Letters

To the Editor: The broadly accepted definition of a cancer survivor recognises that the survivorship begins at diagnosis.1 However, survivorship care pathways conventionally begin at completion of active treatment, presenting a challenge for addressing survivorship needs at diagnosis and for people living with incurable cancer.2 A revision of the concept of cancer survivorship is needed, placing the survivor at the centre of a dynamic experience of life after a cancer diagnosis and opening up the survivorship experience to persons at any stage of cancer and at any phase of their disease trajectory. Until now, clinical care guidelines and models of survivorship have typically not included consumer input, but rather have been developed principally through health professional expert consensus.3,4 In a novel approach from 2019–2020, a panel of 47 experts and consumers across Australia and New Zealand came together to define six key domains of survivorship care in a Prostate Cancer Survivorship Essentials Framework:5 health promotion and advocacy, shared management, vigilance, personal agency, care coordination, and evidence‐based survivorship interventions. These six domains reached high consensus as being essential, with the 26 elements within domains all rated as high importance. Almost one‐third of the 47‐member panel were cancer survivors working collaboratively with medical, allied health and nursing expert representatives. The degree of consensus in such a broad coalition is remarkable, underscoring the validity of the approach that reflects the lived experience driven by survivors’ preferences. Importantly, the central domain related to personal agency of a survivor as a key element that linked all others (Box) and all domains were framed around outcomes that mattered for the patient (eg, empowerment, information, shared decision making, care coordination, symptom management). While the framework was developed for prostate cancer survivorship, none of the elements were unique to prostate cancer, highlighting the potential relevance of the framework to other cancers. More broadly, this approach aligns with existing models of chronic disease management and frameworks of consumer engagement in care that are fundamental to the delivery of health care in Australia and New Zealand. We believe the essentials framework is applicable to other adult cancer patient cohorts and presents an opportunity to move forward on cancer survivorship in Australia, taking forward a unique consumer–practitioner model where the survivor is not just the passive object of care but an actor in their own health and an empowered and supported agent of change. Box – Prostate Cancer Survivorship Essentials Framework

Jeff Dunn · Bogda Koczwara · Suzanne Chambers

To the Editor: The toll of group A Streptococcus is dramatically unappreciated, despite increasing evidence of its burden.1 In Australia and New Zealand, we recently demonstrated that group A streptococcal throat and skin infections cause a sizable burden at the population level — cellulitis is the main contributor to the total burden of all group A streptococcal diseases and acute rheumatic fever and rheumatic heart disease contribute disproportionately relative to their frequency of occurrence.2,3 At a global level, the burden of group A Streptococcus is not abating. Global Burden of Disease data suggest that incident cases and deaths due to rheumatic heart disease alone have surpassed those of meningitis (Box). In 2019, more than 85% of rheumatic heart disease cases occurred among people aged under 35 years.4 No other group A streptococcal‐specific endpoints are available from the Global Burden of Disease data, yet all‐cause cellulitis was ranked the 24th most frequently occurring condition in high income countries in 2019.4 Group A Streptococcus causes outbreaks of poststreptococcal glomerulonephritis, contributing to the burden of chronic renal disease, and it is estimated to be the fifth most lethal pathogen on the planet, behind the human immunodeficiency virus (HIV), Mycobacterium tuberculosis, Plasmodium falciparum and S. pneumoniae, yet expenditure on vaccine development is only 0.17% of that spent on vaccines for HIV infection, malaria and tuberculosis.5 The divergence in numbers of cases and deaths due to group A Streptococcus compared with meningitis partially demonstrates the value of vaccination. Another major benefit of vaccination is a substantial reduction in antibiotic consumption. Indeed, pharyngitis is a major driver of antibiotic consumption globally, and an estimated 17% of antibiotic prescriptions for pharyngitis among children in the United States could be prevented by a group A Streptococcus vaccine.6 Two major initiatives aim to progress vaccine development. The Australian Strep A Vaccine Initiative (ASAVI) and the Strep A Vaccine Global Consortium (SAVAC) are addressing technical and investment barriers and leading at least one of the current vaccine candidates to an efficacy trial for pharyngitis prevention by 2024.5 An effective vaccine may prevent health and economic burdens due to the full range of group A streptococcal diseases and associated antibiotic consumption. Box – Estimated number of new cases (left) and deaths (right) due to meningitis and rheumatic heart disease globally* * Data obtained from the Global Burden of Disease study 2019.4

Jeffrey W Cannon · Julie Bennett · Michael G Baker · Jonathan R Carapetis

To the Editor: In their article, Blakely and colleagues1 describe an infectious disease model for simulating the effect of a lockdown on the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Although we cannot say this work determined pandemic policy, two of the authors have described their close collaboration with the Victorian Government, culminating in the release of a road map to reopening2 based directly on, and released alongside, their modelling.3 The model is stochastic and agent‐based, with 2500 individuals moving around a model space. When both an infected and a susceptible person land on the same patch, there is a probability of transmission. Some individuals are marked as being essential workers; population homogeneity is otherwise assumed.4 Models are necessarily abstractions from reality; it is neither possible nor relevant to include every population group. The question is whether the model effectively captures the dynamics of infection. The combination of model type and population structure has a surprising result. People in the model can only be infected by moving around, and a lockdown is simulated by a reduction in the pace and frequency of movement. At a technical level, the model’s mechanics guarantee the effectiveness of a population‐wide lockdown because it most extensively reduces movement. It is hardly surprising that Blakely and colleagues refer to a lockdown as an “opportunity”.1 The assumption of population homogeneity is robust to exceptions, but only to a point. Using official data, we estimate that, in Victoria, the odds of an aged care worker becoming infected were almost 12 times that of the general population (odds ratio [OR], 11.81; 95% CI, 11.76–11.87). For health care workers, the odds were more than three times higher (OR, 3.19; 95% CI, 3.14–3.23).5 At this level of contact and risk heterogeneity, the model cannot reflect the true virus dynamics. Throughout the period covered by the model predictions, interventions targeted at health care settings were implemented. These interventions, such as closing hospital tea rooms and changing aged care working conditions, cannot be factored into the model predictions because health and aged care workers are not included in the model. By failing to specifically consider the populations that drove the epidemic or the interventions targeted at those populations, any ultimate concurrence between the actual and predicted numbers can only be attributable to chance.

Bradley R Crammond · Vishaal Kishore

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

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

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

To the Editor: Sexual incidents involving patients in hospitals are prevalent and are distressing for patients and staff alike, but they are poorly managed.1 Such incidents are frequently perpetrated by people with acute mental illness (eg, mania, psychosis), substance misuse, personality vulnerabilities, and cognitive impairment (eg, delirium, dementia). Sexual incidents span the age range, although lack of staff's understanding of sexuality and sexual behaviour in older adults2 mandates practice improvement. Sexual safety is defined in health care settings as “recognition, maintenance and mutual respect of the physical [including sexual], psychological, emotional and spiritual boundaries between people”.3 Sexual incidents include sexual offences (criminal offences such as sexual assault) and inappropriate sexual behaviour, ranging from suggestive language to removing clothing, exposure, and public masturbation. State public mental health services have sexual safety policies and guidelines, but no such policies exist for general hospitals. The scholarly literature is similarly limited. Our experience of sexual safety in health care can be described as “a neglected area, there is no training, no one is talking about it and there seems little interest until something happens,” particularly involving older people.1 A hypothetical case based on clinical experience (Box) demonstrates the trivialisation and minimisation of sexual incidents in health care and the associated risks and ramifications. This phenomenon is aligned with the “dirty old man” stereotype, a reflection of ageist societal attitudes towards sex in older people as inappropriate, shameful or funny.4 Consequences of these attitudes for clinical management include poor documentation and communication, inconsistent responses to patient behaviour, and multiple victims, particularly staff. Sexual harassment is both under‐reported by staff5 and dealt with superficially, despite having significant effects on physical and psychological health and burnout.6 These issues are compounded in aged care, where staff ignore or minimise the impact of sexual behaviour, which is often excused by cognitive impairment4 or dismissed as harmless due to frailty or advanced age.5 Aged care staff may feel shame, guilt, confusion and even responsibility for causing the behaviour.5 Conversely, a tension exists between a cognitively impaired person’s right to sexual expression and the health care worker’s right to a safe workplace. Education of health care staff and development of guidelines with response pathways are needed to ensure sexual behaviour is understood and dealt with consistently and respectfully.4 In this situation, ageism trivialises risk and harm, which may have an adverse impact on a safe health care environment. Box – Hypothetical case based on clinical experience describing the trivialisation and minimisation of sexual incidents in health care and the associated risks and ramifications Warren is a 73‐year‐old single man treated in a geriatric ward in a general hospital for delirium. He has a history of cognitive impairment due to long term alcohol misuse and has a guardian for medical decision making. The delirium is slow to resolve and after a few weeks he starts propositioning nursing staff for sex and making sexual comments. Warren often has an erection when nurses assist with personal care and he masturbates on his bed, visible to patients, visitors and staff. He is moved to a single room and a minimum of two staff are present for any clinical interaction. Three female staff members are grabbed on their breasts while providing Warren with care. This is inconsistently documented in his medical record. His sexual behaviour is discussed with some derision in staff handovers. There is no disclosure of his behaviour to non‐ward staff involved in his care (eg, consulting teams), among whom further assaults occur. A security guard is stationed at his door to keep him in his room. He is commenced on a specific serotonin reuptake inhibitor with the aim of reducing libido. Warren continues to be sexually disinhibited in behaviour and comments, a barrier to securing a nursing home placement. General principles: Management must include behaviour assessment and addressing underlying issues (eg, delirium, unmet sexual needs) with practical environmental and governance measures such as formal handover of behaviour between shifts and for consulting teams and clinicians, clear and easily accessible management plans, and support for staff, visitors and other patients. Consider the use of sexual harassment measurement tools for reporting and awareness raising.

Anne PF Wand · Carmelle Peisah

To the Editor: Hoffman and colleagues’1 excellent review highlights the tightrope women walk when pursuing both a career and children. It is clear that, internationally, inflexible workplace policies as well as more insidious outdated attitudes towards working women cause significant damage to society as a whole. While mothers evidently bear the brunt, such discrimination also negatively affects fathers and we would argue that the real issue is “parenthood and medicine” rather than just “motherhood”. A culture that presents balancing a career and children as being a goal that only women should struggle with is itself part of the underlying problem. In recent generations, the traditional expectation for women to assume the role of primary childcarer has undergone a paradigm shift. It is increasingly commonplace for men to take paternity leave and even to return to part‐time work in order to achieve greater presence in their family life. A growing number of same‐sex couples are also choosing to have a family and face additional, unique challenges. Unfortunately, public policy is lagging far behind; in Australia, partners are entitled to only 2 weeks of paid leave after the birth of a child.2 Better access to spousal leave exists overseas, particularly in Scandinavia; for example, in Sweden, parents can share up to 480 days off work after the birth or adoption of a child, divided as however suits the individuals.3 In the United Kingdom, additional paternity leave of up to 50 weeks is available after the standard 2 weeks.4 A study from 2013 found uptake of the additional leave had been disappointingly low, highlighting poor awareness, practical deterrents, concerns around impact on finances and training, and fear of negative perceptions as key underlying reasons.5 With the majority of doctors in Australia having children at some point in their careers, it is time for further research, education and policy change to support all individuals.

Elizabeth Wootton · Gerard Forrest

To the Editor: We identified a geographic and temporal cluster of four patients with drug poisoning occurring within one week in February 2020 from two addresses less than 1 km apart. All patients presented with typical features of opiate poisoning but had no history of opiate use. There was one death, with the three other cases having significant morbidity, which required escalating bolus doses of naloxone. Rapid sample analysis by the New South Wales Pathology Forensic and Analytical Science Service (FASS) using liquid chromatography quadrupole time‐of‐flight mass spectrometry (LC‐Q‐TOF‐MS) found acetyl fentanyl — a synthetic fentanyl non‐pharmaceutical designer drug — in all cases within 3 days. The identification and subsequent response were coordinated by the Prescription, Recreational and Illicit Substance Evaluation (PRISE) program, a collaboration between the NSW Ministry of Health, the NSW Poisons Information Centre and FASS. The analytical confirmation and public health response, involving data collection, risk assessment with a health expert committee and customised clinical and public health response, occurred within 15 days of notification to PRISE. Two further cases were identified by the NSW Ministry of Health in other hospitals in the 2 months prior and 2 months subsequent to our cases. In October 2020, a further cluster of five cases occurred in regional NSW. Ethics approval was granted by the Sydney Local Health District Research Ethics and Governance Office, HREC 2020/ETH01380. The presence of fentanyl analogues as an adulterant in recreational drugs has become common globally but only one case of poisoning by acetyl fentanyl has been reported in the literature in Australia.1,2 This poses a significant risk to unassuming users, particularly users whose primary recreational use is stimulants, as they are likely to be opioid naïve and have worse clinical outcomes. Cases of toxicity from fentanyl and its analogues are often under‐reported because of issues with detection. Synthetic opioids do not test positive on urine drug screen immunoassays; mass spectrometry is required to confirm the diagnosis.3 Acetyl fentanyl is a non‐pharmaceutical designer analogue of fentanyl first described in 2013 after an outbreak with reported mortality in Rhode Island.4 Pharmacokinetic data for acetyl fentanyl are limited, but the drug is 15 times more potent than heroin and has an ED50 (median effective dose) and LD50 (median lethal dose) ten times narrower than morphine.5 The purpose of PRISE is to detect atypical substances in the community, focusing on presentations that are unexpected, severe and/or clusters, and coordinate an appropriate response. Rapid detection and toxicosurveillance allowed for prompt dissemination of information to clinicians and the public. Information directed to user groups is a particularly important harm minimisation strategy. Rapid detection and early dissemination of information may have limited further outbreaks. Clinicians should be informed that atypical presentations in recreational drug use may be due to substitution or contamination by other substances. Notification of cases to Poisons Information Centres can provide treatment advice and facilitate rapid identification and response by providing an access pathway, such as the NSW Ministry of Health PRISE Program.

Varan Perananthan · Chris Tremonti · Emily Nash · Thanjira Jiranantakan · Andrew H Dawson

To the Editor: There is a new player in the treatment of opioid use disorder: extended‐release depot buprenorphine. This has been hailed “a game changer”1 and has proven to be of great benefit, particularly during the current coronavirus disease 2019 (COVID‐19) pandemic. Depot buprenorphine has an impact on presentations to hospital and health services, meaning that all clinicians must be familiar with the advantages and disadvantages (Box) as well as the formulations. Opioid use disorder is a complex, chronic, relapsing health condition that requires lengthy management and is over‐represented in incarcerated people. Opioid treatment successfully reduces illicit use, overdose deaths, and costs. In Australia, there are opioid treatment programs for incarcerated persons, improving individual and community wellbeing and social functioning following release. However, until recently, the treatment perpetuated a daily drug pattern and risks, such as diversion to others, injecting opioid treatments, overdose risks and violent behaviour.2 What changed the game and model of care in Australia is the development of extended‐release depot buprenorphine. The Australian game has two products: one is available as weekly and monthly injection options and the other as a monthly injection. Depot buprenorphine is a subcutaneous injection and must be administered by a health care professional, as inadvertent injection into other structures forms a depot gel that will not provide slow release of the medication and depot gels in a vein may cause serious, life‐threatening health problems.3 Weekly or monthly doses of depot buprenorphine are provided following stabilisation using sublingual buprenorphine, most often for 7 days, and may be started the day after the last daily sublingual buprenorphine. Dose conversion tables exist to match depot buprenorphine to the sublingual buprenorphine dose. Steady state equilibrium is achieved after three to four doses.3 Hospital and health service clinicians must be aware that all buprenorphine formulations complicate routine opioid analgesia for acute pain management, and consideration of other non‐opioid‐adjuvant analgesics is needed (Box).3 Uptake of depot buprenorphine has been welcomed by patients, the community and correctional programs, with many who have transitioned reporting positive outcomes, including reduction in cravings, anxiety, improved attitude, relationships, and general mood.4 The timing of this game changing depot buprenorphine has enabled remote health care and ongoing availability of opioid therapy in the context of the COVID‐19 pandemic.5 Box – Advantages and disadvantages of depot buprenorphine Advantages of depot buprenorphine: it provides greater convenience and does not require attendance for daily dosing it reduces the treatment cost for clients and service providers it has less risk of diversion and non-medical use of the medication it has greater medication adherence and enhanced treatment outcomes it opens opportunities for normal life and to consider employment, study and travel it removes risks related to takeaway opioid treatment doses it reduces stigma and discrimination and has a positive impact on the way that people with opioid use problems are perceived Disadvantages of depot buprenorphine: ul#arrow { position: relative; list-style: none; } ul#arrow li::before { content: '▶ '; position: relative; left: 0; } it complicates routine opioid analgesia in the management of severe acute pain: it may require the use of higher doses of traditional opioids such as morphine; and it may require the use of a mu opioid receptor super agonist such as fentanyl and/or the use of non-opioid analgesic approaches (eg, ketamine infusions or regional analgesia) it provides reduced patient health care, social interactions and support opportunities it results in a loss of control over how the patient manages their dose (especially takeaways)

Katerina Lagios

To the Editor: Doctors’ wellbeing is an important agenda for reducing doctors’ burnout and its consequences. It is often confused with wellbeing related to personal lives that is not controlled by workplaces. My observation is that systems are implementing symbolic solutions, which undermine the efforts of advocacy for system solutions. I see wellness through my experience during teenage years, growing up in the middle of a war. I suffered emotional trauma; more than that, moral injury that was inflicted by the hypocrisy of the system that violated my human rights. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1 All I wanted was for someone to stop the war; I was not expecting to be sent to a wellness officer or to wellness and resilience training workshops. In the past 22 years as a doctor, I am seeing the emergence of the term “moral injury” in health care settings and is linked to doctors’ wellbeing.1 I feel that moral injury within health care settings occurs when workers’ rights, expectations of doctors, and the organisational values and purpose are met with contradictions at workplaces.1 The literature is clear that doctors’ wellness is related to the culture and environment of the workplace rather than issues with the individuals’ resilience (Box).2 Of course, training to fine‐tune skills to manage emotionally challenging clinical situations and self‐care is important, but resilience training should not be about how to tolerate situations that cause moral injury. It will be difficult for systems to address workload‐related stress driven by doctors’ own choices. While some of the system’s problems can only be solved through organisational alignment of values and purpose, medical leaders of all levels need to take ownership of the doctors’ wellness agenda. They need to advocate for removing situations that cause moral injury and focus on cultural and structural solutions within their work teams and units, fostering a sense of belonging, cohesion and autonomy among colleagues, promoting self‐care and minimising burnout. This may create psychologically safe and joyful work teams. Box – Examples of contradictions that may cause moral injury at workplaces Expectations Contradictions Accreditation standards call for better workload and fatigue management Vacancies are not filled in a timely manner to manage the workload Front‐line staff are keen to help patients and colleagues Not enough personal protective equipment sourced Clinicians are keen to adopt Choosing Wisely and patient‐centred models Efficiency not rewarded by enhancing clinicians’ capabilities or supporting their initiatives Research as core business of organisations Prohibitive and time‐consuming regulatory processes for research Clinical directors are expected to lead change Clinical directors are not given necessary support or time to drive change Organisational values call for consultation and engagement with staff Decisions are made unilaterally by colleagues and leaders Nurses and doctors ask for help when patients with violent behaviours pose a threat to their safety Nurses and doctors get told to sort it out themselves

Sabe Sabesan

To the Editor: The article by Giuseppin,1 Chair of the Australian Medical Association Council of Rural Doctors, published in MJA InSight+, on ending geographic narcissism, overcoming metro‐based policy making, and instituting health self‐determination by rural practitioners and communities echoes the feedback we have received from health practitioners and consumers attending our workshops throughout northern Australia. The HOT NORTH (Improving Health Outcomes in the Tropical North) program (Box), funded by the National Health and Medical Research Council, aims to address inequitable health coverage across northern Australia through more widespread implementation of locally designed research and practice. Epidemiological and health service data indicate a higher disease burden and risk profile in northern Australia compared with the rest of the country, with health disparity increasing with age and remoteness and Indigenous Australians living in the north having worse health outcomes than the non‐Indigenous population.2 At 15 HOT NORTH forums held over the past 3 years, attended by over 1600 participants in locations from South Hedland to Thursday Island, we provided an opportunity for communities and local health staff to take control over the agenda, presentations and input to discussions. Participation increased, discussions became more interactive, and pride in the achievements of local health practitioners and researchers replaced the deficit data and focus of many previous presentations. The wider benefits of a consultative, locally designed and led health research and capacity‐building program are captured in the recent HOT NORTH impact report.3 While several initiatives have addressed regional and remote health care (eg, the Centre for Research Excellence in Rural and Remote Primary Healthcare, the Advanced Health Research and Translation Centre in Alice Springs, and Centres for Innovation in Regional Health in north Queensland and in regional New South Wales), we agree with Giuseppin that fundamental shifts in the rusted‐on core–periphery relationships are required to address the inequity of health coverage across Australia. However, in Australia (and its universities), this requires recognition of the pervasive dogma of “winner‐takes‐all” urbanism of “superstar cities”4 with their “creative class”,5 which arguably militates against an appetite and capacity for sustainably reshaping the service delivery and research landscape in response to the remoteness, cultures, power relations, social ties and other dynamics in rural and remote settings. Box – HOT NORTH capacity building, collaborations and regional engagement activities 2017–2019

Kevin Williams · Sean Rung · Bart J Currie

To the Editor: In the retrospective study by te Marvelde and colleagues,1 the proportions of men in public and private health services receiving radical prostatectomy and curative external beam radiation therapy were examined in a multivariable logistic regression analysis. However, only age, International Society of Urological Pathology (ISUP) tumour grade, and comorbidity were studied. Prostate‐specific antigen (PSA) level and T stage are two of the strongest determinants of choice of treatment modality in clinical practice and have not been considered or discussed by the authors. We consider this to be a major flaw in this study and a failure of the peer‐review process to highlight this deficiency, which has a significant impact on the results and subsequent conclusions reached by the authors. Furthermore, patient comorbidities have not been adequately accounted for. The authors identify comorbidity as a factor influencing treatment, but they fail to assess and account for this variable in a reliable way. Victorian Admitted Episodes Dataset (VAED) data for the year preceding the prostate cancer diagnosis and up to 30 days after diagnosis were assessed to identify comorbid conditions other than cancer according to the Charlson Comorbidity Index, categorised as 0 or at least 1. This variable provided little discriminatory power (3% v 6%), and yet it was the only surrogate variable that accounted for comorbidity in the study’s key multivariable analyses. Additionally, the odds ratios for this variable in these analyses were not reported. It should be noted that 38% of the study population were men older than 70 years, but only 3.8% scored 1 or more on the VAED‐derived Charlson Comorbidity Index. We believe that the method used in this study to account for comorbidity is not adequately robust to provide an accurate picture of the patients’ general health status. The authors also cite the ProTect trial2 to suggest no major differences between active treatment options exist; however, they did not identify the vast differences in the disease characteristics of men in the ProTect trial compared with those included in their study (77% ISUP 1 and 2% ISUP 4/5 v 35% ISUP 1 and 18% ISUP 4/5). Moreover, te Marvelde and colleagues did not address clinical outcomes and have not presented evidence that the variation in treatment modalities between public and private services has had a negative impact on the final clinical outcome. Outcomes data can be helpful in identifying systematic shortcomings, inequities and barriers to just health care, but the authors missed the opportunity to highlight these issues. They concluded that the treatment of people with cancer should be consistent, safe, of high quality and evidence‐based, but did not provide evidence that the current practice is to the contrary.

Stephen Mark · Prem Rashid · Peter Heathcote · Kamran Zargar Shoshtari

To the Editor: Improving our understanding of the place of computed tomography (CT) coronary calcium scoring in the assessment of cardiovascular disease risk is critical. However, we disagree with the conclusions in the article by Venkataraman and colleagues1 that the results of their study support the use of CT coronary calcium scoring in individuals with intermediate risk using the Australian cardiovascular disease risk (ACVDR) calculator. Unfortunately, the study has significant flaws in its outcome measures — CT coronary artery calcium scoring and Multi‐Ethnic Study of Atherosclerosis (MESA) — which result in misleading conclusions. The authors examined the predictive power of the ACVDR to detect individuals having a calcium score greater than zero or greater than 100. However, since CT coronary calcium scoring is not a reference standard for cardiovascular disease, this is an invalid outcome for estimating the comparative accuracy of the various cardiovascular disease risk scores. This study also used the MESA risk score as an outcome measure, although this is a risk calculator that has not been validated in the Australian population. As the MESA score was developed to include CT coronary calcium scoring, any risk calculator that also includes this score is likely to appear to perform better than risk calculators that do not. The authors state that their “findings suggest that Australian patients are undertreated by international standards”. The threshold recommended by the current guidelines for cholesterol‐lowering medication in the United States — used by the authors as the international standard — would more than triple the proportion of the Australian population recommended to take medication.2 Primary prevention of cardiovascular disease involves individuals who have not yet had a cardiovascular event, making it particularly incumbent on medical professionals that recommendations consider benefits and harms. The information gained from CT coronary calcium scoring needs to demonstrate that benefits outweigh risks, such as radiation exposure, costs, and incidental findings. Trials to date have shown no improvements in health outcomes. Overall, patients are more likely to be reclassified in a higher risk category, some correctly, but higher absolute numbers may be incorrectly reclassified as high risk.3 Individuals with a calcium score of zero are still at risk of cardiovascular disease, about 0.5% per year. The notion that images seen on CT coronary calcium scoring demonstrate the presence or absence of disease is appealing, but it is a gross simplification.4 While CT coronary calcium scoring may have a place in risk assessment, the findings from this study do not support its use.

Andrew Hayen · Paul P Glasziou · Jenny A Doust

To the Editor: Modelling commissioned by the federal government estimates that the fertility rate in Australia will drop to an all‐time low of 1.59 babies per woman in 2020–21.1 However, anecdotal observation suggests this projection does not reflect the apparent increase in current bookings for antenatal appointments in our (public) practice. Therefore, we reviewed the use of the five Medicare Benefits Schedule (MBS) item numbers for “microbiological serology during a pregnancy” (ie, 69405, 69408, 69411, 69413 and 69415), as one of these numbers is usually billed at the first antenatal visit. In June 2020, the use of these item numbers increased by 25.4% and later declined to a 9.6% increase in September 2020 compared with September 2019 (Box).2 In the period from 2018 up to the start of the coronavirus disease 2019 (COVID‐19) pandemic, the mean fluctuation in billing volume in the same months over different years was about 3% less or more.2 Therefore, the larger than expected surge in antenatal serology orders since the start of the COVID‐19 pandemic likely represents a significant change in behaviour. Furthermore, this increase in serology testing is on the background of an approximate 3% decline in services for pathology tests not related to COVID‐19 from June to September 2020 compared with the same period in 2019.2 Using MBS item numbers as a surrogate for pregnancy‐related appointment bookings has limitations. In general, women accessing public hospital care may have serology tests done as part of state government funding schemes whereby no MBS item is generated. We cannot exclude the possibility that, in the context of changes related to the COVID‐19 pandemic and a move to telehealth, a higher proportion of women may have had pathology tests done via Medicare. However, it would be expected that if fertility were declining, there would have been a reduction in testing. Furthermore, we were unable to exclude repeat testing, although our experience indicates this would account for an insignificant number of tests. This historical trend, and its context in the timing of an apparent “baby boom” (ie, antenatal serology testing is usually done at around 6–10 weeks’ pregnancy), correlates with an increase in conception starting in late March to early April 2020, during the so‐called first wave of COVID‐19 in Australia. Requests for antenatal serology testing increased by 12 869 from June to September 2020 compared with the same period in 2019 (Box). Factoring in miscarriages, this may mean there will be an additional 11 000 Australian babies born in the third quarter of the financial year 2020–21 compared with the same period in the previous financial year. We believe it is unlikely that fertility rates will drop in 2020–21. Box – Combined Medicare Benefits Schedule (MBS) services for item numbers 69405, 69408, 69411, 69413 and 69415 Month Number of MBS services Variation 2019 2020 June 21 883 27 441 +25.4% July 23 867 26 935 +12.9% August 25 118 27 055 +7.7% September 23 929 26 235 +9.6% Total 94 797 107 666 +13.6%

Len Moaven · James Brown

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has created an unprecedented need for real‐time surveillance data to inform decisions and action by public health responders and primary health care practitioners. Early in the pandemic, many countries swiftly produced interactive national dashboards with mapping capabilities.1,2 A dashboard is an online tool for data management which optimises information access and data visualisation.3 Dashboards provide benefits compared with standard reporting, including sharing near real‐time data during rapidly evolving situations, and providing users with the opportunity to interact with the data. If designed appropriately, users can also interrogate data and ask questions based on their specific informational needs. Many dashboards also provide mapping capabilities, allowing for visualisation of spatial distribution of information, and monitoring trends geographically over time.2 Australia does not yet have an official and publicly accessible national interactive dashboard for COVID‐19. Some states and territories have developed publicly available COVID‐19 dashboards, but data are generally aggregated, making it difficult to answer specific questions that include time and location and source of infection. An interactive near real‐time dashboard could improve access to and comprehension of data for primary health care providers and public health responders. Researchers from the Australian National University, Menzies School of Health Research and the University of Queensland are developing a COVID‐19 Real‐time Information System for Preparedness and Epidemic Response (CRISPER) (https://crisper-graphc.hub.arcgis.com/) as a nationwide information and visualisation system for Australia. CRISPER aims to become the principal source of accurate, reliable and spatially explicit real‐time information for COVID‐19 (Box). The system currently uses publicly available postcode‐level data, primarily from state and territory health department websites. Gaining access to nationwide line‐listed data is underway, which will allow additional functionality, including a clinical dashboard detailing clinical outcomes (eg, hospital and intensive care unit admissions, deaths) stratified by demographics, comorbidities, time and place. Also under development is an automatic alert system providing registered users with daily or weekly email alerts on new cases, contract tracing alerts and/or testing rates based on user‐defined geographical areas of interest. We believe that CRISPER will improve accessibility of information for primary health care practitioners and public health responders and will enable them to make more timely and informed decisions. This system may serve as a prototype platform for rapid information sharing for other epidemic‐prone diseases. Box – Features of the Coronavirus Disease 2019 (COVID‐19) Real‐time Information System for Preparedness and Epidemic Response (CRISPER) CRISPER aims to optimise information access and visualisation for COVID‐19 through: a national summaries dashboard detailing cases, deaths and testing — information can be filtered or summarised by states and territories, time periods, and 7‐ or 14‐day rolling averages (https://graphc.maps.arcgis.com/apps/opsdashboard/index.html#/465d9e0cd44247b488b8431a56691417); and an interactive mapping tool of cases, testing and contact tracing alerts by location (postcode, local government areas, public health units) — information can be filtered by time periods and source of infection (currently available for New South Wales). A key feature distinguishing this tool from other dashboards is that the data in the different components are linked; for example, the epidemic curve is dynamic based on cases in the map window (https://graphc.maps.arcgis.com/apps/opsdashboard/index.html#/74e69c2ab40f41c892a652e95373622c)

Emma Field · Amalie Dyda · Colleen L Lau

To the Editor: We thank the MJA for highlighting the fit testing of N95 or P2 respirators in Australian health care workers. Regli and colleagues1 make a compelling case that mandatory fit testing should be implemented in Australian hospitals for frontline staff, in line with South Australian guidelines.2 We note that NSW Health has recently implemented mandatory fit testing in high risk areas.3 We commend these efforts, but they may have important implications that would need planning and consideration in implementation. First, it is clear that anatomical variation of the nasal and malar regions means that some health care workers will only pass the fit tests with particular N95 or P2 respirators.4 This means that along with the implementation of a fit testing program, inventory management systems are also required to facilitate hospital tracking of stocks of particular respirator types and to ensure that sufficient stock is available in high risk areas for individual health care workers. At the Southern Adelaide Local Health Network, we have implemented such a system, which tracks stock levels of all available respirators within the hospital so that key workers who can use only specific types of N95 or P2 respirators will have access to the right type of mask when needed. Second, the coronavirus disease 2019 (COVID‐19) pandemic has disrupted global supply chains, affecting the availability of N95 and P2 respirators. Moreover, fit testing is not a one‐off process, but must be conducted as a rolling program to ensure that all workers have access to appropriately fitting N95 or P2 respirators. Finally, even with an efficient fit testing program, due to anatomical variations, there will always be a proportion of health care workers for whom no masks will be suitable. Along with fit testing, health departments should prioritise health care worker redeployment policies and the development of new technologies to address the needs of the proportion of the workforce with ongoing fit test failure.

Anand Ganesan · Jane Parker · Darius Chapman

To the Editor: In an article on the Human Rights Act 2019 passed by the Parliament of Queensland, Brolan1 noted the Act was “historic but not without challenge”. This challenge is manifest in the case of prisoners. In 2007, the Queensland Coroner recommended prisoners have access to clean injecting equipment.2 We described in 2009 the threat to prisoners’ health of ongoing breaches in infection control,3 which was later evident in the cluster of coronavirus disease 2019 (COVID‐19) cases in the Wacol Youth Detention Centre in Brisbane. In 2018, The Medical Journal of Australia documented the precarious state of harm minimisation in Australia’s prisons. With reference to Queensland, there was only mention to the elimination of hepatitis C infection from one prison and the fact that opiate replacement therapy was not available to all prisoners.4 Furthermore, despite some initial success to improve hepatitis C infection rates among Queensland prisoners,5 they have gone backwards, with reportedly high rates of post‐treatment reinfection in Queensland prisons. How is it possible that Queensland continues to stand out as a model of health service deprivation? Evidence that opiate replacement therapy can be life‐saving for prisoners is conclusive.6 Human rights are universal. The right to health provision and health protection cannot be, and in fact has not yet been, effectively negotiated for or by the community’s most disempowered individuals. Despite human rights protections since 2004, the Australian Capital Territory’s dismal experience7 challenges not just Queensland but all Australians.

Michael Levy · Daniel Mogg