Volume 219 Issue 1

What do the commercial determinants of health look like for goods and services that are human rights?

Jennifer Lacy‐Nichols · Rebecca Bentley · Adam G Elshaug

Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance

Michelle Kennedy · Janine Mohamed

A 62-year-old man with a more than 30-year history of actinic keratoses and keratinocyte carcinomas presented for ongoing management

Sarah K Morton · Selim Ozluer · James Muir

A 33-year-old man presented with a four-month history of polyarthralgia, cutaneous oedema and induration of extremities after swimming

Xingyu Li · Dong‐Lai Ma

Increased prescribing of psychotropic medication for children and adolescents during the COVID-19 pandemic: no cause for alarm

Philip L Hazell

The appropriateness of the increasing psychotropic prescribing to children and adolescents should be further investigated

Stephen J Wood · Jenni Ilomäki · Jacqueline Gould · George SQ Tan · Melissa Raven · Jon N Jureidini · Luke E Grzeskowiak

Prescribing of all psychotropic classes has risen since 2018, and increases were particularly marked during the COVID-19 pandemic

Rae‐Anne Hardie · Gorkem Sezgin · Lisa G Pont · Judith Thomas · Mirela Prgomet · Precious McGuire · Christopher Pearce · Andrew Georgiou

Health care policy and clinical practice should be revised to support more consistent financial disclosure and support

Victoria White · Karla Gough · Colin Wood · Raymond Chan · Michael Jefford

Accurate peri-operative risk assessment is important to enable shared decision making and to optimise the multidisciplinary management of patients undergoing major non-cardiac surgery

Shehane Mahendran · Aravinda Thiagalingam · Graham Hillis · Richard Halliwell · Henry CC Pleass · Clara K Chow

To the Editor: The flavivirus Murray Valley encephalitis virus (MVEV) was isolated in 1951 from the brain tissue of fatal cases of encephalitis.1 Subsequent work by Australian investigators established MVEV as the likely aetiological pathogen of the severe encephalitis “Australian X disease”.1 MVEV is enzootic in northern Western Australia and the Northern Territory, resulting in sporadic human cases.2 In south‐east Australia, however, MVEV activity can be absent for decades only to reappear with significant human outbreaks. The three most recent outbreaks in Australia were in 1951 (45 cases), 1974 (58 cases) and 2011 (17 cases).1,2,3 The case fatality rate is about 18% in hospitalised patients, reflecting the severity of disease.4 Since 1974, Victoria has employed vertebrate and invertebrate surveillance methods to detect MVEV activity before human cases.5 Until 2021, sentinel chicken flocks were placed along the Murray River and tested weekly for MVEV seroconversion during the mosquito season, which runs from November to April. The most recent seroconversions were in 2011, along the Murray River, in Greater Bendigo, and in Greater Shepparton.6 This testing strategy was limited by biological and logistic delays, diminishing the system as an early warning tool. In 2021, sentinel chickens were retired, with flavivirus testing combined into the long‐standing alphavirus mosquito trapping program when polymerase chain reaction (PCR) assays replaced labour‐intensive and insensitive cell culture methods.7 For the 2022–2023 mosquito season, in the setting of Japanese encephalitis virus activity and historic floods, the Victorian Department of Health supported 15 councils to trap mosquitoes as part of the Victorian Arbovirus Disease Control Program (VADCP). Trapped mosquitoes were pooled and submitted for PCR testing. The size and composition of these varied depending on the number of collected mosquitoes, with a preference for analysis of speciated mosquitoes if possible. Detections were confirmed with sequencing at a reference laboratory. As of 23 January 2023, we have detected MVEV in 14 mosquito traps across four local government areas (Box). The positioning and density of the traps are influenced by proximity to population centres and resource considerations, which may influence the likelihood of virus detection in different localities. The first detection was in mosquitoes collected on 4 January 2023. New South Wales and South Australia have also reported MVEV detections in multiple locations. Subsequently, on 17 February 2023 the first human case of MVEV infection in Victoria since 1974 was confirmed after lengthy investigation of a person with illness onset on 16 January 2023. This represents the first detections of MVEV in south‐east Australia in the 2022–2023 mosquito season, the first surveillance detections in Victoria since 2011, and the first confirmed human case in Victoria since 1974. The timing of these signals is notably earlier in the season than previous sentinel chicken seroconversions, which occurred in February 2011, supporting mosquito PCR testing as a rapid surveillance tool. This difference in timing may, however, be explained by inter‐year environmental or sampling factors, and a controlled comparison between mosquito and sentinel chicken surveillance, in the context of subsequent human cases, is required to demonstrate the most useful surveillance tool. Nonetheless, the presence of virus and capable vectors suggests the risk for human infection is present, and, importantly, informs public health actions. MVEV in south‐east Australia is rare and the time between outbreaks is measured in decades. These early mosquito surveillance signals have preceded a human health event which has not occurred in Victoria since 1974. In the absence of an effective vaccine, prevention relies on vector control and health promotion, while case detection requires clinician awareness. Retrospectively, a serosurvey will be essential to measure the extent of human exposure during this period of MVEV activity. Finally, given our understanding of MVEV in Victoria is limited by a paucity of historical events to analyse, researchers should engage in this rare opportunity to study MVEV epidemiology and ecology. Box – Victorian local government areas (LGA) with the first 14 polymerase chain reaction (PCR) detections of Murray Valley encephalitis virus in trapped mosquitoes in 2023 (shaded in red). LGAs where surveillance was undertaken are outlined. The inset shows the Australian state of Victoria shaded‐in and the dates of mosquito collection and notification to the Department of Health * Greater Bendigo LGA.

Maxwell Braddick · Aidan Yuen · Rebecca Feldman · N Deborah Friedman

To the Editor: Curtis and colleagues1 describe important implications for consideration as the metaverse begins to affect health care. These implications are particularly salient for individuals with specific physical impairments, especially vision loss. Emphasis on visual input in the metaverse may have implications for patients with vision loss. The lack of tactile input in the metaverse will disproportionately affect people with profound vision loss. The consequences include social isolation, motion sickness, and reduced access to services. In addition, people who lack stereopsis may also be disadvantaged in a metaverse. These individuals do not experience the stereopsis‐derived depth perception required for the three‐dimensional perception of the visual world. Efforts must be made to ensure that monocular depth cues, including linear perspective and motion parallax, are considered during metaverse development.2 Should health care be provided via the metaverse, vision impairment may limit access to these services. Difficulty accessing services may lead to deterioration in ocular conditions and potentially compound the initial vision loss precluding access.3 There are existing strategies that facilitate the use of visual media for people with vision impairment. These methods have been developed for telecommunication, cinematic and video game technologies. Mechanisms to improve accessibility, including having the capacity to increase text size substantially without disrupting user interfaces, could be employed in all screen‐based technologies.4 Effective accessibility features, such as adaptive audio description, must be available for visually impaired users. Ongoing technological development may facilitate metaverse access for people with visual impairment. There is ongoing research into the optimisation of head‐mounted and digital visual displays to facilitate use for those with vision impairment and visual field defects.5 However, this digital display technology will not facilitate access for people with profound vision loss, such as those with no perception of light. Moving forward, companies should strive to provide equal access to services to all individuals, including those with visual impairment. Regulatory frameworks may help to standardise this incorporation of accessibility. The proactive consideration of the needs of the visually impaired during the development of the metaverse may facilitate the implementation of more effective technology. Engaging disability stakeholders during testing phases of technology may help to identify issues at early stages of development.

James Pietris · Yiran Tan · Weng Onn Chan

The barriers to accessing voluntary assisted dying (VAD) in Victoria cause considerable distress for patients, according to new research. Published in The Medical Journal of Australia, the research examined the barriers faced by patients and their families seeking to access VAD in Victoria as well as what supports were in place. The research made several recommendations, including: improving access to VAD in Victoria; increasing the pool of doctors willing and qualified to be involved in VAD; requiring doctors who will not provide VAD to refer patients to a willing doctor; and investing in system supports, such as adequate funding for both the statewide pharmacy service and VAD care navigators. Professor Ben White, Professor of End-of-Life Law and Regulation, and his colleagues at the Australian Centre for Health Law Research at the Queensland University of Technology (QUT), conducted the study with 32 family caregivers and one patient. “Our research is part of a wider four-year study looking at the regulation of VAD in Australia, Canada and Belgium,” Professor White said. “Our overall goal is to find the most appropriate way to regulate VAD to make sure that it’s safe but also accessible for patients. One of the key bits of evidence that was missing to date was that patient experience and how they experience the process of seeking VAD, such as what are the barriers to access and what are the supports already in place.” Ruthie Jeanneret, a PhD student also at the Australian Centre for Health Law Research at QUT, said one of the key barriers for people wishing to access VAD was finding an appropriate doctor. “Participants explained that it was particularly difficult to find the first doctor or ‘coordinating medical practitioner’ to help them through the process,” Ms Jeanneret said. “The second barrier was the time that it actually took to get through the entirety of the VAD application process.” Another barrier was the ban on medical practitioners using telehealth. “Telehealth is not allowed to be used for VAD consultations, which means that all consultations have to occur in person, which really affects people in regional areas and people with neurodegenerative conditions.” The study also looked at institutional objections to VAD, with some facilities not allowing some or any aspects of the VAD process to occur in their facilities. Professor White said the study also examined what supports were working well for people seeking to access VAD in Victoria. “The role of the VAD care navigators was absolutely crucial,” Professor White said. “These are state-funded health professionals who are based at Peter MacCallum Cancer Centre in Melbourne and at five regional health centres. “Their role is to assist patients under the system and help them through it. “Our research found the people in these roles really helped patients and their families understand the process and navigate the health system.”

Sam Hunt