Letters

To the Editor: This retrospective population‐based study aimed to determine the incidence of type 2 diabetes from 2012 to 2019 in Western Australian youth aged under 16 years, and to examine temporal trends between 2000 and 2019, using data from the Western Australian Children’s Diabetes Database (WACDD).1 The data extracted for eligible patients diagnosed with type 2 diabetes, according to standard criteria,2 included diagnosis year, age, sex and self‐reported Aboriginal or Torres Strait Islander status. Poisson regression was used to determine incidence rates and trends by calendar year, sex, and Aboriginal or Torres Strait Islander status. This study received ethics approval from the Western Australian Child and Adolescent Health Service Human Research Ethics Committee (RGS0000002386). To ensure the validity of our findings, a secondary aim was to estimate completeness of the WACDD for type 2 diabetes diagnosed in patients aged under 16 years from 1999 to 2016. For this purpose, we used the capture–recapture method with two independent sources: the primary source was WACDD, and the secondary source was the National Diabetes Services Scheme (NDSS) database.3 We identified 224 eligible cases from WACDD (2000–2019), of which 129 (58%) were girls and 128 (57%) were Aboriginal or Torres Strait Islander children. The mean age at diagnosis of type 2 diabetes was 13.2 years (standard deviation, 2.0 years), with no differences observed by sex or Aboriginal or Torres Strait Islander status. The overall mean incidence was 2.3/100 000 (95% CI, 2.1–2.7), with an average annual increase of 5.2% (95% CI, 2.8–7.8%). No differences were observed in the mean incidence or incidence rate trends between boys and girls. The mean incidence in Aboriginal or Torres Strait Islander children was 18‐fold higher (incidence rate ratio, 18.31; 95% CI, 14.05–23.86) than in non‐Aboriginal or Torres Strait Islander children (Box). In addition, the incidence increased by an annual average of 6.2% (95% CI, 2.8–9.6%) in Aboriginal or Torres Strait Islander children compared with 3.9% (95% CI, 0.3–7.6%) in non‐Aboriginal or Torres Strait Islander children (Box). Of the 170 eligible cases identified in the WACDD, 107 were ascertained from both WACDD and NDSS, 40 from NDSS only, and 63 from WACDD only. Using the capture–recapture method,3 the WACDD was estimated as 73% complete. This study provides further evidence for the growing incidence of type 2 diabetes in Australian children and highlights the urgent need for community, public health providers, and government to address this disease and its significant burden in young people.4,5 Box – Case numbers, person years of observation, mean incidence (95% CI) and average annual increase in incidence (95% CI) by Aboriginal or Torres Strait Islander status for youth aged under 16 years diagnosed with type 2 diabetes in Western Australia (2000–2019) Non‐Aboriginal or Torres Strait Islander Aboriginal or Torres Strait Islander Combined Cases 96 (43%) 128 (57%) 224 (100%) Sex, female 54 (56%) 75 (59%) 139 (58%) Mean age at diagnosis (SD), years 13.6 (1.8) 13.0 (2.1) 13.2 (1.9) Age range at diagnosis, years 6.9–15.9 6.8–15.9 6.8–15.9 Total person years 8 884 383 644 157 9 528 540 Mean annual incidence (95% CI) per 100 000 person years 1.1 (0.9–1.3) 19.9 (16.6–23.6) 2.3 (2.1–2.7) Average annual increase in incidence (95% CI) 3.9% (0.3–7.6%) 6.2% (2.8–9.6%) 5.2% (2.8–7.8%) CI = confidence interval; SD = standard deviation.

Aveni Haynes · Jacqueline A Curran · Elizabeth A Davis

To the Editor: The Australian Therapeutic Goods Administration (TGA) categorisation system for prescribing medicines in pregnancy lists doxylamine as a Category A medicine — “Drugs which have been taken by a large number ofpregnantwomen … without any proven increase in the frequency of malformations”.1 However, despite this categorisation, many single‐ingredient non‐prescription doxylamine products continue to carry misleading product and consumer information. While correctly assigning Category A, they then contradictorily include warnings such as “do not use during pregnancy” and/or “studies to prove it is safe for the developing baby have not been done”. There is no validity or justification to such statements, which are inconsistent with both available data and the Category A status. Studies on the safety of doxylamine in pregnancy date from the 1980s, when the first meta‐analysis demonstrated that doxylamine was not a human teratogen and should not have been removed from the market by the manufacturer.2 Subsequently, there have been several studies, reinforcing both the safety and efficacy of doxylamine for the treatment of nausea and vomiting in pregnancy (NVP).3 This resulted in the United States Food and Drug Administration (FDA) once again approving doxylamine (with pyridoxine) in 2014 as safe to use in pregnancy, with a specific indication for managing NVP. Furthermore, the Society of Obstetric Medicine of Australia and New Zealand’s practice guidelines recommend doxylamine (and pyridoxine) as first line treatment for NVP.4 MotherSafe — a New South Wales‐based teratogen information service — receives about 20 000 calls annually from health care providers and consumers. Many women call this service after receiving conflicting advice about using doxylamine in pregnancy from pharmacists and other health care professionals, including general practitioners and obstetricians. Moreover, pharmacists also identify a knowledge gap and concerns about off‐label use and discrepancies between the product information, categorisation and other available information sources.5 In some cases, pharmacists have refused to sell doxylamine to women with NVP because of the product information, considering the use of doxylamine for NVP to be off‐label and thus not indicated or safe. Despite raising our concerns with the TGA about the confusing labelling, we are yet to see any progress in correcting this significant misinformation among health professionals and patients. This specific issue highlights wider concerns around Australia’s confusing pregnancy risk classification and the imperative for the TGA to abandon the current alphabetical categorisation and move to a format similar to the one used by the FDA Pregnancy and Lactation Labeling Rule, which requires all packaging and consumer information to include consistent evidence‐based information on medication use in pregnancy and breastfeeding.6

Debra S Kennedy · Ronald P Batagol

To the Editor: Fetene and colleagues1 describe refusal to prescribe or dispense prescriptions to some of their study cohort of people who inject drugs (PWIDs) and concern that their mental health treatment needs may not be met due to SafeScript, Victoria’s real time prescription monitoring system. SafeScript is a live electronic database providing information about the prescribing and dispensing of monitored medicines to each patient, instantly available in real time on a prescriber’s or pharmacist’s desktop (https://www2.health.vic.gov.au/safescript). SafeScript alerts prescribers and pharmacists to the risk of uncoordinated treatment by multiple providers or to the overdose risk of drug–drug interactions. Prescribers and pharmacists may have responded appropriately by offering more effective treatments instead of providing a continued supply of the medication. For instance, benzodiazepines are not recommended for first line or prolonged treatment of anxiety. Many people who misuse drugs have comorbid mental health disorders and need medical support. SafeScript is helping to identify this group of at‐risk patients so they can receive the appropriate medical treatment they require. SafeScript provides a clinical decision support system for prescribers and pharmacists, enabling more informed decisions for safer prescribing or dispensing of high risk monitored medicines. By providing proactive alerts, strong real time prescription monitoring systems, such as SafeScript, reduce overdose deaths from prescription opioids2 and decrease the number of opioid prescriptions, diversion, and opioid‐related morbidity and substance use disorder outcomes.3 Since the rollout of SafeScript, the number of multiple provider episodes and the average morphine equivalent dose have both been trending gradually but consistently downwards. SafeScript was designed with the lessons learnt from the United States. The implementation of this system included several measures to encourage and support a professional response for high risk patients, such as podcasts and face to face and online training, in which more than 4500 prescribers and pharmacists have participated. Furthermore, the SafeScript implementation included upgrading the Drug and Alcohol Clinical Advisory Service, providing trained general practitioner clinical advisors to offer peer support, a consumer pharmaceutical helpline, and increased funding to support professionals and consumers manage benzodiazepine problems. In addition, $273.1 million were invested in drug treatment, support and harm reduction services in 2019–2020,4 representing a 65% increase in investment through the last five Victorian state budgets. This new initiative helps prescribers and pharmacists provide the appropriate clinical care and professional response needed by high risk patients.

Malcolm Dobbin

To the Editor: Influenza vaccination of residents and staff in aged care homes is recommended by national guidelines1 and has been demonstrated to decrease transmission and burden of infection.2 During the current coronavirus disease 2019 pandemic, influenza vaccination of both groups potentially also reduces the risk of mortality associated with influenza virus and severe acute respiratory syndrome coronavirus 2 co‐infection. We sought to evaluate uptake of influenza vaccination by residents and staff in public sector residential aged care services in Victoria, where non‐mandatory vaccination programs are currently used. There are 178 public sector residential aged care services in Victoria, with the majority located in rural communities. In 2018 and 2019, infection prevention staff in public sector residential aged care services were requested to complete a point prevalence survey of all residents on a set date and a period prevalence survey of all staff employed during the influenza season, in order to estimate vaccine uptake. A standardised data collection tool was used, with online submission of summary data via a secure portal hosted by the Victorian Healthcare Associated Infections Surveillance System Coordinating Centre. Consistent with quality assurance activities defined according to National Health and Medical Research Council recommendations, non‐identifiable aggregate data were collated by participating public sector residential aged care services to support quality improvement initiatives. Ethics approval was therefore not required.3 Of surveyed residents, 87% were vaccinated in both 2018 and 2019. Small proportions of residents declined vaccination or had unknown status. In 2018, 87% of surveyed staff were vaccinated, with 8% and 6% reported as declining vaccination or having unknown status, respectively. In 2019, 88% of surveyed staff were vaccinated, with 9% and 4% declining vaccination or having unknown status, respectively (Box). Public sector residential aged care services provide services for older people with complex care needs, representing a population at high risk for poorer clinical outcomes in the setting of influenza infection. Reassuringly, we observed high uptake of vaccination among surveyed residents, comparable to recently reported uptake in New South Wales aged care homes.4 Review of successful vaccination strategies would be beneficial to improve and sustain future programs in individual aged care homes. Our findings also reflect high uptake of vaccination by aged care staff. Looking ahead, mandatory vaccination of staff employed in Victorian hospitals and public sector residential aged care services is planned,5 and this will likely result in additional uptake.6 While we observed low proportions of staff to have unknown status or to decline vaccination, implementation of the new policy will require an ethical and legal focus on these groups, including reasons for acceptable declination and required workforce planning (eg, redeployment). Box – Influenza vaccination uptake by residents and staff in Victorian public sector residential aged care services, 2018–2019 Target population Year No. of facilities surveyed No. of residents or staff surveyed Vaccinated Declined Unknown Residents 2018 177 5162 4482 (87%) 357 (7%) 323 (6%) 2019 178 5082 4427 (87%) 302 (6%) 353 (7%) Staff 2018 177 12536 10894 (87%) 948 (8%) 694 (6%) 2019 175 13844 12181 (88%) 1179 (9%) 484 (4%)

Noleen J Bennett · Alex Hoskins · Leon J Worth

To the Editor: As the coronavirus disease 2019 (COVID‐19) pandemic spread across Europe, we worked in the intensive care unit (ICU) of a Swedish university hospital. We share our experiences and offer some thoughts regarding Sweden’s pandemic response. The decentralised Swedish health system works on three levels (Box). These traditional divisions may partially account for the lack of coordination between care services in the initial phases of the pandemic, where large numbers of deaths occurred in care homes. As the pandemic intensified, safety checks were implemented to protect residents of aged care facilities. This resulted in a quick containment of infections, although tragically too late for many. Our health care region received the fourth highest number of hospitalisations in Sweden.1 We were privileged to work in a system that was well organised, without political conflict and with pre‐existing disaster plans that were quickly converted to pandemic plans. A pandemic‐specific leadership established a centralised inventory and oversaw the acquisition and distribution of beds, staffing, medical equipment, essential drugs, personal protective equipment and disinfection agents. An eight‐step plan ensured a rapid escalation of regional ICU capacity. Intermediate care units were opened, reducing demand for ICU beds. Projected numbers of patients were calculated daily, based on models provided from the Public Health Agency of Sweden and local data. Anaesthesia and intensive care are a combined speciality in Sweden. This enabled the rapid deployment of a large workforce of anaesthetists and nurse anaesthetists to ICUs. Despite these resources, our tripled ICU capacity meant significant staffing challenges, with additional difficulties because of staff illnesses and quarantines. Our impression is that the Swedish response has been controlled and planned for the long term. Daily public announcements from the Public Health Agency became a regular part of our lives and Swedes were generally compliant with recommendations regarding physical distancing and hygiene routines. We are perplexed by reports in the media that life went on as usual in Sweden. In fact, life was very different. Most people worked from home, large numbers were furloughed, many institutions were closed and public events were cancelled. Travel was discouraged and fell dramatically.2 What sets the Swedish approach apart from others is that these measures were largely voluntary, with generally good public support. We avoided an overwhelming wave of patients with an undercapacity of ICU beds, as seen in many other countries. We maintained normal criteria for ICU admissions. This is notable given that Sweden has the second lowest number of ICU beds per capita in Europe.3,4 Results from intensive care are encouraging, with mortality rates generally lower than previously reported.5 Challenges included staff burnout, a shortage of usual sedatives and lack of clinical experience with this new disease, resulting in the use of futile and potentially harmful treatments. However, guidance from a national group of senior clinicians provided regular recommendations6 and there was excellent compliance with advice from regulatory authorities. Up to 70% of elective surgeries were cancelled during the first half of 2020. Cancer‐related surgeries continued to be prioritised during the pandemic, but the longer term effects of cancelled surgeries, outpatient clinics and altered illness behaviour are not known. We are heartbroken at our inability to provide enough comfort to relatives of our patients who succumbed to COVID‐19 when hospital visits were prohibited. As two Australian emigrants working in a Swedish ICU, we are humbled by our ability to contribute to the care of patients during the pandemic. Our Australian medical training instilled in us a sense of duty, tempering any feelings of helplessness. We applaud the tenacity of our Swedish colleagues. We wish our Australian colleagues well and hope that Australia will be protected from the horrors of COVID‐19. Box – Decentralised organisation of the Swedish health care system

Michelle S Chew · Thomas Halliday

To the Editor: Palliative radiotherapy is effective for symptomatic management of bone metastases in cancer patients. However, it may take 2–4 weeks after completion of radiotherapy to achieve maximal clinical response.1 Radiotherapy can be delivered as a single fraction treatment (SFRT), or over a more protracted course of multifraction treatment (MFRT).2 Randomised trials have consistently shown that SFRT and MFRT provide equally effective symptom control,3 and SFRT is associated with lower medical and societal cost,4 allowing for better health services utilisation. Hence, in patients with poor prognosis, the use of SFRT over MFRT should be encouraged to minimise the time patients spend on treatment at the end of life without compromising efficacy. Using the population‐based Victorian Cancer Registry data linked to the Victorian Radiotherapy Minimum Data Set, we evaluated the use of SFRT for bone metastases at the end of life. The study sample included all cancer patients who received radiotherapy for bone metastases between 2013 and 2016, and died within 30 days of commencing radiotherapy. The primary outcome was SFRT use and the associated factors. The Cochrane–Armitage test for trend was used to evaluate temporal changes in SFRT use over time. Logistic regression was used to evaluate factors associated with SFRT use; variables with a P value below 0.1 in univariate analyses were included in multivariate model, which employed the robust standard error, with analyses clustered on patient identifiers to allow for clustering of patients who had multiple courses of radiotherapy. The study was approved by the Austin Health Human Research Ethics Committee (LNR/18/Austin/34). A total of 1069 patients received 1359 courses of radiotherapy for bone metastases at the end of life, of which 396 courses (29%) were SFRT, and 963 (71%) were MFRT (Box). There was no significant change in SFRT use over time: from 30% in 2013 to 32% in 2016. SFRT was more commonly used closer to death: 49%, 29% and 25% of radiotherapy courses delivered within 7 days, 8–14 days, and 15–30 days of death, respectively. There were large institutional provider variations in SFRT use: 33% and 19% of radiotherapy delivered in public and private institutions, respectively. In multivariate analyses, the site of bone metastases, time between radiotherapy and death, and treatment institution type were independently associated with SFRT use. Overall, in this large Victorian population‐based study, less than one in three courses of radiotherapy for bone metastases at the end of life were SFRT, and about one in two courses of radiotherapy delivered in the last week of life were MFRT, meaning that these cancer patients spent multiple days in their final week of life receiving radiotherapy. Acknowledging that estimation of prognosis towards the end of life can be difficult, there are models (eg, the TEACHH model)5 that can be useful in guiding clinicians in this process. Nonetheless, given the large body of evidence supporting the use of SFRT for bone metastases, there is a need to raise awareness of the recommendation to use of SFRT instead of MFRT, especially at the end of life, among radiation oncologists, other health professionals and patients. This can be achieved through health education initiatives such as the Choosing Wisely campaign (https://www.choosingwisely.org.au/). Box – Factors associated with single fraction palliative radiotherapy (SFRT) for bone metastases at the end of life in Victoria, 2013–2016 (1359 courses of radiotherapy) Variable SFRT (n = 396, 29%) MFRT (n = 963, 71%) Multivariate analysis (odds ratio [95%CI]) P Age (years) Mean (SD) 71.7 (11.9) 70.1 (12.3) < 60 62 (24%) 192 (76%) 1 60–69 95 (27%) 252 (73%) 1.04 (0.67–1.61) 0.9 70–79 149 (32%) 312 (68%) 1.29 (0.83–1.99) 0.3 ≥ 80 90 (30%) 207 (70%) 1.17 (0.73–1.88) 0.5 Sex Men 247 (28%) 622 (72%) Women 149 (30%) 341 (70%) Primary cancer type Lung 163 (30%) 373 (70%) Prostate 49 (29%) 118 (71%) Breast 32 (29%) 77 (71%) Gastrointestinal 53 (28%) 138 (72%) Melanoma 21 (25%) 62 (75%) Other 78 (29%) 195 (71%) Target site of radiotherapy Spine 202 (27%) 545 (73%) 1 Skull 9 (6%) 147 (94%) 0.15 (0.06–0.38) <0.001 Rib 35 (51%) 33 (49%) 3.82 (2.10–6.95) <0.001 Shoulder 35 (49%) 36 (51%) 2.80 (1.44–5.42) 0.002 Hip 19 (36%) 34 (64%) 1.67 (0.78–3.54) 0.2 Pelvic bone 20 (27%) 54 (73%) 1.10 (0.57–2.14) 0.8 Extremities 42 (52%) 39 (48%) 3.04 (1.74–5.29) <0.001 Multiple site 34 (31%) 75 (69%) 1.25 (0.73–2.14) 0.4 Time between radiotherapy start date and death 1–7 days 92 (49%) 97 (51%) 1 8–14 days 99 (29%) 246 (71%) 0.40 (0.25–0.65) < 0.001 15–30 days 205 (25%) 620 (75%) 0.33 (0.21–0.51) < 0.001 Socio‐economic status 1st quintile (most disadvantaged) 103 (35%) 194 (65%) 1 2nd quintile 63 (32%) 137 (69%) 0.88 (0.55–1.40) 0.6 3rd quintile 70 (26%) 203 (74%) 0.73 (0.46–1.17) 0.2 4th quintile 55 (22%) 194 (78%) 0.63 (0.39–1.02) 0.06 5th quintile (least disadvantaged) 105 (31%) 235 (69%) 1.00 (0.62–1.61) 0.9 Remoteness of area of residency Major city 262 (28%) 668 (72%) Inner regional 109 (31%) 241 (69%) Outer regional/ remote 25 (32%) 54 (68%) Treatment institution type Public 317 (33%) 633 (67%) 1 Private 79 (19%) 330 (81%) 0.44 (0.29–0.65) < 0.001 Treatment institution location Metropolitan 280 (27%) 746 (73%) 1 Regional 116 (35%) 217 (65%) 1.02 (0.71‐1.47) 0.9 Year of radiotherapy 2013 115 (30%) 262 (70%) 2014 93 (28%) 243 (72%) 2015 84 (26%) 241 (74%) 2016 104 (32%) 217 (68%) MFRT = multifraction radiotherapy.

Wee Loon Ong · Farshad Foroudi · Roger L Milne · Jeremy L Millar

To the Editor: The recent article by Hyde1 synthesised the evidence on the role of children (and schools) in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Hyde concluded that the original perceptions that children do not play a role in transmission are unfounded. Current evidence shows that schools carry a risk of transmission that is dependent on the level of community transmission. Hyde emphasised the urgent need for risk‐reduction measures and advanced the Harvard guidelines for schools.2 We agree with Hyde and suggest that health and education authorities urgently implement risk‐reduction measures in schools. The Harvard guidelines put forth are comprehensive,2 but they need to be taken a step further to include an engaging health education campaign to allay fears and misconceptions and ensure behaviour change. Such messaging around coronavirus disease 2019 (COVID‐19) specifically targeting children has been similarly overlooked to date, and while some children’s books are coming out,3 there are limited age‐specific and engaging health education materials currently available and being systematically implemented in schools. An entertainment education approach can provide a highly effective forum for health education interventions targeting schoolchildren, and we consider this tactic should be applied to COVID‐19.4 An example is the cartoon video The Magic Glasses, which has proved successful in preventing intestinal worm infections in children.5 The cartoon enables children to identify with characters and visualise the intestinal parasitic worms and their eggs in people and the environment to reinforce the importance of good hygiene and associated health behaviour.4,5 This is directly applicable to the transmission dynamics of SARS‐CoV‐2 — whereby the virus would be visualised in people and the environment (Box) — and the associated messages for prevention. Key messages of such an intervention (The Magic Glasses: COVID‐19) could include hand washing, care in coughing and sneezing, tissue use and disposal, physical distancing, mask wearing, and what to do when feeling unwell. Health education and promotion are important components of disease prevention, but during disease outbreaks and health emergencies, they play an even more crucial role in an active response by providing a well established method to communicate and engage quickly and effectively with the public and prevent infections. This concept is especially important in the absence of an effective drug, and while it is highly encouraging that several safe and efficacious vaccines against SARS‐CoV‐2 have been developed and are being administered in a number of countries, a few caveats need to be considered: i) they have not been tested in children; ii) their impact on transmission is yet to be realised; and iii) there will be some time before they are rolled out globally.6 Messaging specifically targeting children, who may well be acting as silent transmitters of the virus, is presently lacking. A video or cartoon‐based entertainment education intervention would fill this need and suitably complement the other preventive measures advocated by Hyde.1 With the current debate around school closure and opening, having these preventive interventions in place would help mitigate the COVID‐19 risk and provide greater confidence to authorities and parents alike for re‐opening schools. Box – Cartoon concept — The Magic Glasses: COVID‐19

Darren J Gray · Gail M Williams · Donald P McManus

To the Editor: Elasticated straps — also known as “octopus” straps or bungee cords — are used to secure loads of various shapes and sizes. Unexpected release of the potential energy stored in these straps can cause catastrophic injuries. The Royal Victorian Eye and Ear Hospital (RVEEH) is the largest eye hospital in Australia and is well positioned to assess and treat a variety of ocular injuries. We explored trends in presentations to the RVEEH emergency department (ED) for such injuries between 2007 and 2018, using the ED triage database and information relating to total numbers of ocular trauma presentations. This study was approved by the RVEEH Ethics Committee (09/886H). Between 2007 and 2018, there were 169 presentations involving an elasticated strap‐related eye injury (145 male and 24 female; mean age, 43.4 years). While most patients had multiple injuries, the most common primary diagnosis was traumatic hyphaema, followed by corneal abrasion and open globe (full‐thickness wounds) injuries (Box). There were 23 admissions, of which 21 required surgical intervention, with vitrectomy, orbital wound exploration and closure, and lensectomy being the most common procedures. The final visual acuity measurements of the 17 patients who were admitted and able to be followed up were 6/36 or better for nine patients and 6/60 or worse for eight patients. While males presented more frequently than females, the absolute number of yearly presentations by gender was stable. Elasticated strap‐related injuries accounted for 0.23% of the total 72 663 ocular trauma presentations in the period. While it is problematic to compare incidence with previous studies, due to factors such as growth of the RVEEH ED, growth of other hospitals around Melbourne, and population growth, elasticated strap‐related eye injuries remain a significant contributor to presentations at the RVEEH. These straps were a known danger in the early to mid‐1990s1 and they remain dangerous more than 20 years later, causing severe ocular damage and requiring operative intervention in 12.4% of patients. Although the total number of elasticated strap‐related eye presentations does not appear to be dramatically rising, the continued presence of severe eye injuries necessitating admission for surgical intervention is cause for concern. Multiple steps can be taken to address the continued challenge of elasticated strap‐related injuries. Thorough assessment of the patient remains crucial to facilitate prompt treatment of vision‐threatening diagnoses. In addition, preventive measures should be undertaken to lessen the likelihood of visual loss caused by these devices. This includes patient education and encouraging the use of alternative devices that are functionally similar but pose no risks to eyesight, such as non‐elasticated straps that can be gradually tightened, braided metal locking straps, or even self‐contained soft roof rack and strap combinations. Regulators should also consider whether the convenience of elasticated straps justifies the danger they continue to pose to eyesight almost half a century after they were first introduced to Australia and the first eye‐related injury was reported.2 Box – Primary diagnoses of elasticated strap‐related eye injury sequelae table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Primary diagnosis* Total cases Traumatic hyphaema 63 (3.3%) Corneal abrasion 42 (24.9%) Open globe injury 11 6.5%) Conjunctival/lid/canalicular laceration 7 (4.1%) Commotio retinae 8 (4.7%) Traumatic iritis/mydriasis/uveitis 7 (4.1%) Periorbital haematoma 3 (1.8%) Corneal foreign body 2 (1.2%) Subconjunctival haemorrhage 2 (1.2%) Traumatic glaucoma 2 (1.2%) Conjunctival abrasion 1 (0.6%) Vitreous haemorrhage 1 (0.6%) Posterior vitreous detachment 1 (0.6%) Retinal detachment 1 (0.6%) Lens dislocation 1 (0.6%) Other injury 5 (3.0%) No abnormality detected 7 (4.1%) Patient did not wait to be seen 5 (3.0%) Total 169

Philip Rothschild · Peter Meagher · Thomas G Campbell

To the Editor: We congratulate Hill and colleagues1 for their timely research on the performance of symptom assessment smartphone applications (apps) in Australia. The apps in the study were selected using structured criteria2 to identify those featuring most prominently in internet search engines and app stores. However, we note that this strategy is biased against an important class of symptom checkers. Because the app store search included “medical diagnosis” and “health symptom diagnosis”, the authors’ approach was less likely to identify many symptom checkers regulated in Europe under the CE (Conformité Européene) Marking system. Specifically, these apps must not describe themselves as “diagnostic tools”, as diagnosis is a function carried out by a doctor. We believe this to be the reason why the CE‐marked Ada health assessment app was not identified or selected by the authors.1 This represents a missed opportunity for analysis, as Ada has been freely available in Australia since 2016,3 and was downloaded at least 200 times more frequently in Australia between November 2018 and January 2019 than either Symptomate or Symcat, which were included in the study (App Annie [www.appannie.com] download data; viewed June 2020). Other studies have found that the Ada app performs well when compared with the other apps assessed, as recently published.4

Stephen Gilbert · Paul Wicks · Claire Novorol

To the Editor: In 1996, two articles showed that bowel cancer screening in subjects aged 45–741 and 45–752 years, recruited in the early 1980s, led to a significant reduction in mortality; since then, the age range in Australia’s screening program remains at 50–74 years. Between 1981 and 2015–2017, the mean life expectancy at birth for men and women in Australia rose by 9.3 and 6.3 years respectively.3 In 2016–2018, the mean life expectancy at 75 years was 12.3 and 14.3 years for men and women respectively, and even at 80 years, the mean life expectancy was 9.1 and 10.6 years respectively,3 suggesting a reduction in morbidity in the 75–79 years cohort over the 1981–2017 period. In 2015, the estimated bowel cancer incidence and mortality rates for Australians in the 75–79 years range were 28% and 82% higher than in the 70–74 years range.4 In the United States, in adults aged 65 years and older, the prevalence of screening was higher than 80% in nine states.5 In Australia, mean participation in the National Bowel Cancer Screening Program (NBCSP) increased with age cohort6 (Box). Although there is an increased risk of complications from colonoscopy with increasing age, a prospective observational study compared the risks in the 75–79 with the 70–74 years range and found no increase in perforation rates.7 A US study found that colorectal cancer screening was cost‐effective at ages 79 and 80 years even in persons with severe comorbid conditions.8 A recent Australian microsimulation study9 suggested that the cost‐effectiveness of screening the 50–79 and 50–74 year groups would be almost identical, although the advantage of a likely high participation in the 75–79 age range was not addressed. It found that the number of immunochemical faecal occult blood tests and colonoscopies would increase by 10–16% and 21–30% respectively if the screening cessation age were extended to 79 years, both of which should be welcomed. Facilities in Australia can cope with such an increase in colonoscopies. In view of the above, the NBCSP age range should be extended to 79 years. At a minimum, a pilot study of such an extension should be undertaken. Box – Australian National Bowel Cancer Screening Program participation Age (years) Participation rates (%) 2014–2015 2015–2016 2016–2017 2017–2018 Mean 50–54 28.5 28.1 29.8 31.9 29.6 55–59 36.8 35.5 35.5 37.3 36.3 60–64 43.2 42.7 43.1 43.7 43.2 65–69 43.5 44.2 47.5 49.6 46.2 70–74 52.5 52.5 52.6 53.1 52.7

Donald J Frommer

To the Editor: Restrictions and concerns associated with coronavirus disease 2019 (COVID‐19) have led to decreased routine immunisation coverage in many countries, including the United Kingdom1 and the United States.2 Australian data showing the COVID‐19 pandemic’s impact on vaccination coverage are not yet available, but it has disrupted services provided by the National Immunisation Program, which funds vaccination for children, adolescents, adults and special risk groups. In the face of ongoing COVID‐19 risk and restrictions, maintaining a resilient routine vaccination program is crucial. The COVID‐19 pandemic has heightened barriers to vaccination. Lockdown restrictions have affected immunisation service accessibility. Specifically, some clinics reduced face‐to‐face appointments in favour of telehealth3 or closed due to insufficient space and increased staffing and other requirements.4 Patients may have rescheduled appointments to avoid COVID‐19 exposure in waiting rooms, while school‐based programs have been disrupted by closures. Reduced consultations limit not only opportunities to vaccinate but also opportunities for health care providers to address vaccine questions and concerns and reinforce trust. Employment changes related to COVID‐19 may also exacerbate cost barriers for people at risk of under‐immunisation, such as migrants, international students, asylum seekers and refugees.5 To improve access, some jurisdictions have successfully established drive‐through vaccine clinics, and pharmacists in some states have been granted expanded permission to vaccinate children against influenza. However, some families may have delayed vaccines due to the COVID‐19 pandemic, and governments may need to consider additional resources for catch‐up vaccination and extensions or grace periods for “No jab, no pay” and “No jab, no play” policies. School‐based vaccination programs should be re‐established as a priority when schools reopen. Publicly available vaccination coverage data will not reflect COVID‐19‐related impacts until as late as December 2020. We recommend early release of more timely data to ensure service providers gain feedback on program performance. We also recommend awareness campaigns promoting timely National Immunisation Program vaccination or catch‐up. Information should be culturally and linguistically appropriate and should be developed through consultation and engagement with diverse communities, including Aboriginal and Torres Strait Islander communities. Australia’s immunisation providers are dedicated and adaptable, but we must now respond quickly to the challenges of COVID‐19 and remain vigilant to maintain routine vaccination coverage across the lifespan.

the Collaboration on Social Science, Immunisation (COSSI) Working Group

To the Editor: We would like to highlight some points arising from the discussion by Hamblin and colleagues regarding euglycaemic diabetic ketoacidosis associated with sodium–glucose cotransporter type 2 (SGLT2) inhibitors.1 First, clinicians should be aware that this condition occurs not only in the perioperative context but also in systemically unwell patients with medical problems. Apart from the periprocedural insult, four categories of precipitating factors are recognised: intercurrent illness; dietary modifications (eg, prolonged fasting, very low calorie diet); medication changes (especially reducing or stopping insulin); and health system factors (eg, use in misdiagnosed type 2 rather than type 1 diabetes, and lack of patient education on the handling of SGLT2 inhibitors perioperatively).2,3,4 Second, diabetic ketoacidosis is more frequently reported with major surgery; for example, cardiothoracic, bariatric and abdominal surgery (postoperative ileus contributing). Third, clinicians should be aware that the current recommendations5 are based on low quality evidence and are potentially subjective. For example, the use of glycated haemoglobin levels < 75 mmol/mol (9%) as one factor to stratify lower patient risk, while intuitive, is not an unequivocal finding in the literature.4 We are in agreement that one should not overreact to capillary ketone levels in the perioperative period; these should be interpreted in conjunction with other acidosis markers (pH, bicarbonate and base excess). We differ regarding the authors’ statement that blood ketone testing is warranted only in unwell or symptomatic patients. In our clinical experience, we have encountered asymptomatic presentations with ketone levels > 2.0 mmol/L and acidosis before colonoscopy, despite the cessation of SGLT2 inhibitors on the day of the scheduled colonoscopy, necessitating deferral and inpatient treatment.6 Bowel preparation, diet modification and changes in diabetes medications are possible contributory factors for a minor procedure such as colonoscopy. Further, not all patients attend a pre‐assessment clinic and on the day of their procedure may be unable to recollect their diabetic medications. For these reasons, as recommended by the Australian Diabetes Society, it is prudent to check capillary ketones (using a single glucose strip) on admission for all patients with type 2 diabetes regardless of symptoms in the periprocedural period.5 Finally, in patients who have not held their SGLT2 inhibitors sufficiently or who have ketosis, the decision to proceed should depend on a nuanced appraisal integrating the complexity of the procedure, precipitating factors, and degree of acidosis.

Emily J Meyer · Venkatesan Thiruvenkatarajan · David Jesudason

To the Editor: Pandemic responses across the world have been highly reactive. However, there remain only three strategic options to managing coronavirus disease 2019 (COVID‐19): mitigation, suppression and elimination (Box).2 With the promise of efficacious new vaccines, mitigation is appropriately not considered as part of Australia’s national strategy. However, our stated goal of achieving “no community transmission” remains poorly defined and risks missing important distinctions between elimination and suppression.3 Effective elimination is dependent both on getting to zero local cases and then staying there, with any new transmission chains immediately halted. All jurisdictions of Australia have now achieved elimination over significant periods, even without articulating this as their strategy. By comparison to suppression, greater relaxation of restrictions may well be allowable under an elimination approach if vigilance is maintained, as New Zealand has demonstrated.4 Although the challenges of ensuring quarantine of returning travellers are well recognised, this is an essential aspect of maintaining elimination and increases in importance as distancing restrictions are eased. Australia’s current strategy appears to imply suppression, with some virus circulating but with case numbers at manageable levels. Whether suppression has been achieved can be monitored by maintaining an effective reproduction number of no greater than one, or equivalently by ensuring the epidemic curve of new community cases is not upsloping. Importantly, the reproduction number and the rate of new cases at any point in time are unrelated — we could have effective suppression and a reproduction number of one with daily case rates of five, ten or 50. Our definition of no community transmission appears to imply complete identification of transmission chains with no “mystery cases”, regardless of the number of new cases. These considerations are important in determining whether we have full visibility of the epidemic and effective contact tracing but do not determine the reproduction number. The rapid spread of the virus necessitates a public health strategy that is clear, robust and agile. Improved control combined with the increasingly clear seasonality of the virus5 suggest that control can be maintained throughout the summer. However, if vaccination has not been widely distributed before winter 2021 and we do not make clear choices, further major outbreaks remain likely. Box – Characteristics of coronavirus disease 2019 (COVID‐19) epidemic response strategies (Trauer et al) Elimination Suppression Mitigation Our definition No cases or transmission, except in quarantined arrivals Very low community case rates; limited transmission Higher case rates, but within health service capacity Key metric of success No locally acquired cases Effective reproduction number not exceeding one,* or a horizontal sloping epidemic curve of locally acquired cases Hospital and ICU occupancy within (expanded) capacity Accrual of significant population‐level immunity No No1 Yes, likely to take many months, with considerable morbidity and mortality Need for mobility restrictions and hygiene measures Mobility may return to near normal while cases and transmission remain at zero; vigilance essential; likely need for episodic restrictions if quarantine escape occurs Continuous need for high levels of restrictions; strong possibility of disruptive lockdowns given that community transmission persists Unpredictable Need for restrictions on international arrivals Extremely high, and increases as distancing restrictions are eased Moderate Less important Current appropriateness for Australian jurisdictions† Reasonable Reasonable Not under consideration ICU = intensive care unit. * The effective reproduction number becomes more difficult to quantify precisely as numbers fall. † Given an effective vaccine appears likely.

James M Trauer · Ben J Marais · Romain Ragonnet · Julian Savulescu · Emma S McBryde

To the Editor: Australia has had a remarkably successful response to coronavirus disease 2019 (COVID‐19), even considering the second wave experienced in Victoria. The Australian rate of COVID‐19‐related deaths of 35 per million population is 15–20 times lower than that observed in countries across Europe and the Americas.1 However, as the second wave in Melbourne has shown, it is important not to become complacent. Using all‐cause mortality data in England and Wales over the peak of the COVID‐19 outbreak in March and April 2020, we directly estimated the number of excess deaths that might have occurred if the outbreak in Australia had been of a similar extent to that in England and Wales. We estimated the relative risk of all‐cause mortality in England and Wales from the COVID‐19 outbreak by dividing the total deaths from all causes for weeks 11–21 in 2020 (9 March – 24 May) by the mean number of deaths for the weeks 11–21 averaged over 5 years (2014–2018) (limited to years when comparable Australian data were available). We calculated age and sex stratified relative risks as there are well documented differences in COVID‐19 fatality by age and sex.2 To estimate the baseline risk of all‐cause mortality in the Australian population, we estimated the mean number of deaths by age and sex for weeks 11–21 over the period 2014–2018. Finally, to estimate the total deaths that might have occurred if Australia had experienced a similar outbreak to England and Wales, we multiplied the baseline expected number of deaths by the age‐specific relative risks for men and women (Box). This resulted in an estimated additional 16 313 deaths in Australia: 9295 men and 7018 women. In contrast, by 26 May 2020 there had been 102 COVID‐19‐attributed deaths in Australia and 1365 excess total deaths from weeks 11 to 21 according to provisional mortality statistics.3 This enormous difference underlies the importance of Australia’s response using a combination of extensive testing and contact tracing, mandatory quarantine of people returning from overseas, and shutdowns to control community transmission. While acknowledging that these measures carry with them substantial social and economic harms, we wish to highlight the scale of the loss of life avoided. Further details of our methods and results are available in InSight+.4 Box – Estimating the relative risk (RR) for death in England and Wales during weeks 11–21 in 20201 and applying it to the Australian2 population (Stanaway et al) Age group (years) RR for death in England and Wales* Mean total deaths† in Australia, 2014–2018 Total expected deaths in similar outbreak‡ Estimated absolute increase in number of deaths§ Males 0–14 0.86 167.2 144.3 −22.9 15–44 1.06 864.0 916.7 52.7 45–64 1.46 2629.4 3844.7 1215.3 65–74 1.47 3111.6 4573.3 1461.7 75–84 1.62 4589.4 7461.7 2872.3 ≥ 85 1.73 5118.2 8834.2 3716.0 Total 1.57 16 429.8 25 774.8 9295.0 Females 0–14 0.92 127.2 116.8 −10.3 15–44 1.10 440.2 482.4 42.2 45–64 1.36 1670.0 2265.8 595.8 65–74 1.35 1960.6 2640.8 680.2 75–84 1.48 3714.8 5493.0 1778.2 ≥ 85 1.52 7591.6 11 523.9 3932.3 Total 1.46 15 504.4 22 522.7 7018.3 * Calculated as deaths in 2020 (weeks 11–21)/average deaths in the same period 2014–2018. † Weeks 11–21. ‡ Average deaths in Australia × RR. § If outbreak in Australia had been similar to the United Kingdom. Calculated as expected deaths minus average deaths. Data source: Office of National Statistics website. Deaths registered weekly in England and Wales, provisional. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales (viewed July 2020). The number of deaths for weeks 11–21 in the period 2014–2018 by age and sex were provided on request from the Australian Bureau of Statistics.

Fiona Stanaway · Les M Irwig · Armando Teixeira‐Pinto · Katy JL Bell

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen

To the Editor: The New South Wales Department of Health has taken necessarily stringent steps to reduce the risk of workplace outbreaks during the coronavirus disease 2019 (COVID‐19) pandemic. Currently, two nasopharyngeal samples, analysed by polymerase chain reaction (PCR), negative for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) are required before asymptomatic individuals can return to high risk workplaces (eg, hospitals, schools and prisons) or close proximity living arrangements (eg, residential aged care facilities, military barracks, and group homes).1,2,3 In Newcastle, existent hospital in the home services have been redeployed as part of a tiered pandemic response under the banner “COVID Care at Home”. COVID Care at Home offers daily telehealth monitoring and efficient clearance certification for patients in isolation or excluded from workplaces. In our experience with 45 patients with COVID‐19 admitted to COVID Care at Home, increased PCR surveillance also uncovered cases of prolonged RNA detection. One passenger from the vessel Ruby Princess tested positive for COVID‐19 52 days after the initial swab and more than 60 days after the first day of symptoms. A review of international data showed that PCR positivity usually persists for 20–30 days regardless of symptomology.4 Cases of SARS‐CoV‐2 RNA detection persisting for 60 or even 80 days have been recorded in the literature.5,6 In the case of our patient, the ongoing exclusion from the workplace created significant psychological and financial burden due to lack of leave entitlement. Similar policies in countries with less worker security are likely to have even greater workforce impact. To tackle the issue of prolonged positivity, we have convened a panel of clinicians in the disciplines of infectious diseases, population health, and microbiology to make informed decisions about patients with prolonged viral RNA detection in regard to their ongoing need for isolation and exclusion from high risk environments. PCR positivity is not synonymous with infectivity.7,8 Regardless, to maintain the good results Australia has enjoyed thus far, we will need to persevere with a high level of vigilance. Making informed and safe decisions about clearance for high risk environments and supporting patients with prolonged exclusions from their workplace will be an ongoing challenge for Australian clinicians during the COVID‐19 pandemic.

Eliza Jane T Milliken · Sarah Browning · Danielle A Rohl

To the Editor: We write in reference to the recommendations published by Brewster and colleagues1 to report our centre’s experience with tracheal intubation in adults with coronavirus disease 2019 (COVID‐19) in Australia. Intubating patients with COVID‐19 requires careful balance between providing adequate pre‐oxygenation while concurrently maintaining staff safety through minimising aerosolisation. Guidelines from the Safe Airway Society (SAS),1 the Australian and New Zealand Intensive Care Society,2 and overseas3 emphasised rapid sequence induction techniques with the minimisation of bag valve mask ventilation. Our institution developed a specific tracheal intubation protocol for the intubation of patients with suspected or confirmed COVID‐19 incorporating the recommendations of the SAS.1 Eight patients with confirmed COVID‐19 have been intubated in our intensive care unit. The demographic characteristics of these patients are similar to those reported internationally,4,5 with a male predominance (seven out of eight) and a mean age of 69 years (range, 52–77 years). Before intubation, each patient was receiving high flow nasal oxygenation, with flow rates of 15–50 L/min and fraction of inspired oxygen (Fio2) 60–100%. All patients were pre‐oxygenated via bag valve mask with a positive end expiratory pressure valve in the assembly, as per the SAS recommended circuit set‐up.1 Video laryngoscopy with indirect view was used and a full view of the glottis was established for six of the eight patients; in the other two patients only the epiglottis was seen. All patients were intubated successfully on the first attempt with a bougie. During intubation, desaturation to peripheral capillary oxygen saturation (Spo2) 70% or less occurred in six of the eight patients, although the Spo2 recovered to more than 90% within one minute of being connected to the ventilator in five patients and within several minutes in the remaining patient. No patient received manual ventilation, and none of the patients developed haemodynamic instability during the intubation period. Our centre’s experience, while modest in number, highlights the significant risk of desaturation during intubation for patients with respiratory failure and COVID‐19 using a conservative approach to pre‐oxygenation and apnoeic oxygenation that minimises aerosolisation. We note the now updated SAS statement saying that “patients with severe disease are likely to require manual ventilation to prevent profound oxygen desaturation”.1 Whether manual ventilation, alternative pre‐oxygenation methods, or other strategies, such as potentially tolerating desaturation as transient and expected, is the most suitable method for patients with COVID‐19 remains to be determined.

Katherine E Triplett · Luke W Collett