Issues
Volume 218 Issue 10
Editor’s Choice
COVID‐19: no longer a global health emergency, now a long term challenge
COVID‐19 is the focus of the research and editorials in this issue of the MJA. Despite the World Health Organization (WHO) declaring on 5 May that COVID‐19 is no longer a global health emergency, it remains a substantial threat. According to WHO statistics, from 3 January 2020 to 10 May 2023, there have been 11 270 821 confirmed cases of COVID‐19 in Australia, including 20 393 deaths (https://covid19.who.int/region/wpro/country/au). As with international data, these figures are certainly underestimates. COVID‐19 challenged and changed our health system and indeed our society in profound ways. A research article by Tan and colleagues explores mortality among people admitted to Australian intensive care units (ICUs) for reasons other than COVID‐19 during the COVID‐19 pandemic (doi: 10.5694/mja2.51933). What they found was disconcerting: from March 2021 until June 2022 there was a rise in in‐hospital mortality among people admitted to Australian ICUs with conditions other than COVID‐19, a trend which reversed the decrease in mortality seen in the preceding five years. The authors discuss a few possible contributors, including “the withdrawal of strain mitigation strategies (eg, staff redeployment), increased demand for ICU services, and changes in the availability of experienced staff following losses to burnout or leave”. They conclude that “Changes to health service delivery during the pandemic and their consequences should be investigated further”. In a related editorial, Kirk and Mitchell note that these findings “raise important questions as to why, one year into the COVID‐19 pandemic, in‐hospital mortality rose for people admitted to intensive care without COVID‐19” (doi: 10.5694/mja2.51946). Describing the ICU as “a microcosm of our health care system”, they conclude that “ICUs can be the canary in the coal mine for a health care system” and that “it is critical that we identify which parts of the health care system need repair”. COVID‐19 in children has been the topic of much medical and public debate. Ibrahim and colleagues look at the characteristics of 1193 children who were SARS‐CoV‐2‐positive and who presented to Australian hospitals in 2020 and 2021 (doi: 10.5694/ mja2.51934). This research comes from a long term collaborative program: the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Although 341 children required treatment in intensive care, and sadly, two children died, they concluded: “During 2020 and 2021, most SARS‐CoV‐2‐positive children and adolescents who presented to participating hospitals could be managed as outpatients. Outcomes were generally good, including for those admitted to hospital.” Sorrell and colleagues write persuasively in their editorial on what is now emerging as the health legacy of COVID‐19 — long COVID (doi: 10.5694/mja2.51950). The number of individuals who are potentially affected is enormous. A report from the Australian Institute of Health and Welfare in December 2022 estimated that long COVID — defined as symptoms lasting more than 12 weeks — affects 5–10% of Australians who have had COVID‐19 (https://www.aihw.gov.au/reports/covid‐19/long‐covid‐in‐australia‐a‐review‐of‐the‐literature/summary). These are alarming estimates and indicate that the true health burden of COVID‐19 is still to be determined. The challenges of long COVID range across the entire health system which begins with diagnosis, and the need for a standard (although necessarily evolving) definition. Sorrell and colleagues note that “health system planning for long COVID is constrained by the paucity of data on its incidence, clinical manifestations, and its effects in different risk groups, geographic locations, and health care settings”. Further, many published studies are small and local. Once diagnosed, patients need coordinated, multidisciplinary medical and social care. Crucially, as Sorrell and colleagues note, “We must ensure equitable access to services (including in our rural and remote communities)”. Although the immediate health emergency of COVID‐19 is now at an end, at the MJA we recognise that the long term health effects are profound and require a whole‐of‐system, equitable approach — a topic we have reflected on before (doi: 10.5694/mja2.51840). We continue to welcome submissions of articles on COVID‐19, especially on long COVID, and research that addresses the challenges of health system planning, coordinated care and equity highlighted by Sorrell and colleagues.
Virginia Barbour
Perspectives
Access to oral COVID‐19 antivirals in the community: are eligibility criteria and systems ensuring equity?
With substantial SARS-CoV-2 transmission in the community, early oral antiviral access has become a pillar of our response
Nicole L Allard · Jose Canevari · Nick Haslett · Benjamin C Cowie
Avoiding severe drug hypersensitivity reactions: a case for HLA genotyping for at‐risk patients
Several human leucocyte antigen alleles are associated with severe drug hypersensitivity reactions, and Asian Australians have a relatively high risk of carrying such alleles
Jana Stojanova · Richard O Day · Graeme Suthers
Medical education
Locally acquired respiratory diphtheria in Australia
A 32-year-old woman from a remote Indigenous community in Far North Queensland presented to her local health clinic with a one-day history of odynophagia
Simon Smith · James Stewart · Joshua Hanson · Julian Harris · Fred JJ Chuang · Gavin Quail · Bryan Hawarden · Roshni Lad · Shannon McNee · Benjamin McCartney · Tonia Marquardt · Ian Wilson · Catherine Tacon · Bernard CS Whitfield
A solitary triangular alopecia
An otherwise well, five-year-old girl was brought in by parents for review of a bald patch over the left frontotemporal scalp
Tim Aung
Adapting clinical trials in health research: a guide for clinical researchers
Flexibility of design is not a panacea, but adaptive clinical trial designs offer the potential for more efficient research
Elizabeth G Holliday · Natasha Weaver · Daniel Barker · Christopher Oldmeadow
Editorials
Long COVID in Australia: achieving equitable access to supportive health care
Our stressed health system needs innovative solutions to care adequately for people with post- COVID-19 conditions
Tania C Sorrell · Martin Hensher · Lena A Sanci
Has the COVID‐19 pandemic unmasked the fragility of the Australian health care system?
Further research is needed to determine the reasons for poorer outcomes during the COVID-19 pandemic
Lucy E Kirk · Imogen Mitchell
The inter‐hospital transfer of critically ill patients with COVID‐19: a double‐edged sword
We must continue to review and document the safety and outcomes of transfers, despite their apparent safety
Peter T Morley
Research
The characteristics of SARS‐CoV‐2‐positive children in Australian hospitals: a PREDICT network study
Most children with COVID-19 can be cared for adequately in primary care, relieving the demand for emergency department services
Laila Ibrahim · Catherine Wilson · Doris Tham · Mark Corden · Shefali Jani · Michael Zhang · Amit Kochar · Ker Fern Tan · Shane George · Natalie T Phillips · Paul Buntine · Karen Robins‐Browne · Vimuthi Chong · Thomas Georgeson · Anna Lithgow · Sarah Davidson · Sharon O'Brien · Viet Tran · Franz E Babl
Mortality among people admitted to Australian intensive care units for reasons other than COVID‐19 during the COVID‐19 pandemic: a retrospective cohort study
Increased in-hospital mortality may reflect changes in care across the Australian health system that need to be rectified
Sing Chee Tan · Tess Evans · Matthew L Durie · Paul J Secombe · David Pilcher
Inter‐hospital transfer and clinical outcomes for people with COVID‐19 admitted to intensive care units in Australia: an observational cohort study
In-hospital mortality was not higher for transferred patients, confirming careful case selection and sustained commitment to care by hospitals
the SPRINT‐SARI Australia investigators
Research letter
Myocarditis in Australian children following SARS‐CoV‐2 infection or COVID‐19 vaccination: a retrospective case series
Awareness that the myocarditis risk in children with SARS-CoV-2 infections differs from that for adults should inform vaccination strategies
Patrick Walker · Timothy C Lai · Silja Schrader · Nigel Crawford · Daryl R Cheng
Narrative review
Cardiovascular risk management following gestational diabetes and hypertensive disorders of pregnancy: a narrative review
Pregnancy can be seen as a stress test for cardiometabolic conditions, where the physiological demands of pregnancy can unmask women at risk for CVD
Simone Marschner · Anushriya Pant · Amanda Henry · Louise J Maple‐Brown · Lisa Moran · N Wah Cheung · Clara K Chow · Sarah Zaman
Letter
Home‐based palliative care services after COVID‐19
To the Editor: The impact of the coronavirus disease 2019 (COVID‐19) pandemic continues to affect institutional care, both acute and aged care services. More hidden is the impact on community care, especially community palliative care. Community palliative care aims to enable people to die where they wish. About 70% of the population seek to die at home, but between 4% and 12% actually do.1 During the COVID‐19 pandemic, however, data from three Melbourne community palliative care services indicated a rise in deaths at home of between 30% and 50% (personal communication, John Doran, Manager, Melbourne City Mission Palliative Care; Janet Phillips, Chief Executive Officer, Peninsula Home Hospice; and Kelly Rogerson, Chief Executive Officer, Palliative Care South East; December 2022). This increase has not been recently reported in Australia. One factor may be family reticence to admit their family member for inpatient care because of continued visitor restrictions2 — also reflected in international literature.3,4 Consequentially, the client profile has changed as more people present with complex needs and a higher number need terminal care. This requires lengthier visits from clinical staff — one service employed a registrar to support general practitioners (personal communication, Janet Phillips, December 2022). More emphasis is placed on telehealth, now routine, often substituting every second scheduled visit; and many staff work from home (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). The use of in‐home overnight respite has markedly increased, providing additional support to family carers (personal communication, Janet Phillips, December 2022). Perhaps because of increased workload, locum doctors are less available, meaning that palliative care staff are increasingly called on to support terminal care, including complex symptom management, and to verify death (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). Staff are still required to do regular risk assessment, including COVID‐19 testing, and to wear personal protective equipment, aligned with Department of Health guidelines for health care workers.5 A significant number of inpatient bed‐days are saved when people are supported to die at home, which may reduce the burden of care in institutional settings.6 Further work is required to measure the impact of home‐based care on outcomes for terminally ill people and their families and to understand the value of that care to the health care system.
Margaret O'Connor
Women and health
Tania Janusic
Advancing menopause care in Australia: barriers and opportunities
Susan R Davis · Karen Magraith
Focusing on the challenges facing primary care
Aajuli Shukla
A step in the right direction: the potential role of smartwatches in supporting chronic disease prevention in health care
Graeme Mattison · Oliver J Canfell · Doug Forrester · Chelsea Dobbins · Daniel Smith · David Reid · Clair Sullivan
The impact of climate change on skin health
Austen Anderson · Fiona Bruce · H Peter Soyer · Crystal Williams · Rebecca B Saunderson
Hypertensive retinopathy in the paediatric setting
Nandini Singh · Kanika Chaudhri · Caroline Catt