Volume 218 Issue 5

Urgent and sustained political engagement is needed to address the health impacts of climate change

Maddie Heenan · Lucie Rychetnik · Elly Howse · Paul J Beggs · Tarun S Weeramanthri · Fiona Armstrong · Ying Zhang

System-wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing

Pat Dudgeon · Abigail Bray · Roz Walker

Ongoing surveillance for emerging and re- emerging infectious diseases is essential to assess their impact on blood and breastmilk safety

Philip Kiely · Veronica C Hoad · Claire E Styles · Iain B Gosbell

Clinical trials improve care and save lives but need more clinician and consumer engagement

Angela L Todd · Don Nutbeam

A 19-year-old man presented with a two-day history of intermittent pleuritic chest pain and associated fevers

Nilanthy Vigneswaran · Elaine Cheong

Widespread, inexpensive CAC scanning could economically expand access to statin therapy to those at highest risk

Erfan Tasdighi · Michael J Blaha

Expanding eligibility for statin therapy should selectively target people with subclinical atherosclerosis rather than simply lowering treatment thresholds

Prasanna Venkataraman · Amanda L Neil · Geoffrey K Mitchell · Tony Stanton · Stephen Nicholls · Andrew M Tonkin · Gerald F Watts · Thomas H Marwick

People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis

Allison Carter · Hamish McManus · James S Ward · Tobias Vickers · Jason Asselin · Greta Baillie · Eric PF Chow · Marcus Y Chen · Christopher K Fairley · Christopher Bourne · Anna McNulty · Phillip Read · Kevin Heath · Nathan Ryder · Jenny McCloskey · Christopher Carmody · Heather McCormack · Kate Alexander · Dawn Casey · Mark Stoove · Margaret E Hellard · Basil Donovan · Rebecca J Guy

The benefits of DAA therapy for children with HCV infection are now attainable in Australia in normal practice

Jessica A Eldredge · Michael O Stormon · Julia E Clark · Scott Nightingale · Brendan McMullan · Brooke Andersen · Christina Travers · Winita Hardikar

Prison settings are risk environments for HCV transmission and should therefore be a priority setting for harm reduction and clinical and educational interventions

Rebecca J Winter · Yumi Sheehan · Timothy Papaluca · Graeme A Macdonald · Joy Rowland · Anton Colman · Mark Stoove · Andrew R Lloyd · Alexander J Thompson

To the Editor: Over 26000 Australians experience out‐of‐hospital cardiac arrest (OHCA) each year, with almost nine in ten of these patients not surviving to hospital discharge or 30 days.1 Although it is known that swift defibrillation increases the possibility of patient survival in these situations, and that initial defibrillation by first responders (regardless of training) is associated with greater survival than initial defibrillation by emergency medical services,2 in Australia, less than 2% of OHCA cases receive defibrillation by a bystander.1 It is likely that this is driven by the limits to publicly accessible automated external defibrillators (AEDs) in Australian communities.3 On 30 November 2022, South Australia took a major step to deal with this problem and reduce death from OHCA. The SA Parliament passed the Automated External Defibrillators (Public Access) Bill 2022,4 making SA the first state or territory in Australia, and one of few in the world, to mandate the public provision of AEDs. The legislation, introduced by Member of the Legislative Council, the Hon Frank Pangallo of the SA‐BEST party, had bipartisan political support and backing from various organisations, and follows a recent public health campaign to install AEDs in Adelaide. The Bill will come into effect for government and public buildings in 2025 and a variety of private buildings in 2026, with awareness campaigns, grant programs, and communication with organisations being the focus of the interim period. The expected cost to the SA government of $7.2 million across four years is weighed against the $2 billion gross domestic product loss that Australia incurs annually as a result of sudden cardiac arrest.5 The health and economic benefits of public access defibrillation to Australian society are large. For the benefit of all Australians, other states and territories should follow the example set by SA and move to implement similar laws mandating the public availability of AEDs in their communities.

Joshua G Kovoor · Gregory J Page · Pramesh Kovoor

To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.

Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson