Letters

To the Editor: There has been recent important discourse about the adverse impact of coronavirus disease 2019 (COVID‐19) on mental health, with modelling from the Brain and Mind Centre predicting increases in suicide in the wake of the pandemic.1 Links with the economic downturn have been emphasised, with financial stressors and loss of productivity among the youth and working adults playing a large part, leading to a call for proactive investment in mental health services.1 This is of undisputed, urgent importance. However, there has been relative silence about the effects of the pandemic on suicide risk in older adults, especially men aged 85 years or over, who have the highest rate of suicide of all age groups in Australia.2 Older adults are particularly vulnerable to the social ramifications of the pandemic, including social distancing, if not frank social exclusion by quarantine, exacerbating pre‐existing loneliness,3 particularly for those in residential care. Management of older people with pre‐existing mental illness as well as the expected increases in depression and anxiety3,4 have been confounded by changes in service provision and access to mental health services.3 Similarly, delays in presentation and management of physical illness combined with the suspension of elective procedures4 may contribute to untreated pain and other distressing physical symptoms, also identified as risk factors for suicide.5 Furthermore, calls to reopen the economy knowing the risk this poses to older people — seen by some as “expendable” — reflects societal ageism and adds to older people's own internalised ageism.6 Perceptions of disconnection from society and feeling burdensome and devalued are already known associations with late‐life self‐harm and suicide.5 In addition to fuelling active self‐harm, there has been speculation regarding links between the pandemic and increased requests for voluntary assisted dying.7,8 These reports suggest that such requests have been driven by anxiety about dying, fears of loss of control, and inability to access help for distressing symptoms. This is not unfounded, given the complexity of providing appropriate palliative care to older patients who are dying, particularly to those in nursing homes, ever more so during the COVID‐19 pandemic.4 We add to the call to act urgently and flatten the mental illness and suicide curve1 for Australians of all ages.

Anne P F Wand · Carmelle Peisah

To the Editor: In Australia, gestational diabetes mellitus is diagnosed by 75 g oral glucose tolerance test (OGTT). The diagnostic criteria are fasting plasma glucose (FPG) ≥ 5.1 mmol/L, one‐hour glucose level ≥ 10.0 mmol/L, and/or 2‐hour glucose level ≥ 8.5 mmol/L.1,2 International consensus favours OGTT over single measures of glucose because, in the pivotal Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, hyperglycaemia at each time point was independently associated with adverse outcomes, individual measures were not well correlated with one another, and no single measure was clearly superior in predicting adverse outcomes, such as birthweight above the 90th percentile, shoulder dystocia and pre‐eclampsia.2,3 To reduce contact time at pathology collection centres during the coronavirus disease 2019 (COVID‐19) pandemic, measurement of FPG alone has been advocated.4,5 One guideline advised that a result below 4.7 mmol/L may not merit a follow‐up OGTT.4 Another advised diagnosing gestational diabetes mellitus by stand‐alone FPG greater than 5.1 mmol/L.5 To determine the proportion and characteristics of gestational diabetes mellitus cases that would be missed by using alternative criteria, we extracted the results of all obstetrician‐referred OGTTs performed by our private community‐based laboratory between January 2017 and April 2020. The analysis, including determination of Wilson score confidence intervals (CIs), was performed with SAS 9.4 (SAS Institute). Of 16 169 patients, 1790 (11.1%) were diagnosed with gestational diabetes mellitus by OGTT. A rule‐out threshold of FPG below 5.1 mmol/L would have resulted in 1202 cases (67%; 95% CI, 65–69%) being missed, and a threshold below 4.7 mmol/L would have resulted in 831 cases (46%; 95% CI, 44–49%) being missed (Box). Women with gestational diabetes mellitus and normal fasting glucose did not have significantly lower one‐ or 2‐hour concentrations than those with increased fasting glucose (data not shown). Missing the diagnosis of gestational diabetes mellitus exposes women and their newborns to significant risks, including birth weight above the 90th percentile, primary caesarean delivery, neonatal hypoglycaemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinaemia and pre‐eclampsia. Use of fasting glucose to screen for gestational diabetes mellitus would miss a large proportion of cases, with the potential for significant harm to mothers and their offspring. Clinicians must recognise the substantial limitations of stand‐alone FPG so that pregnant women can be adequately counselled and, if opting out of OGTT, considered for careful monitoring for consequences of undiagnosed gestational diabetes mellitus, such as accelerated growth or polyhydramnios. In regions without significant community spread of COVID‐19, modifying sample collection procedures to ensure strict physical distancing and having dedicated collection centres for vulnerable populations may be better than using deficient diagnostic criteria. Box – Distribution of fasting glucose results at 24–28 weeks’ gestation in patients with (n = 1790) and without (n = 14 379) gestational diabetes mellitus* (GDM) The vertical grey lines denote thresholds below which new guidelines propose that oral glucose tolerance testing is not required during the coronavirus disease 2019 (COVID‐19) pandemic. * Diagnosed using oral glucose tolerance test.

Ranita Siru · Johan H Conradie · Melissa J Gillett · Emily Gianatti · Michael M Page

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has required rapid adjustments in health service delivery.1 The Victorian COVID‐19 Cancer Network (VCCN) is a joint initiative of the Victorian Comprehensive Cancer Centre and Monash Partners Comprehensive Cancer Consortium. Through expert groups, the VCCN aims to provide support and advice to clinicians and health care services treating cancer patients during the pandemic. The VCCN Telehealth Expert Working Group conducted a survey to understand the barriers and enablers to the rapid adoption of telehealth in health services during the first week of April 2020. Seventeen cancer services from across metropolitan and regional Victoria and Tasmania responded. Notably, all respondent cancer services had implemented some form of telehealth since the pandemic. Healthdirect, the Victorian Department of Health and Human Services’ supported telehealth platform, was used in 40% of services, with 25% using phone only and others using platforms such as Skype, FaceTime and doxy.me. With the unprecedented increase in the uptake of telehealth,2 there is a tremendous opportunity to integrate telehealth into routine practice, potentially improving inequities and inefficiencies in the delivery of cancer care for suitably selected patients. Our survey results suggest several areas for attention to support telehealth, including the need for further investment in information technology infrastructure across health services and administrative support to facilitate changes in practice and workflow (Box). The survey results also highlight the educational and training needs of consumers and health professionals during telehealth implementation. Aboriginal and Torres Strait Islanders, people from culturally and linguistically diverse backgrounds and of lower socio‐economic status, and older patients may have greater needs and will require additional support from both government and relevant organisations to ensure equity of access to cancer care via telehealth. We strongly advocate the need to establish evidence‐based, patient‐centred and sustainable telehealth in cancer management. Research into the experience of patients and clinicians should be prioritised to ensure the consistent quality of telehealth consultation with face‐to‐face consultation in appropriate clinical circumstances. Box – Barriers to implementing telehealth: survey results

Zee Wan Wong · Hannah L Cross

To the Editor: In their recent article, Ioannidis and Boyack focused on the misuse of author‐ and journal‐based metrics.1 The “predatory and other easy journals” they allude to are becoming increasingly difficult to distinguish2 in a widening continuum of journal quality that is seeing some overlap between predatory journals and indexed (eg, in Web of Science, Scopus or PubMed) journals that are traditionally perceived to be of peer‐review quality and whose scholarly content has been editorially authenticated.3 This increasing overlap between predatory and indexed journals is accentuated by an increasing lack of reproducibility, often revealed through post‐publication peer review of indexed journals.4 Predatory journals may also seek scholarly validation by allowing citation of their papers to infiltrate supposedly reputable databases.5 However, the continued inability to identify such journals invalidates calls to ban such entities or to not cite papers from currently blacklisted predatory journals, as was recently suggested by the International Committee of Medical Journal Editors.6 Increasing retractions in the biomedical literature as a result of post‐publication peer review — which identifies errors and misuses such as the manipulation of citations discussed by Ioannidis and Boyack, including inflated and coercive self‐citation— affect author‐based metrics and journal‐based metrics differently. It is incumbent upon authors, editors and publishers to correct inflated, skewed or distorted author‐ and journal‐based metrics. To achieve this, retractions need to be destigmatised. Moreover, inflated author‐ and journal‐based metrics (eg, H‐index, Journal Impact Factor [Web of Science Group], CiteScore [Elsevier]) need to be adjusted with corrective, but not punitive, measures, to correct for imbalances and unfair rewards that may be associated with the attribution of citations of retracted (and thus potentially invalid) literature.7 Self‐citations that support stated claims are valid, independent of their number, and involve no ethical breaches. However, the misuse of self‐citations to manipulate author‐ and journal‐based metrics, such as citation cartels,8 raises ethical red flags. Independent of the possible ethical parameters of inflated or coercive self‐citation, such metrics can also be adjusted downwards to reflect the more balanced perspective of an author‐ or journal‐based metric.9 If the identity of predatory journals can be clearly determined and unanimously agreed upon, then the journal‐based metrics of valid, indexed scholarly journals that cite such journals should be adjusted accordingly.

Jaime A Teixeira da Silva

To the Editor: A recent article highlighted a case where self‐collection enabled detection of an early cervical adenocarcinoma and curative treatment in a previously underscreened woman.1 This case underlines the important benefits from self‐collection making cervical screening more accessible and acceptable to women who have previously declined or delayed screening. Unfortunately, self‐collection is currently very underutilised in Australia. Although it is currently restricted to women aged 30 years and over who are 2 or more years overdue for cervical screening, potentially around a million women are eligible.2 In contrast, data from Medicare, VCS Pathology, and the National Cancer Screening Register suggest that fewer than 6000 self‐collected tests were processed over 2018 and 2019, indicating that less than 1% of eligible women have had a self‐collected test. What drives this discrepancy? Self‐collection is highly acceptable to underscreened Australian women, and very high uptake can be achieved with appropriate clinical support.3 A recent survey reported that many practitioners, especially outside Victoria, do not yet feel comfortable discussing or recommending self‐collection, and lack confidence that self‐collection is a reliable test.4 Potentially, this is due to an initial delay in self‐collection being available, confusion about eligibility, and current restrictions giving the false impression that self‐collection is less sensitive. Self‐collection is now available to eligible women nationally (provided samples are sent to one of two accredited laboratories, which accept samples from anywhere in Australia), and updated evidence demonstrates that polymerase chain reaction‐based human papillomavirus (HPV) testing is equally sensitive for detecting pre‐cancer in self‐collected and clinician‐collected samples.5 Another barrier may be difficulties for providers in checking whether women are eligible. The rollout of the provider portal into the National Cancer Screening Register, allowing providers to view a woman's screening history at the point of care, will be important in addressing this issue. Many screening‐eligible women who have not had their first HPV test are now overdue and could be eligible for self‐collection. Self‐collection is a reliable test now available nationally to eligible women, which can have a transformative effect in the lives of underscreened women, as shown in the recent case study.

Megan Smith · Marion Saville · Karen Canfell

To the Editor: The recent article by Akram and Sadashiv1 presents a timely and most welcome opportunity to enhance awareness, in the medical community at large, of the investigation and treatment options for proximal deep vein thrombosis (DVT) of the lower extremity. Diagnosis of lower extremity DVT is generally made or confirmed with duplex ultrasound assessment. Standards in Australia and New Zealand state that duplex ultrasound for DVT should determine the proximal extent of the thrombus, as well as identify structures causing extrinsic compression that may have contributed to the thrombosis.2 This information assists the clinician in determining the need to consider specific treatments, such as venous stenting for May–Thurner syndrome or placement of a caval filter in cases where there is a free‐floating thrombus in the inferior vena cava. Duplex ultrasound can play a key role in the diagnosis of May–Thurner syndrome.3 Technical factors, such as the presence of bowel gas, may inhibit ultrasonographic views of the abdominal and pelvic vasculature, and may therefore prevent attainment of the required information. Further, clinical experience in vascular surgery services in Australia and overseas has shown that, despite the above‐mentioned standards, it is common for there to be no attempt to obtain adequate proximal views during ultrasound DVT scans. Clinicians should therefore be wary of the limitations of ultrasound DVT scans and consider alternate imaging modalities such as computed tomography venography in cases where ultrasound has yielded inadequate information. Clinicians should also be aware of the potential of clot removal therapies such as catheter‐directed thrombolysis to improve long term outcomes for patients with proximal lower extremity DVT, whether or not May–Thurner syndrome is identified as a predisposing factor. Recent studies have reported improvements in the incidence and/or severity of post‐thrombotic syndrome in patients receiving catheter‐directed thrombolysis compared with those treated with anticoagulation alone.4,5 The appropriateness of catheter‐directed thrombolysis for some patients is acknowledged in the relevant guidelines,6 although patient selection remains a topic of debate. Lower extremity DVT is a common condition encountered in both inpatient and community settings. Due to technical considerations and quality variations, ultrasound DVT scans do not always yield adequate information to determine the optimal therapeutic approach. In such situations, consultation with a vascular specialist is strongly encouraged.

Trevor MY Kwok

To the Editor: In Australia, 2020 began with raging bushfires, and we now confront the coronavirus disease 2019 (COVID‐19) pandemic. While health protection is currently at the top of the public policy agenda, can we rise from these huge ruptures and “build back better”? The full health costs of the bushfires, including the mental health toll, are yet to be quantified. No sooner had the bushfires abated than the battle against the COVID‐19 pandemic began. The immediate public health response has been well managed in Australia.1 Although Victoria is currently grappling with a second wave of infections, by international comparisons the number of cases and deaths around the country has remained low.2 Government leaders have listened to health experts and acted on evidence, including the need for strict physical distancing in the absence of a vaccine, supplemented by universal masking in Victoria. As governments move to revitalise the economy with financial stimulus, what guidance can health experts provide to inform this stimulus? One clear priority is that stimulus accelerates the decarbonisation of the Australian economy. Climate change is a recognised health issue. Published as the bushfires erupted, the 2019 MJA–Lancet Countdown on health and climate change report3 found that Australia is extremely vulnerable to the impacts of climate change on health. There are also health co‐benefits from action on climate change. The clearest example is the transition to renewable energy generation. Globally, in 2015 alone, more than 460 000 preventable deaths were attributable to coal burning.4 An urgent transition to renewable energy would be an evidence‐based public policy response to these deaths and assist a global green recovery from the pandemic which is called for by the World Health Organization.5 Australia is well placed to lead such a recovery as indicated in a recent report by ClimateWorks Australia,6 which provides a blueprint to achieve net zero emissions by 2050 through accelerated uptake of mature zero emission technologies and the rapid development and commercialisation of emerging zero emission technologies in harder to abate sectors (Box). Beyond stimulus for decarbonisation, investments in affordable housing, mass transit infrastructure, safe routes for walking and cycling, regeneration of degraded ecosystems and infrastructure to support working from home would also benefit health through reduced homelessness, improved levels of physical activity, and improved urban air quality. Australia has, thus far, avoided the high COVID‐19 case numbers and death rates seen in some other countries because of evidence‐based decision making. It is essential that decisions about the stimulus for economic recovery are similarly grounded in evidence. The health and wellbeing of current and future generations of Australians depend on it. Box – Summary table of key emissions‐reduction solutions by sector CCS = carbon capture and storage.

Selina N Lo · Anna Skarbek · Anthony Capon

To the Editor: Before the coronavirus disease 2019 (COVID‐19) pandemic, we had been thinking about how best to re‐imagine our university medical program to enhance student experience and learning outcomes. Globally, questions have been raised regarding the utility and format of the pre‐clinical content taught in medical programs in the junior years,1 particularly lectures, which have increasingly low attendance rates. There is emerging evidence that blended approaches to education meet the connectivity, flexibility and interactivity expectations of learners,2 and have potential to combine the best of both online and face‐to‐face teaching. Packaging content in digestible chunks, combined with active learning activities online such as adaptive tutorials, discussions and reflections, results in more meaningful educational experiences for students than didactic lectures.3,4 The COVID‐19 pandemic forced a rapid transition to entirely online teaching for junior medical students. Even components of clinical teaching (other than physical examination) had to proceed in this format. Despite the pace of this transition, both formal and informal student feedback indicated that students have an extremely high level of satisfaction and engagement with online learning activities. The clinical training components of the program have, by necessity, also become more streamlined. COVID‐19 has forced us to examine all elements of our medical program. This is an opportunity to review the curriculum for future doctors, especially its alignment with the skills and capabilities they will need in their careers. Clearly, we need to facilitate the development of teamwork and communication skills, which will prepare students for effective patient care and multidisciplinary, interprofessional practice. Additionally, we have an obligation to support medical students in developing skills in reflection, adaptive problem solving, leadership and lifelong learning, all of which are needed to adapt to a rapidly changing health care environment.5 Some important aspects of university life, such as such as friendships, personal identity development, exposure to diversity and self‐care skills, will be much harder to achieve in a solely online environment, but as we develop plans to reintroduce elements of face‐to‐face teaching, we need to ensure that these are integrated with, and informed by, the advances made in medical education during the past few months.

Adrienne J Torda · Gary Velan · Vlado Perkovic

To the Editor: Australia's social distancing policies to contain the spread of coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), have had social consequences. Social distancing and school disruptions have increased parental responsibilities. There has also been an increased opportunity for parents to use alcohol to cope with increased stress.1 Parents, especially mothers, have taken to social media to share “memes” about needing a drink to survive staying at home (Box). These posts are mostly shared with the aim of creating an online environment for peer support and stress relief, but they risk normalising the use of alcohol as a coping strategy and promoting the false belief that alcohol is good for mental health.2 Alcohol is a central nervous system depressant that may relieve stress in the short term, but regular drinking increases psychological distress and the risk of alcohol‐related harm.3 A review of recent advertising complaints indicated that some alcohol advertisers have been quick to capitalise on COVID‐19.4 An investigation of a social media account found an average of one alcohol advertisement every 35 seconds, with themes of easy access without leaving home (58%), buy more (35%), drink during COVID‐19 (24%), and drink to cope (16%).5 Australia has a regulation system for alcohol advertising, which most people mistakenly believe is government‐funded.6 It is in fact an industry‐funded quasi‐regulatory system that is activated by consumer complaints and lacks systematic independent monitoring.7 Further, regulations do not prevent certain social media platforms from being used by alcohol brands to post advertisements and engage with consumers.8 In light of the alcohol industry's opportunistic advertising through social media, it is questionable how well Australia's regulatory system protects parents and other targeted populations at risk from exposure to constant encouragements to drink during these challenging times. Box – Examples of parental drinking‐related memes during the coronavirus disease 2019 (COVID‐19) lockdown

Janni Leung · Jason Connor · Leanne Hides · Wayne D Hall

To the Editor: The issue of cancer overdiagnosis highlighted by Glasziou and colleagues1 is not new. The problem lies in how clinicians translate caution into the care of individual patients. In August 2019, non‐clinician epidemiologists, via the media, alarmed and confused many post‐menopausal women by reminding us that menopausal hormone therapy (MHT) mildly increases breast cancer risk.2 This was already known; breast cancer is common in post‐menopausal women, with or without a history of MHT use. Women taking MHT understandably comply with government‐recommended and funded screening mammography.3 Thyroid cancer overdiagnosis has been recognised for many years and is addressed in international evidence‐based management guidelines.4,5 The Royal Australasian College of Physicians has the EVOLVE program, endorsed by the Endocrine Society of Australia, to guide clinicians to order fewer thyroid ultrasounds.6 The adoption of thyroid ultrasound reporting systems such as TIRADS has already reduced the number of thyroid fine needle biopsies.7 Furthermore, active surveillance, rather than surgical intervention, is now advocated and supported by evidence for the management of small low risk thyroid cancers.5 Data from overseas show that older patients may accept surveillance over surgery, but younger patients demand intervention due to uncertainty about tumour behaviour. Active surveillance becomes expensive with time.8 Clinicians face anxious patients seeking guidance over mixed messages from the popular press. Genomics and better personalised medicine may eventually allow prognostication. For now, addressing clinical and family histories, physical examination, and appropriate investigations are done on a case‐by‐case basis. Thyroid cancer guidelines have already been adjusted and expanded to outline an individualised approach.

Diana L Learoyd

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic is placing increasing pressure on the health care resources of nations. Particular concern is held for supplies of N95 (or P2) masks and surgical masks — personal protective equipment designed to achieve close facial fit and protection from more than 95% of 0.3 μm test particles. These masks are recommended for routine care of patients on airborne precautions, with current guidelines indicating that N95 masks are single use.1 Further highlighting the importance of N95 masks in protecting health care workers during the COVID‐19 pandemic, a recent study of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infection rates among medical staff in Zhongnan Hospital of Wuhan University showed that none of the staff (0/278) who wore N95 masks and followed frequent disinfection and handwashing became infected during the period of 2–22 January 2020 compared with 4.7% (10/231) of staff who did not wear masks, despite the fact that the latter group worked in lower risk areas.2 Previous outbreaks of respiratory viruses, including the 2004 SARS outbreak and the 2009 H1N1 influenza pandemic, have highlighted the risks of shortages of N95 masks during these events.3 If demand for N95 masks outstrips the current supplies, what options will be available for health care workers in Australia and elsewhere? During the 2009 H1N1 pandemic, reusing masks was common practice in Californian hospitals in response to shortages.4 The reuse of masks involves health care workers donning the same mask for multiple close patient contacts and doffing it at the end of each patient contact before eventually discarding it.3 To support the reuse of masks, a growing number of studies have investigated decontamination practices.5,6,7,8 A comparison of decontamination methods has found that physical decontamination methods (eg, ultraviolet germicidal irradiation [UVGI]) are less destructive to the mask filter than chemical methods (eg, bleach).7 UVGI exposure at high doses has been shown to have only a very small impact on particle penetration, but it had a variable effect on mask structural integrity.6 It was suggested that the rate‐limiting step for repeated disinfection cycles would be the physical degradation of the mask material; however, this could also be used as a visual cue to determine when the mask should be discarded. A study into the efficacy of UVGI decontamination of H1N1 influenza‐contaminated N95 masks has also shown that significant reductions in influenza viability could be seen when N95 masks contaminated with viable H1N1 influenza virus and soiled with saliva or skin oils were treated with 1 J/cm2 UVGI for about one minute.5 In terms of useability, after UVGI treatment, differences in the fit, odour, discomfort, or increased difficulty in donning of masks were also found to be minimal.9 In the absence of equipment to perform effective UVGI‐irradiation, what other options are available? While steam appears to have some potential,10 it is safe to say that the answer is currently unclear and may need novel solutions. For example, could solar disinfection — a method that has been shown to be effective for decontaminating RNA virus‐contaminated water in polyethylene terephthalate bottles at high temperatures (eg, 40°C) — be an effective solution to disinfecting N95 masks for reuse in the Australian climate?11 Urgent research is needed to validate current methods and investigate novel solutions for the potential decontamination of N95 masks to protect health care workers and patients. Quality assurance systems to evaluate the performance of a decontaminated mask are an obvious concern. In terms of the efficiency of biological decontamination, available data show that indicator organisms such as Bacillus spores12 or influenza virus substitutes (eg, MS2 bacteriophage13) can be indicators of disinfection. Measuring filter performance, particular particle penetration is less straightforward and may require specialised equipment. In these circumstances, ensuring that published protocols are used only on the N95 masks they have been evaluated on may be important, given that different N95 masks are affected differently by the same decontamination method.8 Furthermore, avoiding the unnecessary use of N95 masks when the use of surgical masks is recommended and improving the potential for local production and sourcing of personal protective equipment will also assist in reducing Australia's reliance on dwindling international stockpiles during the COVID‐19 pandemic and in preparation for any future respiratory viral infection outbreaks.

James M Branley · Adam Polkinghorne · Gwendolyn L Gilbert

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has focused whole‐of‐government efforts on protecting Australia's health. Border closures, case quarantine, public health interventions and social distancing have controlled COVID‐19 case numbers, limiting community acquisition. Workplaces at particular risk of occupational exposure to COVID‐19 — hospitals, aged care facilities and, interestingly, abattoirs — require effective infection control. Presenteeism in this context refers to the occupational transmission risk that employees infected with severe acute respiratory syndrome coronavirus 2 pose by continuing to work despite being symptomatic. Such presenteeism may be an issue common to a number of industries.1 Occupational infection has occurred among Australian hospital staff, notably in North West Tasmania.2 Delayed recognition of COVID‐19 cases leading to infection control breaches, presenteeism with infected health care staff working for up to 7 days with respiratory symptoms, along with other factors all contributed to this hospital outbreak.2 In total, 73 of the 114 outbreak cases were hospital staff.2 Meat processing facility workers have been a notable at‐risk group in the United States, with over 4000 COVID‐19 cases reported, representing up to 3% of affected facility workforces and resulting in 20 COVID‐19 related deaths.3 In Australia, a COVID‐19 cluster was reported among abattoir workers in Melbourne.4 There are meat processing industry work practices that enhance COVID‐19 acquisition risks.4 Commonly, the layout of meat processing facilities challenges implementation of appropriate distancing between workers, who may be spaced as little as 30 cm from colleagues during routine operations. Compliance with wearing face masks is difficult given the pace and physical demands of work. Financial imperatives appear to motivate food processing employees to work even if unwell.3 Australian aged care workers and airline baggage handlers have also experienced COVID‐19 outbreaks. Despite concerns expressed by teachers and early childhood educators, as of 16 June 2020, no major outbreaks had occurred in schools and only one cluster had been reported in a NSW childcare centre.5 A NSW investigation of possible transmission in schools showed only two secondary cases in students.6 Some schools have been closed for deep cleaning after detection of community acquired cases of COVID‐19. Design and implementation of effective, industry specific, infection prevention policies are crucial for employer compliance with the Australian Work Health and Safety Strategy principle that “all workers, regardless of their occupation or how they are engaged, have the right to a healthy and safe working environment”.7 This requires strong, industry group, leadership. Recognition of workplace specific infection risks, provision of reliable personal protective equipment, redesign of work practices, discouragement of presenteeism, and improved access to sick leave must all be attended to for the sake of Australia's workforce.

Damon Eisen

To the Editor: The National Disability Insurance Scheme (NDIS) is one of the largest health reforms in Australia's history.1 The scheme aims to give people with a disability choice and control over their daily lives.2 It is designed to operate as nation‐wide disability “markets” from which services can be “purchased”.2 NDIS participants are allocated a budget from which they purchase the services they require. The NDIS is very different from our previous disability models, which saw people receiving standardised services from a more limited number of government and not‐for‐profit organisations, and a less decentralised workforce. The NDIS is a visionary reform; however, we are now seeing that it is also designed to spread an epidemic such as coronavirus disease 2019 (COVID‐19) to thousands of people with a disability. The NDIS has created a “gig economy” within the disability services sector. Individuals are paid for discrete services, from showering and feeding, to social support activities, to household tasks. This means as many as ten different carers entering a participant's home, performing a care service, and then moving on to another home. The workforce is now predominantly casual, and there are growing numbers of self‐employed.3 This structure is primed to spread infection because: large numbers of carers are moving between homes; carers are not paid if they do not perform care tasks, which deters people from self‐isolating; and much of the workforce is disparate and there is no central registry, which makes it difficult to provide new information such as hygiene practices to all people. Unfortunately, many people who are part of the NDIS have comorbidities,4 making them vulnerable to COVID‐19 by both physiology and system design. Previous research has raised concerns about the readiness of the workforce to handle complex disability under normal circumstances, let alone in the context of a pandemic.5 While government agencies are working to communicate hygiene practices with NDIS participants, challenges such as personal protective equipment shortages and high worker motility need to be addressed. Otherwise, the health care system will need to ready itself for a disproportionate number of people with disability.

Gemma Carey

To the Editor: The great complexity and unmet need in rare diseases is highly challenging for the estimated two million Australians with a rare disease.1 The coronavirus disease 2019 (COVID‐19) pandemic has created enormous health, social and economic burdens, exacerbating the challenges and uncertainty facing people with severe, chronic and often disabling rare disease. Systemic, nuanced, flexible and coordinated responses are required. The vulnerability of rare disease patients is evidenced by the preliminary results of a global survey of over 5000 mostly European rare disease patients,2 which found that nine out of ten patients are experiencing interrupted care because of COVID‐19. Issues include frequent cancellation or postponement of surgeries and transplants, allied health and primary care or specialist appointments, and interrupted psychiatric care. There are reports of losing access to in‐home and hospital therapies and diagnostics, and of closures of hospitals and units that provide ongoing rare disease care. Over half of respondents with access to follow‐up care through hospitals chose not to attend in fear of contracting COVID‐19. Despite a relatively smaller Australian COVID‐19 burden, these sentiments are echoed locally. The Australian National Strategic Action Plan for Rare Diseases1 has three pillars: awareness and education; care and support; and research and data. This policy framework underpins rational, evidence‐based and evolving responses for Australians with a rare disease. The peak body, Rare Voices Australia, drew on the Action Plan to formulate a statement3 outlining measures to ensure the rare disease community is protected and considered in the national COVID‐19 response. Issues addressed in the statement include triage; clinical care guidelines informed by rare disease experts; continuity and coordination of care; stricter isolation and enhanced testing; and increased utilisation of digital health, including virtual clinics and telemedicine. Subsequently, Rare Voices Australia also called for governments to exercise flexibility around school attendance for rare disease families. Positively, the European survey2 revealed increased participation in telemedicine, with a high degree of satisfaction. Australian rare disease specialist clinics have historically provided care over vast distances. Australia's transition to telehealth therefore provides an opportunity to connect with families, particularly those with huge disease burden, within their community. This may enable transition to more person‐centred health care, a foundation principle of the Action Plan.

Gareth S Baynam · Carol Wicking · Kaustuv Bhattacharya · Nicole Millis

To the Editor: The use of Bluetooth‐enabled apps like Australia's COVIDSafe to contact trace people exposed to coronavirus disease 2019 (COVID‐19) raises challenging moral and public health questions. Leins and colleagues1 rightly note that such tracing may endanger human rights. Yet the ethical decisions for governments and citizens are complex. The absence of vaccines and effective treatments, and the significant asymptomatic transmission of SARS‐CoV‐2, compels reliance on traditional tactics of social distancing, quarantine and contact tracing.2,3 Although the added value of digital contact tracing over manual tracing remains uncertain, even marginal improvements may interrupt disease transmission, save lives and improve public health resourcing. This could especially benefit vulnerable and disadvantaged people who suffer disproportionate harms,4 without treating digital contact tracing as a “silver bullet”. Whether, and which, digital contact tracing options are warranted depends on tough cost–benefit judgements. COVIDSafe's centralised storage of data on Amazon's servers facilitates access by governments with extraordinary power to interfere in citizens’ lives. Alternatively, decentralised data storage on smartphones has privacy advantages — but providing individual app users with the discretion to act on notifications of potential exposure to COVID‐19 may compromise disease control efforts. A hard choice exists between allowing personal data to be accessible by democratically elected governments versus powerful technology giants like Apple and Google which support decentralised data storage.5 Even greater invasions of privacy have been proposed, however, with location tracking options such as Norway's Smittestopp app (https://helsenorge.no/coronavirus/smittestopp) promoted as necessary to understand community interactions and the effects of social distancing policies for current (and future) outbreaks. While Leins and colleagues highlight significant ethical drawbacks, a full ethical analysis of digital contact tracing must also weigh its potential benefits. Certainly, citizens should agitate for strong protections to prevent abuse of power and misuse of personal information. However, even when governments offer ethically suboptimal contact tracing options, it may be permissible and even a moral requirement, all things considered, for citizens to support options to help protect the community. For its part, the Australian government should recognise that deploying digital tracing without sufficient transparency and community and expert input leaves citizens with harder moral decisions.

Simon Coghlan · Marc Cheong · Benjamin Coghlan

To the Editor: We congratulate Cheung and colleagues1 on their large cluster randomised trial of routine blood glucose and automated glycated haemoglobin (HbA1c) testing in emergency departments. This trial reaffirmed the high prevalence of unrecognised diabetes in patients presenting to the emergency department, while demonstrating the feasibility of algorithmic detection. However, the rate of documented follow‐up plans in patients with suspected or newly diagnosed diabetes was low and did not benefit from the trial intervention. Cheung and colleagues1 and Hare and Shaw,2 in their accompanying editorial, suggest that this may relate to diabetes services already operating at full capacity or to overburdened staff documenting abbreviated plans at discharge. The trial highlights the difficulty in improving outcomes when multiple non‐integrated health professionals manage a condition and, hence, the importance of continuity of care. The RAPIDS trial3 was an early intervention model of care consisting of integrated continuous acute diabetes care provided by a dedicated, proactive specialist inpatient diabetes team (IDT). The intervention involved an IDT using a networked blood glucose meter system to remotely identify inpatients with diabetes (known and newly diagnosed) to directly manage these patients, compared with usual care, where diabetes management was mostly provided by parent unit teams.3 This trial showed that direct diabetes management by a dedicated IDT improved glycaemia and decreased the rate of hospital‐acquired infections. During the RAPIDS trial, in patients with newly discovered hyperglycaemia (random capillary glucose > 11.1 mmol/L without known diabetes), treatment and follow‐up plans were documented in 11/34 patients (33%) with usual care, comparable to findings by Cheung et al. However, with the IDT intervention, 22/28 patients (79%) had treatment and follow‐up plans. Similarly, in patients with newly diagnosed diabetes (HbA1c ≥ 6.5%), diabetes treatment was commenced in 8/17 patients (47%) with usual care, and in 11/12 patients (92%) with IDT intervention3 (unpublished data). It is likely that the presence of an IDT at one of the control hospitals in the trial by Cheung and colleagues contributed significantly to the improved plan documentation in that arm. We thus echo the editorial and professional society voices asserting the importance of resourcing clinical services for diabetes in Australian hospitals.4 Establishing IDTs in our hospitals will enable excellent diabetes care despite the increasing prevalence of this disease in Australia.

Spiros Fourlanos · Rahul Barmanray · Mervyn Kyi

To the Editor: Gestational diabetes mellitus (GDM) is being diagnosed with increasing frequency in Australia, with the greatest prevalence reported in South Asian women.1,2 South Asian women, comprising Indians, Sri Lankans, Bangladeshis, Afghanis and Pakistanis, are more likely to have GDM and develop type 2 diabetes than Caucasian women.1,2 Data from the landmark Mothers after Gestational Diabetes in Australia trial show that about 40% of the 573 women recruited into the trial were from an Asian background.2 Retention rates for the intervention and usual care groups were 73% and 79%, respectively.2 The Royal Australian College of General Practitioners3 and the Australasian Diabetes in Pregnancy Society4 recommend oral glucose tolerance testing 6–12 weeks post partum for women who experienced a GDM‐complicated pregnancy. Repeat testing should be performed every 1–2 years among women with normal glucose tolerance and the potential for further pregnancies. If further pregnancy is not possible, follow‐up testing should be performed every 3 years, with more frequent retesting depending on clinical circumstances.5 Although studies have been conducted to evaluate the implementation of post partum guidelines generally in women with a history of GDM,6 there is no information about the implementation and uptake of guidelines in high risk ethnic populations. Additionally, there is evidence to suggest that culturally specific GDM follow‐up care would increase adherence to diet and lifestyle modifications during the interconception period in high risk ethnic women.7 Therefore, as a high risk group for progression to type 2 diabetes following GDM, South Asian women in Australia should be targeted for testing, and culturally appropriate lifestyle interventions, before conception. General practitioners have a critical role in the post partum, interconception and pre‐pregnancy care of women with previous GDM. This is even more pronounced in high risk populations such as South Asians. More culturally appropriate resources are therefore required to assist with recommended lifestyle modifications to reduce risks for future development of GDM or type 2 diabetes. There is an urgent need for qualitative research to focus on identifying the barriers and enablers to the implementation of the Royal Australian College of General Practitioners guidelines for the management of GDM, with a particular focus on GDM interconception care for South Asian women. Findings may be used to inform the development phase of an intervention aimed at improving the implementation and uptake of GDM guidelines among high risk populations in Australian general practice.

Asvini K Subasinghe · Alison J Nankervis · Jacqueline A Boyle · Danielle Mazza

To the Editor: There is marked concern among health care workers in Australia regarding the safety of caring for patients with coronavirus disease 2019 (COVID‐19), which partly relates to highly publicised reports of health care workers dying from COVID‐19 overseas. The concern has caused high levels of anxiety in many health care workers, the use of personal protective equipment (PPE) outside of government guidelines, and many seeking exemptions from being involved in the care of patients with COVID‐19. The reports of health care worker deaths overseas generally do not explore whether the infection was contracted caring for patients or through community contact, or whether appropriate PPE was worn. In March 2020, a clinic was established to screen staff from Royal Melbourne Hospital and neighbouring hospitals who had developed a fever or new respiratory symptoms. A targeted history was taken and a swab was performed according to public health department recommendations at the time. In addition to this, a public screening clinic run by the hospital was also available for health care workers practising in the broader community, so those working in non‐hospital settings could be identified and tested. At 6 April 2020, 1160 symptomatic staff had been assessed in the staff clinic and the majority had been swabbed for COVID‐19, while a number of health care workers also attended the public clinic. Across both staff and public screening clinics, 11 health care workers were found to be positive for COVID‐19. Of these, eight had a history of travel or close contact with a COVID‐19 case in the community. The other three had no obvious COVID‐19 contact in the workplace, during a period when fewer than ten patients with COVID‐19 were treated at the hospital. Two of the staff, while identifying as health care workers, did not work in a clinical hospital setting and were judged to be at low risk of contracting infection from an unwell patient in their workplace. The other worked in a hospital ward where no known COVID‐19 infected patients had been managed. Although a dedicated service for screening and supporting staff may not be feasible in all settings, it does provide access to rapid testing which gives valuable reassurance for staff. Importantly, monitoring the data helps to contextualise our local experience. These data indicate that COVID‐19 is very uncommon in health care workers at present, and that the large majority who have contracted COVID‐19 have done so away from work. There is already intensive training in the use of appropriate PPE in the workplace, and we continue to reassure health care workers that this affords high level protection. Victorian census data in 2016 suggest that approximately 12% of adults identify as health care workers,1 which gives some context to the state‐wide data suggesting that 11% of positive cases to date have occurred in health care workers.2 This is not to trivialise the risk that frontline health care workers face, particularly when caring for unrecognised cases without using PPE. Our data show that currently, community acquisition of COVID‐19 is likely to be occurring in health care workers more often than work‐related acquisition. Health care workers should focus on taking measures (eg, social distancing and hand hygiene) to protect themselves from COVID‐19 when away from work. Ongoing monitoring of the epidemiology related to staff clinic presentations may help provide information on local risks.

Stephen Muhi · Louis B Irving · Kirsty L Buising

To the Editor: We read the perspective by Weinstein and colleagues1 with interest and agree that treatment of snake envenoming in Australia is complex, and that clinicians should seek expert advice in cases of severe or unusual envenoming. There is 24‐hour specialist clinical toxicologist support available through the national Poisons Information Centre network (13 11 26), which takes 300 calls annually regarding snakebite. However, we are concerned that the authors argue for just one non‐evidenced‐based solution — higher doses of antivenom — despite the extensive evidence that this historical approach does not lead to better outcomes. They suggest that the reduction in antivenom doses is based on a study of snakebite data in Australia from 2005 to 2015,2 which concluded that as “the usual antivenom dose for all major snake groups has decreased to one vial, with no evidence of adverse consequences, this approach should be retained” (emphasis added).2 However, the evidence supporting the move to lower doses of antivenom was based on a series of around 15 earlier studies.2 Serial measurement of venom concentrations using enzyme immunoassays in patients with snake envenoming demonstrated complete neutralisation after any dose,2 and the time course of recovery was unaltered by antivenom dose. The evidence suggests benefits from earlier antivenom but not from higher doses.3 Weinstein and colleagues cite a study by O'Leary and colleagues4 when they state that using “samples from rodents injected with venom … inaccurately determines a true neutralising dose”. However, the cited study measured venom–antivenom complexes in vitro to determine the antivenom concentration at which every venom molecule is bound to at least one antivenom molecule, as a measure of efficacy.4 It showed that this was similar to the manufacturer's original recommendation of a dose of a single vial of antivenom. Weinstein and colleagues criticise the use of data from the large multicentre prospective cohort, the Australian Snakebite Project, which reports both clinical and laboratory outcomes and measures venom concentrations. They provide no citations to support their contentions, other than single cases and opinion (often citing their own previous views). A coroner's case in which a person died after three vials of antivenom is strangely cited as highlighting concerns that a single vial of antivenom is insufficient. They suggest two vials may be sufficient, or even larger doses, but offer no research or studies to support this, and no guidance as to when larger doses are required. They also do not provide a useful or practical alternative approach to the treatment of snake envenoming. Current national evidence‐based guidelines and Poisons Information Centres recommend that one vial of brown snake antivenom and one vial of tiger snake antivenom be given as soon as possible in most snake envenoming cases in Australia.5 This ensures that the most common snakes are covered, as snake venom detection kits are unreliable.2 It also means an equivalent of two vials of antivenom is administered, because Australian “monovalent” antivenoms are in fact polyvalent.6 Evidence‐based guidelines continuously evolve, and we believe the key to better outcomes is early identification of envenomed patients and prompt access to the latest evidence‐based advice by consulting a clinical toxicologist through the Poisons Information Centre.

Geoffrey K Isbister · Nicholas A Buckley