the superior mesenteric vein (the arrow shows the contrast, axial plane) Box 2 – Time course and management IV = intravenous; IVIg = intravenous immunoglobulin; SC = subcutaneous.

Jay Hocking · Sanjeev D Chunilal · Vivien M Chen · Tim Brighton · James Nguyen · Jocelyn Tan · Stephen B Ting · Huyen Tran

A 78-year-old woman presented with a recurrent painful ulcerating rash on her hands

Yanjun Chen · Gim Gee Teng · Winnie ZY Teo

Is a policy of mandatory vaccination for health care workers permissible under Australian law?

Dev AS Kevat · Danielle CA Panaccio · Sam C Pang · Jessica M Dean · Caitlin C Farmer · Patrick D Mahar

Responses to the health care needs of this vulnerable group have improved, but further progress is needed

David I Ben‐Tovim · Kim Vien

National surveillance would facilitate strategies for preventing or managing conditions that predispose people to severe streptococcal disease

Jeffrey W Cannon · Asha C Bowen

Supporting physicians to practise rurally is complex and should be part of a multifaceted strategy to provide more health care in the bush

Jennifer A May · Anthony Scott

Objective: To determine rates of potentially preventable hospitalisation of people with intellectual disability in New South Wales, and compare them with those for the NSW population. Design: Retrospective cohort study. Setting: Potentially preventable hospitalisations in NSW, as defined by the National Healthcare Agreement progress indicator 18, 1 July 2001 ‒ 30 June 2015. Participants: Data collected in a retrospective data linkage study of 92 542 people with intellectual disability in NSW; potentially preventable hospitalisations data for NSW published by HealthStats NSW. Main outcome measures: Age‐adjusted rates of potentially preventable hospitalisation by group (people with intellectual disability, NSW population), medical condition type (acute, chronic, vaccine‐preventable), and medical condition. Results: The annual age‐standardised rate for people with intellectual disability ranged between 5286 and 6301 per 100 000 persons, and for the NSW population between 1278 and 1511 per 100 000 persons; the rate ratio (RR) ranged between 3.5 (95% CI, 3.3–3.7) in 2014–15 and 4.5 (95% CI, 4.2–4.9) in 2002–03. The difference was greatest for admissions with acute (RR range: 5.3 [95% CI, 4.9–5.7] in 2014–15 to 8.1 [95% CI, 7.4–8.8] in 2002–03) and vaccine‐preventable conditions (RR range: 2.1 [95% CI, 1.6–3.0] in 2007–08 to 3.4 [95% CI, 2.2–5.2] in 2004–05). By specific condition, the highest age‐standardised rate was for admissions with convulsions and epilepsy (all years, 2567 per 100 000 population; v NSW population: RR, 22.2; 95% CI, 21.3–23.1). Conclusion: Age‐standardised rates of potentially preventable hospitalisation are higher for people with intellectual disability than for the general population. The reasons for these differences should be investigated, and strategies for averting potentially preventable hospitalisation developed.

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

The social determinants of incidence should be addressed, and other relevant host, pathogen, and health system factors investigated

Cameron M Wright · Rachael Moorin · Glenn Pearson · John R Dyer · Jonathan R Carapetis · Laurens Manning

When SARS-CoV-2 prevalence is low, a risk-based approach to screening could improve testing efficiency and reduce resource needs

Eloise Williams · Katherine Bond · Deborah A Williamson

To the Editor: We read the recent article from Haines and colleagues1 with interest and noted that it is featured on the front cover of the print version of the Journal. We agree that the Bupa model for provision of general practitioner services to residents of aged care facilities has promise, as illustrated by this study. However, we wish to point out that, despite these promising findings, this Bupa model has been terminated. The arrangement at the time of the Haines study (2012–2014), whereby GPs were employed by the company as part of a broader care model to provide medical services to residents of Bupa aged care facilities, no longer exists — as known among GPs and in the industry. That care model was reviewed and Bupa GPs were taken off salary when it was observed that GP Medicare billings did not match or exceeded their income. They were advised that they could continue only as contractors, with financial reimbursement being made through their Medicare billings alone. A handful of GPs apparently have remained on salary and they are those who are able to ensure that their billings cover their income. Most GPs chose to sever their ties once the focus of the company shifted. Some remain as contractors, with the acknowledgement that their relationship within the care home has changed. The responsibilities of education, meeting attendance and audits, which are not eligible for a Medicare rebate, are no longer performed. The termination of Bupa GPs as salaried employees coincided with other changes within the care staff structure. We interpret this to mean that promising models of practice that may improve the health of people living in residential aged care facilities can be compromised by corporate decision making that has motivations in addition to, or even at variance with, provision of good health care. Our interpretation is based on the contamination‐adjusted intention‐to‐treat analyses presented by Haines and colleagues.

Ian D Cameron · Helen Steinke · Susan E Kurrle

In reply

Terry Haines · Andrew L Robinson · Andrew J Palmer

To the Editor: In a recent MJA article, Dyer and colleagues1 stated, “Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations”. However, the Australian numbers quoted are not comparable to the other 31 countries in the Organisation for Economic Co‐operation and Development (OECD) database.2 The “almost 20% of the population aged ≥ 80” refers to all persons in residential aged care at some time over the course of a year, whereas other countries mainly report point‐in‐time data. Only two countries (Australia and Greece) submitted data relating to residents over an entire one‐year period. In 2018, the Australian point‐in‐time rate for people aged ≥ 80 years was 13.9%.3 Point‐in‐time or census data are the appropriate numerator for calculating age‐specific usage rates for residential care, the standard method used in Australia for national purposes and the most common metric internationally. For people aged ≥ 65 years, the point‐in‐time rate was 4.5%4 rather than the 6.0% reported by Dyer et al. This is the difference between the 174 875 residents aged ≥ 65 years living in residential aged care at 30 June 2018 and the 234 617 who had lived in residential aged care during the 2017–18 financial year. For residents aged ≥ 80 years, the comparable figures were 137 537 (point‐in‐time) and 186 952 (the financial year).3 The Box presents statistics from the OECD countries used by Dyer and colleagues but incorporating point‐in‐time data for Australia.3,4,5 For persons aged ≥ 65 years, Switzerland has the highest rate at 5.6%. Seven countries then pack closely in between Australia (4.5%) and Denmark (3.9%). Given OECD data have inevitable limitations for comparative purposes, based on differences in national systems and reporting, these seven countries have similar levels of use. For people aged ≥ 80 years, rates are highest in Switzerland (16%), New Zealand (14%) and Australia (13.9%). Four additional countries sit close behind: the Netherlands, Sweden, Denmark and Canada, all in the 12.3–12.7% range. Nationally, the accurate 2018 usage rates for Australia are 4.5% for people aged ≥ 65 years and 13.9% for those aged ≥ 80 years. Internationally, Australia is a relatively high provider of residential aged care, but there are a number of countries with similar or higher levels of provision. Although there is insufficient evidence to claim that Australia is over‐reliant on residential care, the authors’ argument for increased investment in community‐based care is nonetheless an important one. Box – People aged ≥ 65 and ≥ 80 years using long term care as a percentage of total age group — international comparison of selected Organisation for Economic Co‐operation and Development (OECD) countries (2018) Percentage of people aged ≥ 65 years Percentage of people aged ≥ 80 years Switzerland 5.6% 16.0% New Zealand 4.3% 14.0% Australia 4.5% 13.9% The Netherlands 4.2% 12.7% Denmark 3.9% 12.7% Sweden 4.3% 12.6% Canada 4.0% 12.3% Germany 4.1% 10.7% Korea 2.7% 9.0% Japan 2.6% 7.2% United States 2.4% 6.1% Poland 0.8% 1.6% Data sources: For Australia, point‐in‐time usage data were extracted from the Australian Institute of Health and Welfare GEN Aged Care Data;3 for all other countries, data were extracted from OECD Statistics.5 Data are for 2018, or the most recent OECD data available in the case of Denmark (2014), the Netherlands (2017) and the US (2016). OECD data definitions indicate the point in time for Canada, Germany, the Netherlands, Poland, Switzerland and the US, a one‐month reference period for New Zealand and Japan, and are inadequately specified for Denmark, Sweden and Korea.2

Diane M Gibson

In reply

Suzanne M Dyer · Dominic Tilden

To the Editor: We are two international medical graduates who have been inducting, assessing and mentoring international medical graduates for many years. We found the article by Yeoman and colleagues1 very interesting and agree with their conclusions. However, one of the most important innovations by the Australian Medical Council (AMC) — the introduction of the workplace‐based assessment (WBA) program2 — was not mentioned. The current clinical examination by the AMC tests the clinical competency of the candidates. What is needed is an assessment of performance, as it is well known that many international medical graduates struggle in the workplace after passing the clinical examination. The AMC introduced the WBA program and is now conducting this assessment in nine accredited sites after it was pioneered in Newcastle2 in 2010. These sites are accredited by the AMC and the program replaces the AMC examination. The WBA programs use various tools, including mini clinical assessments, case‐based discussions, multisource feedbacks, and directly observed procedural skills. All these tools are well validated. The assessment duration varies from 6 to 12 months. The variability in the blueprint of the assessments and the duration of the programs provide the opportunity to test their reliability. The results are reviewed by the AMC before candidates are awarded the AMC certificate. The lessons learned from the WBA program can be and are being used in undergraduate and postgraduate settings. The AMC is to be congratulated for introducing this innovation in medical education and assessment.

Balakrishnan (Kichu) R Nair · Mulavana Parvathy

When Professor Susan Sawyer started in adolescent medicine, the field barely existed

Cate Swannell