Letters

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

In reply

David J Brewster · Christopher J Groombridge · Jonathan J Gatward

To the Editor: One evening in February 1974, my fellow endocrinologist Don Gutteridge phoned me to tell me about an ABC television program that I had missed. It had featured an interview in Perth with Sir Richard Kirby, recently retired as Australia’s chief judge in industrial relations. He was showing typical signs of advanced thyroid deficiency. He had slow, coarse speech, periorbital oedema, sparse scalp hair, and was “not as sharp as a chief judge should be”. Don had phoned him at his hotel to discuss the diagnosis. The judge’s response was that he did indeed have symptoms including marked cold intolerance and he had coronary artery disease. Don firmly advised him to have his thyroid tested as soon as possible and in addition he wrote to Sir Richard’s Melbourne physician pointing out that caution was needed when starting thyroxine therapy if the patient had heart disease. Later a Christmas card arrived: “Sincere thanks for a timely telephone call and advice to an old stager who was in need and did not know it … I’m on the treatment and ever since have been a younger, newer and better man.” The before‐and‐after photographs in Blanche d’Alpuget’s biography of Sir Richard1 show a marked improvement in his appearance (Box). He had been unwell for years. Two cardiologists had advised him to retire in 1969. By 1971, he was spending most of his time at his home in Berrara, NSW, feeling ill and sluggish despite a rigorous diet, no cigarettes and almost no alcohol. The story did not end there. In 1979, Don was invited to Sydney to appear on Channel 7’s This is your life television program featuring Sir Richard (https://www.fwc.gov.au>file>your‐life‐sir‐richard‐kirby). “I always saw you with a halo” enthused Sir Richard, sizing up the tall and rangy dark‐haired young doctor, “but I thought you must be an old bloke like me.” Others on the show included Bob Hawke, then President of the ACTU, past Prime Minister Gough Whitlam, and many legal colleagues. Kirby served on three Royal Commissions. He assisted in the mediation of Indonesian Independence from Dutch rule for the United Nations, and he negotiated equal pay for Aboriginal stockmen. His passion to achieve equal pay for women could have been his greatest legacy had bad health not intervened. An undiscovered thyroid deficiency may well have altered the course of Australian industrial relations. Within a month of being treated with thyroxine, Kirby looked and felt better than for almost a decade. He died 27 years later in 2001 at the age of 97. The insidious and subtle onset of hypothyroidism can easily be overlooked by patients, relatives and doctors. Screening for thyroid‐stimulating hormone levels will ensure that an important diagnosis is not missed. Any suspicious symptoms should lead to a careful examination to identify the end‐organ signs of thyroid deficiency, including the slow relaxation phase of tendon reflexes, coarse dry skin, cool extremities and a hoarse voice.2 Box – Sir Richard Kirby before (A) and after (B) treatment for hypothyroidism

Timothy A Welborn

To the Editor: Cardiac injury has been reported in about 20% of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital.1 Elevated troponin is associated with higher complications and death rates.2,3 We report our experience in managing the cardiovascular care of all patients with COVID‐19 admitted to our 783‐bed quarternary hospital in Perth between 1 February and 1 May 2020. The hospital approved the data collection for a clinical quality improvement audit and provided an exemption from ethics review and approval to publish the results. Patients with COVID‐19 with an abnormal electrocardiogram (ECG) showed markers of increased disease severity, had a longer hospital stay and intensive care unit (ICU) admission. Eighteen patients (11 males), with a mean age 59 years (standard deviation [SD], 18), were admitted for a mean 14 days (SD, 15) with symptoms of cough (78%), fever (72%), dyspnoea (61%), fatigue (44%), chest pain (22%), and presyncope (5%). The mean presentation was 6 days (SD, 4) from onset of symptoms. Eight patients required admission to the ICU, and we recorded no deaths. The comorbidities included obesity (four patients), ischaemic heart disease (two patients), diabetes mellitus (four patients), and hypertension (six patients). Cardiac investigations included ECGs (72%), high sensitivity troponin (67%), brain natriuretic peptide (7%), and echocardiogram (6%). Upon admission, eight patients (63%) had an abnormal ECG, which included PR depression, biphasic T waves, PR prolongation, Q waves, ST elevation, atrial flutter, right bundle branch block, and atrial trigeminy. Two patients had elevated troponin. All brain natriuretic peptide and echocardiogram results were normal. Patients who did not have an ECG had low risk markers for disease severity. Patients with a normal ECG had a mean heart rate 84 beats/min (SD, 11), mean QRS duration 92 milliseconds (SD, 9), and mean QTc interval 414 milliseconds (SD, 59) compared with patients with abnormal ECGs, who had a mean heart rate 93 beats/min (SD, 11), mean QRS 96 milliseconds (SD, 18), and mean QTc 400 milliseconds (SD, 110). Seven patients had repeat ECG during their admission. Five patients developed new abnormalities on follow‐up ECGs, including transient ST elevation, sinus bradycardia, junctional rhythm, atrial fibrillation, and complete heart block. Our data show a consistent trend of increased disease severity in patients with abnormal admission ECG (Box). Patients with abnormal ECG required longer hospital admission (61% longer), double the incidence of documented arrhythmias, and double the requirement for oxygen, ventilation and inotropic support. Measures of significant inflammatory response (ferritin, C‐reactive protein, D‐dimer) were markedly higher in patients with abnormal ECG. Half of the patients developed an abnormal rhythm during admission: complete heart block (one patient), supraventricular tachycardia (one patient), atrial fibrillation (three patients), sinus tachycardia (three patients), and sinus bradycardia (one patient). Cardiac procedures performed were transesophageal echocardiogram/cardioversion (one patient), and pacemaker implantation (one patient). Our limited experience suggests an ECG may be helpful in prognostication and triaging of all patients with COVID‐19. An abnormal rhythm may arise from cardiac stress due to cytokine response, direct myocardial viral injury, or physiological strain from multi‐organ injury. Pulmonary injury from pneumonia, acute respiratory distress syndrome and pulmonary emboli can lead to significant right ventricular strain that predisposes to arrhythmia. Sepsis, and related cytokine response, is associated with atrial fibrillation. Myocardial inflammation and subsequent scarring can lead to ventricular arrhythmia and conduction disorders. ECG is a low cost test that can be performed easily and rapidly with minimal risk of viral exposure to staff. ECG should be an essential test in the COVID‐19 pandemic. Box – Characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital Total Abnormal ECG Normal ECG No ECG Total number of patients 18 8 5 5 Age (years), mean (SD) 59 ± 19 67 ± 14 52 ± 15 53 ± 24 Admission (days), mean (SD) 14 ± 15 21 ± 19 13 ± 11 3 ± 2 Ferritin (μg/L), mean (SD) 1594 ± 1658 2328 ± 2141 1089 ± 620 970 ± 1206 Creatinine (μmol/L), mean (SD) 103 ± 64 110 ± 71 86 ± 33 110 ± 82 CRP (mg/L), mean (SD) 166 ± 165 255 ± 198 124 ± 108 39 ± 42 D‐dimer (mg/L), mean (SD) 4.17 ± 6.23 7.03 ± 8.29 1.99 ± 1.39 0.64 ± 0.42 Arrhythmias 9 7 < 5 na Number of patients requiring oxygen 10 6 < 5 < 5 Oxygen use (days), mean (SD) 19 ± 14 23 ± 15 15 ± 11 4 ICU admission (days), mean (SD) 19 ± 11 23 ± 11 12 ± 9 Nil Ventilation (days), mean (SD) 14 ± 10 18 ± 10 7 ± 5 Nil Inotropic support (days) mean (SD) 13 ± 12 18 ± 12 5 ± 6 Nil CRP = C‐reactive protein; ECG = electrogardiogram; ICU = intensive care unit; na = not applicable; SD = standard deviation.

Kaitlyn Lam · Sarah McClelland · Michael J Dallo

To the Editor: The recently published article by McAlister and colleagues1 highlights the importance of health care organisations becoming aware of their environmental impact. However, there are several misconceptions inherent in the analysis. The first misconception is that pathology organisations may not be aware of their environmental responsibility. The available literature describes how laboratories can reduce their impact2 and, in addition, some laboratories have ISO 14001 certification, which demonstrates their compliance with international standards of environmental performance, efficient use of resources and reduction of waste. The second misconception in the analysis is that pathology testing produces a significant carbon footprint compared with other health care activities. Data from the British National Health Service show that indicative carbon emissions from inpatient admission, additional bed‐day stay, and outpatient appointments are about 380, 80 and 50 kg carbon dioxide equivalent (CO2e) emissions respectively, compared with 82 g CO2e for a haematology test.3 The highest emissions were associated with the consumables used in the collection process or the transport of the reagents from the overseas manufacturer to the laboratory. The third error is that there is significant overutilisation of pathology tests. While there is some overtesting,4 considerable evidence also shows widespread underutilisation of testing.4,5 A 15‐year meta‐analysis identified that, on average, the rate of pathology testing overuse was 20.6%, but the underuse was 44.8%.4 It is noteworthy that a 2018 systematic review and meta‐analysis found significant overutilisation in diagnostic imaging.5 It is essential that all organisations reduce their environmental footprint. Health care organisations must ensure they achieve this goal without compromising patient care. Focusing on carbon emissions for phlebotomy without understanding the role pathology testing plays in early diagnosis and monitoring of disease may lead to more expensive interventions, poor patient outcomes, and a greater impact on the environment.

Tina Yen · Tony Badrick

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

To the Editor: The MJA and Madden and colleagues1 display foresight and leadership in advocating for a transition to environmentally sustainable health care. The current coronavirus disease 2019 (COVID‐19) pandemic exposes dual sustainability challenges: uncertain provision of personal protective equipment (PPE) in the face of a fractured global supply chain and burgeoning waste from single‐use materials. Australia has an opportunity to respond to both challenges by accessing local capability and switching to reusable PPE as appropriate. An apt place to begin is PPE gowns. Personal experience at an Australian hospital in March 2020 saw intensive care of one patient with COVID‐19 requiring more than 50 single‐use gowns during a 24‐hour period. This quantum highlights the need to reconsider the source and composition of PPE materials. The National Health and Medical Research Council (NHMRC) guidelines2 state that gowns should be impervious to fluid, with no standards or levels applied. The oft‐used system from the American Association for the Advancement of Medical Instrumentation (AAMI) grades gowns, single‐use or reusable, within a range: level 1 being splash‐resistant, and levels 2–4 being impervious to water columns placed upon them of 20, 50 and 100 cm respectively.3 Application of these levels is at the discretion of Australian health care providers, rather than mandated in the NHMRC guidelines. Fluid impervious level 2 provides an ample barrier to respiratory‐borne pathogens. A transition to reusable level 2 gowns, when appropriate, provides an opportunity to reduce waste because they can be repeatedly sanitised by clinical laundry practice (detergent and > 60°C hot water). One reusable gown has been estimated to replace 50 disposable gowns.4 By way of reducing reliance on distant supply chains, Australia currently has capacity to mill the fabric and manufacture reusable fluid impervious level 2 gowns today, and these gowns could be registered by the Therapeutic Goods Administration. Current experience suggests policy makers and clinicians are unaware of this possibility. The perception that single‐use is the best choice indicates education is needed to assure clinicians that reusable gowns can provide at least equal protection for many clinical and intensive care unit tasks (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2] endures less on cloth than plastic).5 Activating local manufacture of reusable gowns would assure availability and potentially provide more environmentally and financially sustainable health care, while maintaining patient care and staff PPE supply.

Forbes McGain · Meriel Chamberlin · Jane Milburn

To the Editor: Health care workers are at occupational risk of contracting coronavirus disease 2019 (COVID‐19) and may act as vectors of transmission. The guidelines from the Department of Health prioritise health care workers as a risk group for diagnostic testing.1,2 After confirmation of diagnosis, in addition to resolution of symptoms, polymerase chain reaction (PCR) negativity on at least two consecutive respiratory specimens collected 24 hours apart and at least 7 days after symptom onset was required before health care workers were permitted to return to work.1,2 Since 10 March 2020, there have been 11 health care workers managed at our hospital diagnosed with mild COVID‐19 not requiring hospitalisation, with repeated specimens tested by PCR (Box). All patients with COVID‐19 assessed and managed at the Austin Hospital were prospectively included in a clinical database approved by the Austin Health Human Research Ethics Committee (database reference number: CD 20002). The median time from PCR positivity to the second negative swab was 32.5 days (range, 11–53 days). None of these health care workers received any specific antiviral or immunomodulatory treatment. Our current understanding of the viral kinetics in COVID‐19 is incomplete. Pharyngeal viral shedding is very high early in the course of illness3 and may be prolonged.4 However, nucleic acid detection cannot differentiate between infectious and non‐infectious virus. In a study of nine patients with mild COVID‐19, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was not recoverable by culture after day 8 of illness despite high viral loads by PCR.3 In another contact tracing study, there were no secondary cases in the group that was exposed after 6 days.5 These findings suggest that infectivity and transmissibility is low after the initial illness. In Australia, although there was allowance for the return to work of health care workers with prolonged PCR positivity, this was predicated on rounds of testing in what was assumed to be a “small proportion of people”.1,2 Culture for viable virus is not readily available. The findings in our cohort indicate that persistent positivity is the norm and is in line with international studies.4 Current guidelines for health care workers’ return to work appear conservative, with significant workforce implications if outbreaks were to occur in health care settings. Further studies are urgently required to determine the infectivity in patients with prolonged SARS‐CoV‐2 viral shedding to find a balance in policy that benefits health care workers, hospitals and patients. Box – Health care workers with mild coronavirus disease 2019 (COVID‐19) Patient number Age (years) Sex Duration of symptoms (days) Number of swabs collected after first positive swab Days between first PCR positive swab and second negative swab* 1† 62 Male 10 5 42 2 20 Female 5 5 34 3 24 Female 1 5 32 4 32 Female Patient asymptomatic 5 33 5 56 Male 23 3 na‡ 6 26 Female 8 6 43 7§ 62 Female 28 7 53 8 50 Female 12 2 11 9 35 Female 11 2 13 10¶ 52 Female 14 3 21 11 55 Female Unable to ascertain 2 23 na = not applicable; PCR = polymerase chain reaction. * Of two consecutive negative swabs. † Patient with asthma. ‡ The last collected specimen from patient 5 was PCR positive 11 days after initial positive specimen. The nucleic acid detection assay used was the AusDiagnostics Coronavirus Typing (8‐well) assay. This is a multiplex‐tandem PCR assay that employs two rounds of amplification. The cycle take‐off value for the last positive specimen on patient 5 was 23 cycles in the second round of amplification. § Patient with hypertension. ¶ Patient with rheumatoid arthritis.

Kyra YL Chua · Natasha E Holmes · Jason Kwong

To the Editor: The recent discussion on chronic liver disease and ultrasonographic surveillance is welcome.1 Over two decades ago, investigators at Westmead Hospital in Sydney showed that ultrasonographic surveillance of 232 Australian patients with chronic liver disease (most of whom had cirrhosis) was superior to α‐fetoprotein in the detection of hepatocellular carcinoma (HCC).2 In this research, we detected six HCCs with ultrasound for an annual cohort incidence of 1.4%; we calculated that each HCC detected cost $US8472 (in 1998 dollar terms). Further, the superior detection of HCCs with ultrasonography did not translate into improved survival either because of tumour multicentricity, metastases at diagnosis, or patient comorbidity factors precluding surgery. Since that time, our technical expertise in liver screening with ultrasound has grown. Nevertheless, we remain concerned by the relatively poor sensitivity compared with computed tomography or magnetic resonance imaging. In addition, specialists in diagnostic imaging understand that the distorted liver architecture from cirrhosis and the presence of regenerating nodules pose significant challenges in distinguishing HCC from benign lesions. While published meta‐analyses3,4 offer some promise, they are by their very nature highly selective in the data evaluated and seldom consider the downstream costs of false positive tests. It is perhaps unsurprising that recent appropriateness criteria guidelines from the American College of Radiology sound a note of caution on the role of ultrasound in this context.5 Despite the above, there remains a need to perform a contemporary analysis of the potential benefits and costs of screening in patients with cirrhosis in Australian settings. However, as a recent Australian HCC surveillance study6 has concluded, it is difficult to interpret survival outcomes from selective retrospective studies, and conducting a randomised controlled trial may be nigh on impossible.

George Larcos