Letters

To the Editor: In their observational study, Kimmel and colleagues1 examined the impact of inpatient rehabilitation (IPR) for isolated lower limb injuries on functional outcomes in working‐aged people using inverse probability of treatment weighting (IPTW) propensity score analysis. It concerns us that the study lacks real clinical perspectives in disability management. Firstly, the authors assumed exchangeability in the baseline characteristics of patients discharged home and patients admitted to IPR. Exchangeability of the samples is a prerequisite for IPTW propensity score analysis.2,3 However, this is a flawed assumption in the Australasian context, where patients discharged home are medically stable, have minimal physical disability and have sufficient psychological coping skills. In contrast, patients admitted to IPR are deemed unsafe to be discharged home, with greater disability, home hazards, or inadequate support. IPR addresses complex therapy and care needs while alleviating pressure on acute beds. Secondly, the study examined disability and returning to work without considering all relevant determinants of health and functioning as listed in the World Health Organization’s International Classification of Functioning, Disability and Health. Rather than IPR resulting in a poorer functional outcome through hospital‐related complications, it is our experience that persons who require IPR will have a higher physical, functional, psychological, personal and social complexity or vulnerability, which may result in the observed long term disability. Thirdly, the study identified adverse 12‐month outcomes in patients discharged home. This control group were physically and functionally fit for discharge home, but 67% reported suboptimal recovery on the extended Glasgow Outcomes Scale (GOS‐E) and 16% failed to return to work at 12‐month follow‐up. Given that return to previous jobs plateaus by 6–12 months,4 gaps in care may aggravate problems by preventing timely access to multidisciplinary interventions to address the medical, psychological, physical, occupational and social impact of a traumatic injury. Finally, we encourage the authors to present the 12‐month follow‐up data in the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for pain scores, anxiety and/or depression, and other domains of the EuroQol EQ‐5D‐3L Scale.4 Pain perception and depressive symptoms are known predictors for functioning and returning to work following an orthopaedic trauma and likely confounded the results.5

Pearl Chung · Mark Haran

To the Editor: In a recent letter published in the MJA, Muhi and colleagues1 reviewed the source of acquisition by 11 health care workers with coronavirus disease 2019 (COVID‐19) who presented for symptomatic screening at a single clinic. Travel and transmission outside the workplace were considered the likely source of infection for most of them. Data on COVID‐19 cases collected for public health purposes in Western Australia up to 1 June 2020 were reviewed to inform local public health strategies to protect health care workers. Fifty‐seven cases of COVID‐19 among health care workers or workers in health care settings with direct patient contact were identified. Fifty‐six cases were confirmed by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) polymerase chain reaction (PCR) test, and one case had positive SARS‐CoV‐2 IgG serology indicating past infection. Thirty‐one health care workers acquired their infection from a cruise ship or overseas, and 26 health care workers acquired COVID‐19 within Australia. The likely source of the 26 locally acquired cases is shown in the Box. Ten health care workers acquired the infection in the workplace. A further eight had no known contact with a COVID‐19 case but worked during their incubation period. These health care workers may have acquired the infection from an unidentified patient with COVID‐19, from another health care worker, or via fomite transmission at work. Extensive contact tracing did not reveal an alternate source in a setting of limited community transmission. Where possible, whole genome sequencing was used to substantiate epidemiological findings. Transmission of COVID‐19 occurred between health care workers, emphasising the need for staff to recognise not only the risk from patients but also from colleagues, where use of personal protective equipment and physical distancing may be relaxed. There were no cases among staff in COVID‐19 clinics, suggesting that the use of personal protective equipment does mitigate risk. Workplace fomite transmission was the putative source on three occasions, which reinforces the importance of regular environmental cleaning, rigorous cleaning of shared equipment, and good cough etiquette and hand hygiene practices within health care facilities. Our review describes a larger cohort of COVID‐19 cases among health care workers, encompassing metropolitan and regional settings. With international travel restrictions, an increasing proportion of locally acquired infections among health care workers may be expected. From this analysis and others,2 colleagues and fomites should be recognised as potential workplace sources of infection, in addition to direct patient contact. Box – Likely source of coronavirus disease 2019 (COVID‐19) infection for locally acquired cases by Western Australian health care workers (HCWs) Source of infection Cases Direct HCW to HCW transmission 7 Likely fomite transmission 3 Unknown, but worked during incubation period* 8 From a close contact outside of work 5 Contact not identified, but interstate travel 3 Total 26 * No alternate source of infection identified in the context of limited community transmission.

Rebecca J Hogan · Suzanne McEvoy

To the Editor: The clinical trial landscape has arguably progressed more in the past 6 months than in the previous 10 years. The needs of humanity in the global pandemic catalysed the necessity to evaluate study design, implementation, governance, technology and collaboration. The race for effective therapies and a vaccine highlighted the need to expedite drug development and approval. While clinical trials in oncology have used master protocols for many years, with clear guidance from regulatory authorities1 and a gradual adoption in other therapeutic areas,2 these have become the blueprint for coronavirus disease 2019 (COVID‐19) clinical trials developed by the World Health Organization, ensuring the ability to test a broad range of therapies. COVID‐19 has also triggered the adoption of technology to support trials, accelerating the move to a digital age of clinical trials.3 Platforms to deliver online recruitment, electronic consent, wearable devices, artificial intelligence and electronic systems for source data and regulatory documents now provide the solution to maintaining clinical trials activity, at a time when restrictions challenge the viability of face to face trial operations. The need for comprehensive, integrated electronic medical records is evident, with enduring access for parties for data verification, but raises issues of access, privacy and cybersecurity. Out of necessity, clinical trials have also adopted teletrials, like the need in medical practices to adopt telemedicine,4 resulting in a dispersed, decentralised model of operation. The pressure to adapt clinical trial delivery has seen previously perceived barriers fall away. By focusing on common goals, collaboration, technology, and building solid foundations to evaluate our progress to ensure research integrity and safety, a new era of clinical trials will unfold. The clinical trials team of the future will evolve, incorporating a core team with information and communication technology capabilities to support training, management and development of trial systems in a networked model of delivery. While this is a welcome push into a new technological era, with an opportunity to retain new elements and abandon outdated models, we must proceed with thoughtful consideration and evaluation of our progress.

Alana Sarah · Olivia Dean · Michael Berk

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

To the Editor: Public health strategies to control coronavirus disease 2019 (COVID‐19) in Australia aim to test, identify and isolate all cases including those among children.1 We investigated the intended actions of parents if their child developed COVID‐19 symptoms, such as a runny nose, sore throat, cough, fever, chills, loss of smell, diarrhoea, and/or nausea and vomiting.1 We collected data during 15–23 June 2020 via an online survey of 1834 Australian parents of children aged 3–17 years who attended childcare, kindergarten and/or school.2 The sample was limited to these respondents as one of our objectives was to test if children would be kept home from childcare and/or school (isolate). The questionnaire was administered by a private vendor as part of the Royal Children’s Hospital National Child Health Poll, a recurring periodic online survey. Participants were randomly selected from a representative consumer panel of over 350 000 Australian adults — who were recruited onto the panel via online and offline methods such as door knocking, phone calls, letters etc — using quotas to achieve a nationally representative sample reflective of age, sex and state populations. The sample size was justified based on the commonly used margin of error of 3% for estimating a proportion. Only one parent per household could complete the questionnaire and households were not permitted to participate in more than one poll. Participants had no direct contact with the research team. Responses were voluntary and anonymous. Respondents were incentivised for participation in the form of points towards shopping gift cards. The study protocol was approved by the Royal Children’s Hospital Human Research Ethics Committee (RCH HREC 35254). Intended actions of parents if their child developed possible COVID‐19 symptoms are presented in the Box. We classified parents as “seeking COVID‐19 test or medical advice” or not. The sample characteristics are presented in the Supporting Information. We found that 1458 of 1834 parents (78.95%, weighted) of children with symptoms compatible with COVID‐19 intended to seek a COVID‐19 test for their child. There is little published research exploring why some parents may not present children for COVID‐19 testing. A recent Australian study has identified barriers to testing among adults, including a belief that testing is painful, a lack of knowledge about how to get tested, and worry about getting infected at the testing centre.3 These barriers may also apply to parents in relation to testing for children. Additional barriers may include financial implications of time off work to take a child for testing and fear of the social stigma associated with a diagnosis of COVID‐19.4 As upper respiratory tract infections are common among children and often present with similar symptoms to COVID‐19,1 parents may misattribute possible COVID‐19 symptoms to the common cold. Messages from governments may be unclear and parents may not believe that general directives apply to children.5 Timely testing is a critical aspect of containing the pandemic in Australia. With one in five parents indicating they would not present their symptomatic child for COVID‐19 testing, further research is urgently needed to identify and understand barriers to testing in order to inform targeted strategies and messaging to enhance testing uptake in children. Box – Intentions of parents if child developed symptoms compatible with coronavirus disease 2019 (COVID‐19), Australia, 2020 Number (%)*† Keep child home from school or child care until all their symptoms have gone 991 (53.22%) Take child to a doctor (GP or hospital) for a COVID‐19 test 810 (44.66%) Keep child home from school or child care for a couple of days 672 (36.34%) Call the GP for advice 618 (33.62%) Take child to a COVID‐19 testing centre 452 (23.33%) Call the COVID‐19 hotline for advice 415 (22.69%) Send child to school or childcare if they seem well enough 47 (2.66%) Not sure what to do 34 (1.73%) Take child for test‡* 1458 (78.95%) GP = general practitioner. * The cumulative percentage is greater than 100% as respondents could select more than one option. † The sample was nationally representative in terms of the distribution of national resident population by state; however, the distribution of parent sex by state and socio‐economic status was slightly over‐representative of female and more advantaged residents (Supporting Information). Hence, the data were weighted by state, sex and the Index of Relative Socio‐economic Advantage and Disadvantage (IRSAD). ‡ “Take child for test” was defined as at least one of the following options: take child to doctor or testing centre for a test, call GP for advice or call the COVID‐19 testing centre.

Mary‐Anne Measey · Monsurul Hoq · Anthea L Rhodes

To the Editor: The Coroners Court of Victoria made several recommendations in 2020 after a 38‐year‐old man died alone at home.1 The cause of death was determined to be sepsis in the setting of an adrenal crisis. The key coronial recommendations1 were to emphasise to the general medical community the non‐specific nature of symptoms of impending adrenal crisis (eg, fatigue, nausea, loss of appetite, vomiting),2 to record the diagnosis of adrenal insufficiency prominently as an alert in medical records,3 and to encourage endocrinologists to provide sick day or steroid stress dosing letters to patients, general practitioners, and family members and carers. The Endocrine Society of Australia (ESA) endorses these recommendations. A standard patient letter has been developed and is now available on the ESA’s Hormones Australia website.4 We strongly support medical record alerts for the diagnosis of cortisol deficiency due to Addison disease or hypopituitarism. It is crucial for doctors to have a high index of suspicion for the possibility of impending adrenal crisis in a patient with known adrenal insufficiency. The clinical syndrome evolves from acute adrenal insufficiency with symptoms of malaise, nausea and lethargy — all of which are non‐specific and may be considered part of another pathological process — to adrenal crisis, which is associated with hypotension initially manifest by postural blood pressure falls greater than 20 mmHg.2,3 Prevention involves advice on stress dosing:1 triple glucocorticoid dosing for 3 days (ie, the 3 × 3 rule),2 parenteral hydrocortisone at home (SOLU‐CORTEF Act‐O‐Vial, Pfizer) when unable to take tablets,3 and the availability of personal alerts (eg, a MedicAlert bracelet [MedicAlert Foundation], a steroid card) when the person is delirious or very unwell (Box). The incidence of adrenal crises is increasing in Australia.3 Missed cases or failure to treat them because of overestimation of the risks of glucocorticoid therapy are unfortunately too common. Box – Practical steps to reduce the risk of adrenal crisis Ensure that others are aware of the diagnosis of established adrenal insufficiency Prominent medical alert in GP and hospital medical records Patient carries either a steroid card, which lists diagnosis and glucocorticoid therapy, or uses a MedicAlert bracelet (MedicAlert Foundation) A sick day or steroid stress dosing letter should be provided by the endocrinologist to the patient with adrenal insufficiency, with a copy to their GP Encourage the patient with adrenal insufficiency to provide copies of the letter to their next of kin, close relatives or carer Have a high index of suspicion for an impending adrenal crisis Beware of non-specific symptoms of nausea, vomiting or lethargy in a patient with established adrenal insufficiency Prevent an adrenal crisis in patients with established adrenal insufficiency When unwell, follow the 3 × 3 rule (ie, three times the usual glucocorticoid dose for 3 days) and seek urgent medical attention if not improving Promptly treat an impending adrenal crisis The patient and/or carer should be trained to administer 100 mg SOLU‐CORTEF Act‐O‐Vial (Pfizer) intramuscularly* if vomiting occurs or the patient is unable to swallow tablets GP = general practitioner. * Some authorities recommend the off‐label use of a subcutaneous injection as this is easier for patient and/or carer to administer.

Peter S Hamblin · Bu B Yeap · David J Torpy

To the Editor: Hereditary cancer predisposition syndromes (HCPS) account for at least 10% of paediatric cancers.1 Li‐Fraumeni syndrome (LFS) is a dominant HCPS caused by mutations in the TP53 gene and is associated with an 80–90% lifetime risk of cancer, commencing in infancy.2 Children of affected individuals are at 50% risk of inheriting the family mutation. Surveillance programs, involving clinical review and medical imaging, are being used in paediatric populations with HCPS, as significantly higher overall survival is reported with early tumour detection.3 In 2018, the Paediatric Surveillance Clinic was established at Perth Children’s Hospital to provide surveillance for asymptomatic children with, or at 50% risk of developing, LFS and with other HCPS, and to address the needs of their families. Families with at‐risk children can choose to attend the clinic, allowing them to receive information, support and sufficient time to make a decision regarding genetic testing. The quarterly clinic is in a general paediatric setting and offers surveillance for mutation‐positive children in line with eviQ guidelines — a free resource of evidence‐based, consensus‐driven cancer treatment and genetic testing protocols hosted by Cancer Institute NSW.4 Children at 50% risk of LFS, who have not had genetic testing, receive a six‐monthly clinical review and prompt assessment of any concerning symptoms during the interim period. Over an 18‐month period, the Paediatric Surveillance Clinic has seen 11 children from five families, aged from 3 months to 14 years. Most of these children are at risk of or have a TP53 mutation and one child has a VHL (Von‐Hippel‐Lindau) mutation. The Paediatric Surveillance Clinic offers a holistic service with a multidisciplinary team consisting of a general paediatrician, a paediatric nurse, a paediatric oncologist, a genetic counsellor and a clinical geneticist. The clinic has highlighted the specific and unmet needs of families dealing with HCPS and has allowed for essential integration of genetic, paediatric and oncology services for these families.5 As the number of identified HCPS grows, the Paediatric Surveillance Clinic will continue to offer a flexible service that supports families, assisting with decisions around genetic testing and surveillance for malignancy during childhood and adolescence.

Nicholas Leedman · Murray Princehorn · Nicholas Gottardo · Claire Franklin · Rebecca D'Souza · Catherine E Kiraly‐Borri

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised concerns of a subsequent increase in suicides,1 but limited empirical data are available on this topic.2,3 We analysed numbers of suicidal presentations (including suicidal ideation, non‐suicidal self‐injury and suicide attempts) to emergency departments (EDs) within the Gold Coast Hospital and Health Service before and since the spread of COVID‐19 in Queensland, Australia. Cases were identified from ED administrative data through relevant diagnoses, presenting problems and keywords, followed by a manual investigation of triage narratives to exclude false positive cases, such as non‐deliberate injuries or poisonings. The numbers of ED visits between January and August 2020 were compared with the projected numbers, calculated by applying an annual increase of 13.5%4 to presentations during the same period in 2019. From March 2020 onwards, a marked divergence between observed and projected numbers is noted, corresponding to the oscillations in the numbers of diagnosed COVID‐19 cases in Queensland (Box). At the peak of the pandemic, the reductions in suicidal presentations were the largest (29.8% in March and 23.6% in April 2020). Over the next 2 months, daily numbers of diagnosed COVID‐19 cases remained low and the difference between observed and projected numbers gradually narrowed (20.8% in May and 14.6% in June 2020). In July 2020, observed numbers exceeded projected numbers by 11.4%, but then declined again in August 2020, coinciding with another resurgence of COVID‐19. Between March and August 2020, the Gold Coast Hospital and Health Service had 554 less suicidal presentations than expected. The well documented negative impact of COVID‐19 on all aspects of society, including mental health,5 suggests that a substantial reduction of suicide risk during this time is unlikely. Instead, our results may reflect changes in help‐seeking behaviour, with fewer people willing to seek help for suicidality through in‐hospital consultations due to fears of contracting COVID‐19.6 Ongoing promotion of telehealth and enabling safe hospital presentations or alternatives to ED7 is therefore needed to prevent the adverse outcomes of the COVID‐19 pandemic due to delayed access to care. Limitations of this work include potential underestimations of suicidal presentations due to coding issues8 and the inability to differentiate between types of suicidal presentations. Box – Numbers of suicidal presentations to the Gold Coast Hospital and Health Service in 2019 and 2020, and numbers of daily coronavirus disease 2019 (COVID‐19) cases in Queensland, Australia Error ranges for the projected 2020 numbers are 95% confidence intervals.

Jerneja Sveticic · Nicolas JC Stapelberg · Kathryn Turner

To the Editor: Siru and colleagues have raised potential concerns about the strategy recommended by the Australian Diabetes Society (ADS) and other peak bodies to diagnose gestational diabetes (GDM) during the coronavirus disease 2019 (COVID‐19) pandemic.1 In their study, 46% of subjects diagnosed with GDM had a fasting blood glucose level (BGL) < 4.7 mmol/L but elevated post‐load blood glucose levels, and would be missed by the ADS‐recommended strategy. The authors suggested that this exposes women and their newborns to significant risks with the potential for significant harm. No outcome data were provided to justify these assertions. Evidence from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study suggests that such women do not have increased rates of pregnancy‐associated complications.2,3,4,5 The subgroups with the highest odds ratios for newborns who were large for gestational age had an elevated fasting BGL and any elevation of post‐load BGL (odds ratio > 3), whereas subgroups having only elevated fasting or post‐load BGL had a considerably lower odds ratio, equivalent to the diagnostic threshold for GDM of 1.75.2 Further, women with a fasting BGL < 4.5 mmol/L had low rates of some complications irrespective of their post‐load BGL.3 A subsequent analysis of 6128 patients from five centres involved in the HAPO study did not observe any increase in pregnancy‐associated complications in women with a fasting BGL below the 75th centile (4.6 mmol/L).4 A recent analysis of 5974 women in the HAPO study assessed the ADS‐recommended COVID‐19 GDM strategy and reported no increase in any complication.5 There were fewer cases of pregnancy‐associated hypertension and caesarean delivery, with similar rates of large‐for‐gestational‐age newborns and neonatal hypoglycaemia. These data provide reassurance. There is no evidence of harm. When this strategy is used, women with a fasting BGL < 4.7 mmol/L are spared being labelled with GDM and do not require education, monitoring, more frequent follow‐up or transfer to specialist services, freeing up valuable health care resources. Importantly, they will not be advised to inappropriately restrict their dietary intake or commence therapy with insulin or metformin with the potential for harm. An initial fasting BGL test would eliminate the need for a pregnancy oral glucose tolerance test in the majority of women, identifying a smaller group of women at risk of pregnancy‐associated complications where management can be more appropriately targeted.

Michael C d'Emden · Jacobus PJ Ungerer · Susan J Jersey

To the Editor: We read with interest the analysis and comments by Shand and colleagues.1 The authors show a rise in the dispensing of intravenous iron agents in the period from 2013 to 2017 for women. They suggest that this may be an issue relating to the inappropriate use of this agent. However, we question whether the data can support this suggestion, and feel this should be viewed cautiously because of the study limitations. The study did not examine the reasons for the escalation in prescriptions. The rise in numbers is not surprising. Iron deficiency anaemia is common and undertreated.2 While dietary modifications and oral iron are the first line treatment, oral iron is limited by the high occurrence of side effects in up to 50% of users.3 The new intravenous agents allow a full treatment in one visit — often in primary care — which is safe and effective. The authors are rightly concerned about safety; however, it is reassuring that studies have demonstrated the relative safety of these agents.4 During the study period, ferric carboxymaltose became more widely available, with its listing on the Pharmaceutical Benefits Scheme easing a financial barrier to women who need treatment. A number of education programs and various patient blood management initiatives to detect and treat iron deficiency that occurred during the study period could influence the study findings. A noteworthy activity was the landmark Patient Blood Management Collaborative facilitated by the Australian Commission on Safety and Quality in Health Care.5 The assumption by the authors that the number of women receiving treatment is equivalent to the number of dispensing claims by pharmacy is likely incorrect, as there are situations when an individual can have multiple dispensing claims. The study is timely because it highlights a serious condition affecting a large proportion of Australian women that must be better managed. Despite the various endeavours to improve access to treatment for women, iron deficiency remains undertreated and under‐recognised.

Pradeep Jayasuriya · Toby Richards · Bernd Froessler

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