Letters

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

To the Editor: Harms related to the inappropriate use of prescription drugs include fatal and non‐fatal overdose and are a significant public health concern in Australia.1 In response, Victoria recently introduced SafeScript (https://www2.health.vic.gov.au/safescript) — a system similar to the widely implemented real time prescription monitoring (RTPM) systems in the United States.2 The Victorian RTPM system is designed to help health professionals make safer decisions when supplying high risk medicines.3 RTPM systems have been associated with unintended consequences, such as a transition from pharmaceutical opioid use to illicit opioid use, which has been associated with an increased risk of overdose and spread of blood‐borne viruses.2,4 Indeed, a 2019 American study suggests that lowering prescription opioid supply through initiatives such as RTPM use will only have a modest effect on opioid‐related deaths, unless supported with a multipronged approach including increased access to pharmacotherapy and harm‐reduction services.5 In Victoria, the implementation of an RTPM system may be of more benefit than seen in the US since these services are widely available. We have begun to explore effects of the introduction of SafeScript through analysis of data collected through the Burnet Institute's SuperMIX study — a prospective cohort study of about 1300 people who inject drugs (https://www.burnet.edu.au/projects/89_supermix_the_melbourne_injecting_drug_user_cohort_study). We introduced questions related to RTPM use in March 2019, with a total of 387 interviews conducted since the implementation of SafeScript in Victoria. We found that 20% of participants (48/242) who used a medicine monitored by SafeScript reported being refused a prescription by a general practitioner. One‐third (16/44) of those who have been refused were requesting the prescriptions for the treatment of anxiety and 45% were refused two or more times by doctors. Three per cent of participants (8/245) reported having a prescription they had already been receiving withdrawn. In addition, six out of 241 participants were refused dispensing of a prescribed medicine by a pharmacist. One‐third of participants (15/47) who had been refused a prescription were told this was due to a risky combination of medicines or having multiple providers. A third of participants (14/45) who had been refused a prescription reported an intention to not seek medication from their doctors in the future. Most had moderate to severe anxiety (33/41) and depression (36/41) disorders measured through a self‐administered Patient Health Questionnaire (PHQ). In the case of refused prescriptions requested for the treatment of anxiety, ten out of 13 patients had moderate to severe anxiety disorder and 11/13 patients had severe depression disorder, suggesting unmet treatment needs in patients denied prescriptions. RTPM systems such as SafeScript may help prevent the inappropriate use of prescription medications. Our initial analysis provides early insights on the impacts of SafeScript on this cohort, indicating careful implementation is required, particularly for people who inject drugs living with concurrent mental illnesses. The use of RTPM systems may reduce medicine‐related harm if integrated mental health and drug treatment services are adequate. It is not clear whether this is the case in Victoria. It is important to understand what happens when people are refused prescriptions — what care they receive and whether this care is appropriate for their needs. Increased mortality following restrictions to prescribed medicines is reported elsewhere.2 Rigorous research should evaluate the impact of RTPM use in Australia to understand if similar outcomes are observed.

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

To the Editor: The coronavirus disease 2019 (COVID‐19) outbreak has become a public health emergency globally.1,2 Until 26 May 2020, there were 7126 confirmed cases reported in Australia (https://coronavirus.jhu.edu/map.html). However, specimens of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) independently isolated in Australia (in Sydney, the Gold Coast and Melbourne)3 exhibited very unusual mutations, which have not been identified in other countries (Box, A). Up to 29 April, 1319 sequences of the Australian SARS‐CoV‐2 isolates are available in the website of the Global Initiative on Sharing All Influenza Data (GISAID).3 Except for the NSW03 and NSW01 isolates, viral mutations are located at the stem‐loop II motif (s2m), an extremely conserved RNA element in the 3’ untranslated region (3’‐UTR) (Box, A). The NSW02 and VIC01 isolates have deletion of 41 and ten nucleotides respectively. All Queensland cases have single G‐to‐A substitution (nucleotides 29714/QLD01, 29736/QLD02, 29736/QLD04, and 29737/QLD03). Moreover, patients with NSW05, NSW06, NSW07, NSW15, NSW18, NSW19, NSW21, NSW24, NSW26, NSW28, or NSW31 (nucleotide 29696) have single G‐to‐U substitution at the same nucleotide. This substitution is only present in Australian patients and has not been found in SARS‐CoV‐2 isolates from other countries. Phylogenetic analysis showed that SARS and 30 other coronaviruses and astroviruses all possess the genetic element s2m, suggesting that this motif is conserved in both nucleotide sequence and secondary structure folding during evolution in an otherwise rapidly mutable RNA genome.3,5 The three‐dimensional crystal structure of the s2m RNA element of the SARS virus shows that guanosine (19), which is mutated in Australian isolates, is critical for tertiary contacts to form an RNA base quartet involving two adjacent G–C pairs (G19, C20, G28, and C31)4 (Box, B). Because s2m plays an essential role for the viral RNA to substitute host protein synthesis, we hypothesise that the disruption of s2m could alter the viral viability or infectivity dramatically. The s2m sequence of coronaviruses is highly conserved, and spontaneous mutations in this motif were not expected to have occurred during the apparent short period when SARS‐CoV‐2 has been present; therefore, it is highly likely that the changes are due to recombination.5 Because a high frequency of recombination events in coronaviruses occurs, RNA recombination could either enhance the adaptation process to its new host like humans or cause unpredictable changes in virulence during infection. Box – Mutations, deletions and recombination breakpoints in the stem‐loop II motif (s2m) of Australian severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) isolates Panel A: Deletions and mutations in the primary, secondary and tertiary structures of the coronavirus disease 2019 (COVID‐19) s2m RNA genetic element based on the three‐dimensional crystal structure of the SARS virus. Conventional RNA helical base pairings are indicated in italics. Sequence complements are indicated using colour‐coded brackets. The G19 mutation (arrowhead) of the Australian SARS‐CoV‐2 is shown with purple colour. Asterisks label the RNA recombination breakpoints based on analysis of 1319 Australia SARS‐CoV‐2 sequences using Recco algorithm (https://recco.bioinf.mpi-inf.mpg.de/) (P < 0.002). Panel B: Schematic representation of the s2m RNA secondary structure of the SARS virus, with tertiary structural interactions indicated as long range contacts.4

Ting‐Yu Yeh · Gregory P Contreras

To the Editor: On 11 March 2020, the World Health Organization declared COVID‐19 a pandemic. Australia has enacted public health measures to reduce the number and severity of cases.1 These measures, alongside disease burden, profoundly impact the health care system. However, the place of medical students in the COVID‐19 response is unclear. The gravity of the COVID‐19 crisis has led governments to take drastic measures. The graduation of over 10 000 Italian final year students has been expedited to supplement the overburdened workforce.2 In the United Kingdom, the Medical Schools Council has encouraged prioritising qualification of final year students to support the over‐encumbered National Health Service.2 Medical Deans Australia and New Zealand recognises the value of final year medical students, releasing a statement outlining appropriate roles.3 These involve routine aspects of care independent of the COVID‐19 response, in various clinical settings with which students are already familiar. Moreover, with clinical placements being disrupted, senior students may gain valuable practical exposure aligned with course requirements. Considering the noted mental health effects of COVID‐19,4 student contributions may relieve the burden on professional staff while alleviating any sense of helplessness, improving the mental wellbeing of students and staff alike. Importantly, medicine embodies altruism and humanity, with many students undertaking the vocation for this reason. As imminent doctors, senior medical students may therefore feel impassioned to contribute to the COVID‐19 response. Involving students, however, is not without risk. With the reported asymptomatic infectious period, expanding the workforce elevates infection risk. Exposure to patients with COVID‐19 should therefore be minimal. Further, the risk of litigation is pertinent as students are less experienced than professional staff. Responsibilities should be within capabilities, under supervision and institutional medico‐legal protection. Lastly, additional work hours may impede formal medical education; academic penalties should not be levied, on‐the‐job learning should be duly acknowledged, and accessibility of course materials should be maximised. Indeed, medical student involvement should be implemented following principles developed by key stakeholders.3,5 Extraordinary times call for extraordinary measures. With appropriate legal, operational and training safeguards, senior medical students have a role in the COVD‐19 response if they desire.

Jim H‐S Wang · Sarah Tan · Kyle Raubenheimer

To the Editor: The advent of coronavirus disease 2019 (COVID‐19) has generated an unparalleled level of interest from the medical and non‐medical community. As clinician‐scientists, we watch in astonishment at the exponential growth of academic publications in journals. In January 2020, PubMed saw a sharp rise in the number of publications related to COVID‐19, which continues to grow (Box). We could not help but wonder if this has generated a race to publish. Of course, publishing is crucial to help confront one of the most devastating global health issues of the century. However, it is well recognised that external pressures to publish can muddle the intrinsic pursuit for scientific curiosity and excellence,1 and COVID‐19 has certainly provided the incentive for many clinicians and scientists alike to seek rapid publication. This may, unfortunately, fuel competition in the research/publishing field, which was exemplified by the concerning lack of research collaborations when humans were faced with natural disasters,2 including the 2003 severe acute respiratory syndrome coronavirus (SARS‐CoV) outbreak.3 The urgent nature of this situation means a number of preliminary studies and publications on COVID‐19 are fast‐tracked through the peer review process — or not at all — in the hope of rapidly publicising important findings, opinions and experiences. However, hastily penned observations may mislead and do more harm than good. A recent non‐peer‐reviewed publication on a preprint server likening SARS‐CoV‐2 structurally to the human immunodeficiency virus (HIV) was quickly retracted after the scientific community highlighted serious flaws in the study.4 Furthermore, a preliminary study5 supporting the use of hydroxychloroquine as a COVID‐19 treatment prompted a flurry of off‐label use and media attention. The study was later criticised as being too small and biased, and provided insufficient evidence to recommend its use.6 In summary, rapid publishing allows extensive dissemination of knowledge and sharing of experiences; yet the astute clinician needs to keep an open mind and analyse what is being published, for this cannot take the place of rigorous scientific evaluation and best clinical practice. This is a challenging time in the academic world and COVID‐19 will, no doubt, test our abilities to untangle the vast range of literature available. Box – Monthly and cumulative published articles on coronavirus disease 2019 (COVID‐19)* * We conducted an online search in PubMed and included all articles with the terms “coronavirus”, “COVID‐19”, “COVID” and/or “SARS‐CoV‐2”. The information is correct as of 30 April 2020.

Adrian YS Lee · Ming‐Wei Lin

In reply: Lee and Lin raise an important point about the need for caution in interpreting rapidly published articles in the era of coronavirus disease 2019 (COVID‐19). At the Medical Journal of Australia, we are acutely aware of the need to balance rapid dissemination of key data with the need to maintain our usual high standards of quality and accuracy. We have taken the view that in these unprecedented times, rapid sharing of information is critical, but we recognise the risk of errors this infers. In response, we have implemented a preprint and rapid review process for selected manuscripts of an urgent nature (Box). In order to minimise the risk of errors, all manuscripts are carefully reviewed by myself, our team of experienced and medically qualified editors and, where appropriate, our consultant biostatistician, before being selected for preprint in the MJA. Only where the editorial team have a high level of confidence in the validity and importance of the article will it be selected for rapid preprint publication. Before full acceptance of the manuscript to be published online and in print and, in selected cases, before we accept an article for preprint, we organise a rapid double blind peer review followed by revision in line with our usual stringent processes. In these circumstances, we endeavour to have this process completed within 7 days of preprint publication so that any errors can be quickly identified and corrected. We are very grateful to our reviewers who have been very generous in their assistance with this new process. One final check in our process on full publication is review and editing by our experienced scientific and structural editors, who meticulously check all articles for consistency, accuracy and referencing, while finessing them for readability and clarity of presentation — their expertise is invaluable in ensuring published manuscripts are presented accurately and in the best possible light. We acknowledge that contradiction and error may be inevitable during this rapidly evolving situation but would like to assure our readers that at the MJA, when errors occur, they will be rectified in a timely manner and with full transparency. While we are living in a world of rapid change, our commitment to providing Australian health and medical researchers, clinicians and policy makers with the world‐leading general medical journal they deserve stands strong. Box – MJA process for rapid publication of selected coronavirus disease 2019 (COVID‐19)‐related manuscripts* * Timing is indicative and may vary according to the complexity of the manuscript.

Nicholas J Talley

To the Editor: Rising obesity rates in high income countries have resulted in a growing demand for weight‐loss products.1 Unfortunately, drugs that increase energy expenditure often have severe adverse effects. 2,4‐Dinitrophenol (DNP) uncouples oxidative phosphorylation, inducing a hyper‐metabolic state. It was first used for weight loss in the 1930s but was banned due to deaths.2 It has recently had a resurgence in popularity in the body building/body sculpting arena as a “fat burner” and “pre‐event shredder”, and is available online and as an undeclared ingredient in supplements.1 DNP was up‐scheduled in Australia in 2017 to Schedule 10 (“substances of such danger to health as to warrant prohibition of sale, supply and use”).3 We used data from the New South Wales Poisons Information Centre (NSWPIC) and the National Coronial Information System (NCIS) to evaluate effects of up‐scheduling. Ethics approval was granted from the Sydney Children's Hospitals Network (LNR/16/SCHN/44) and from the Victorian Department of Justice (CF/15/18367) human research ethics committees. There were 24 DNP exposures reported to NSWPIC between 2004 and 2018, with an increasing trend (Box). Most patients (71%, n = 17) were male, 83% (n = 20) were adults aged 20–74 years, and 92% (n = 22) were in hospital or were referred to hospital by NSWPIC. The NSWPIC database showed one death — an adult man who had a cardiac arrest after taking four DNP capsules — and NCIS recorded three more deaths from DNP. All deaths occurred since 2015, with two occurring since the 2017 rescheduling. Despite up‐scheduling, we have identified rapidly increasing harms from DNP, which suggest a resurgence of DNP use. Increasing use and deaths have also been reported in the United Kingdom4 and the United States.5 This highlights the need for urgent action by state and federal law enforcement agencies and awareness campaigns targeting high risk groups. It is important to note that the Therapeutic Goods Administration makes scheduling changes but does not enforce non‐medicinal product restrictions, which is the role of police and Fair Trading. It is likely that DNP is frequently obtained online and often disguised for shipping (eg, labelled as turmeric), thus complicating detection.1 Increased incoming mail screening and awareness and education at gyms may be an option to restrain the use of DNP. Medical practitioners should warn patients of the dangers of illicit weight‐loss supplements. Box – Time trends in 2,4‐dinitrophenol exposures reported to the New South Wales Poisons Information Centre (NSWPIC) in 2004–2018. Up‐scheduling to Schedule 10 was announced in September 2016 and implemented in February 2017. The timing of deaths is censored due to low numbers; however, all deaths occurred since 2015, including two since the 2017 scheduling

Rose Cairns · Jacques Raubenheimer · Jared A Brown · Kylie McArdle · Nicholas A Buckley

To the Editor: The narrative review of diverticular disease by You and colleagues1 is most welcome. While highlighting the ubiquity of the problem and factors that facilitate the development of the disease and outlining an evidence‐based strategy to assess and manage the condition, it is also important to note patient factors, such as comorbidities treated with certain medications, which may facilitate uncomplicated disease becoming complicated. Further, commencing certain medications in patients with diverticular disease may often have unappreciated risks.2,3,4,5 Patients in the prevalent age group often have comorbidities, many of which may be treated with non‐steroidal anti‐inflammatory drugs, corticosteroids, opioids2 and, occasionally, with immunosuppressive therapy. Of these medications, the risk of perforations is highest with corticosteroids.4,5 Specifically, corticosteroids used in the management of rheumatic disease may increase the risk of diverticular abscess perforation 30‐fold.5 The association between complications of diverticular disease and the administration of various medications, particularly corticosteroids, must be emphasised,2,3,4,5 as both uncomplicated and complicated disease may present with non‐specific symptoms, suggesting a broad differential diagnosis.1 Medications must not be overlooked as an iatrogenic risk for complications for both existing and new users.

Mark H Arnold

To the Editor: Thiopurines are used in oncology, immunology and inflammatory bowel disease (IBD). In the coronavirus disease 2019 (COVID‐19) pandemic, patients taking thiopurines face uncertainty as to the risk of serious complications or death if infected. Traditionally, thiopurine use has been associated with an increased risk of opportunistic viral infections.1,2,3 A large IBD registry study found that using thiopurines and having active disease were associated with a higher risk of serious viral infection.3 However, all identified causative agents were species of the Herpesviridae genus.1,2,3 The risk associated with thiopurine use can therefore not yet be generalised to other virus genera, and indeed only corticosteroid use is associated with risk of contracting influenza in patients with IBD.4 COVID‐19 is caused by a novel coronavirus — the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) — and there are no available data from previous coronavirus strains such as SARS‐CoV or Middle East respiratory syndrome coronavirus (MERS‐CoV) to allow for estimation of risk in patients taking thiopurines.3,5 Although, intuitively, immunosuppression with thiopurines may increase the risk from COVID‐19, there are in vitro and in silico data to suggest that thiopurines constrain maturation of MERS‐CoV via inhibition of a viral protease.5 Although this study has not been replicated for COVID‐19 or progressed into animal models, it does raise the possibility that thiopurines use may not necessarily increase the risk of contracting COVID‐19. Thiopurine withdrawal is associated with a 12‐month relapse rate of 17–53% in patients with Crohn's disease and 11–77% in patients with ulcerative colitis.6 This is an important consideration in COVID‐19, as disease relapse requiring steroid use has previously been associated with increased risk of viral complications.3,4 The consequences of thiopurine withdrawal due to COVID‐19 are not yet clear and this information is eagerly awaited as many centres collect prospective data. Preliminary data from SECURE‐IBD — a COVID‐19 database for IBD — report 87 COVID‐19 cases to date in patients taking thiopurines, of whom 52 were managed as outpatients and 35 were admitted to hospital, with two reported deaths.7 These evolving data provide cautious support for the relative safety of thiopurines but cannot be interpreted conclusively in the setting of the rapidly evolving situation. Perhaps the best advice we can currently offer patients is that effective control of disease may carry less risk than poorly considered withdrawal of therapy. The Gastroenterological Society of Australia has issued recommendations that the minimum level of immunosuppression should be continued to control disease although a drug holiday may be considered in some patients with long term stable disease.8 This dilemma highlights the importance of online registries to gather vital data as we work together as a profession to provide evidence‐based advice for our patients during this pandemic.

Thomas M Goodsall · Samuel P Costello · Robert V Bryant

To the Editor: Climate change is this century's greatest global health threat. As the MJA considers the role of the health care sector in climate change, we urge readers to consider hospital food environments. Australia's health care system should be promoting diets that are healthy for both humans and the planet. A growing body of evidence suggests that healthier human diets have significant environmental co‐benefits. For example, reduced consumption of processed discretionary foods and red meats and increased consumption of fruits, vegetables and legumes have been shown to reduce the risk of certain non‐communicable diseases while also reducing diet‐related greenhouse gas emissions.1,2 Hospital food environments provide a useful intervention point to model and promote healthy, sustainable diets to Australians, as millions of meals are served to patients and their families in hospitals each year. Hospital food retailer guidelines have recently been developed by state governments and health care providers.3,4 To optimise health care food environments, a first step is to remove fast food outlets, vending machines and sugar‐sweetened beverages from hospitals. Inpatient food guidelines, however, are mostly outdated and sustainability is rarely considered. Inpatient food services should prioritise the delivery of fresh, locally sourced, unrefined foods with minimal packaging. Meals should adhere to dietary guidelines, be personalised to patients’ health needs, and minimise food waste. A recent audit by the Victorian Government into inpatient food services may provide an important opportunity to initiate reform.5 The Mater Group hospitals’ “at your request” room service exemplifies a cost‐effective food service model, showing improvements in patients’ nutrient intake, clinical outcomes, food waste reduction and patient satisfaction.6 Australia can also learn from the growing number of global initiatives to improve hospital food, including the New Zealand Ministry of Health's sustainability commitments, which include recommendations to encourage plant‐based eating, sustainable food sourcing and reductions in food waste.7 We should also look to innovative programs such as hospital rooftop gardens, hospital teaching kitchens, and traffic light labelling systems. To protect the health of humans and the planet, we urge state governments and health care providers to urgently evaluate hospital food quality, inpatient food services and retail food environments and implement new mandatory standards.

Genevieve Moseley · Luke Spajic · Georgia Behrens

To the Editor: We welcome the recent article by Secombe and colleagues1 highlighting the impact of alcohol policy reforms in the Northern Territory, namely the influence of the minimum floor price on critical care admissions.1 We agree that the social costs and harms of alcohol in the NT are too high,2 and are reassured by the improved health outcomes associated with the implementation of emerging alcohol policies.3,4 There have been, however, other notable alcohol and social policy investments in the NT, including the introduction of Police Auxiliary Liquor Inspectors (PALIs). PALIs are uniformed inspectors, stationed at takeaway alcohol outlets, who seek to prevent the consumption of alcohol in restricted areas. These areas include all land defined as Aboriginal land as per the Aboriginal Land Rights (NT) Act 1976,5 within 2 km of a licensed venue, and in certain regulated public and private areas. PALIs ascertain where individuals purchasing alcohol will be consuming their purchase by requesting a form of identification, alongside questions regarding intended drinking location. If a valid (non‐restricted) address cannot be provided, purchase is not permitted. The first squad of PALIs graduated on 20 August 2018. As noted by Secombe and colleagues, the minimum floor price was introduced on 1 October 2018. Considering the time of implementation of both policies, it is imperative that we better understand the intersection between PALIs, the minimum floor price and other alcohol policy initiatives, such as the Banned Drinker Register.6 The recent analysis by Secombe et al provides a partial snapshot of the impacts of a highly complex public health issue. Given that a suite of alcohol policies has been introduced by the NT Government to combat alcohol‐related harms,6 a more sophisticated evaluation approach is required to understand these relationships. This means a broader range of data sources need to be used to evaluate the impacts of alcohol policies in the NT. This should include health, police, corrections, domestic violence, child protection, and education data. Furthermore, to advance comprehensive understandings of these alcohol reforms, it is also imperative to include qualitative approaches that explain how and why different alcohol policies work.

Sarah C Clifford · Kalinda E Griffiths · James A Smith

Editor’s note: This is an update of a Letter to the editor originally published as a preprint on 16 March 2020 (https://www.mja.com.au/journal/2020/212/8/covid-19-precautions-easier-said-done-when-patients-are-homeless). To the Editor: Implementation of advice to the public and general practitioners on minimising the risk of COVID‐19 exposure and transmission is immensely difficult for people experiencing homelessness and for the health services working with them. Yet this is a population group more vulnerable to infection than most.1 The elevated risk factors for COVID‐19 are substantial, as people experiencing homelessness have a much higher prevalence of comorbidity and chronic disease compared with people of the same age who are housed.2 To illustrate further, among the 4000 active patients seen by Homeless Healthcare (Australia's largest specialist homelessness GP practice based in Perth), nearly all patients have comorbidities, 13% have chronic respiratory conditions, 79% smoke (associated with poorer lung health and risk) and 8% have diabetes (associated with supressed immunity). There are parallel calls in Australia and the United Kingdom for clearer government guidance as to how the precautionary measures can be applied in homeless populations. There are a myriad of challenges to this, both for people who are homeless themselves and for those providing health care to this vulnerable population group. These challenges include: Regular hand washing and hygiene (and accessing soap or sanitiser and bathrooms in order to do this) is extremely problematic if living on the street. Self‐isolation by staying at home if you feel unwell and suspect having symptoms is impossible if you do not have a home to live in. Reducing face‐to‐face health service contact is being advocated to GPs and health services in Australia and the UK. The Australian Government has just announced Medicare rebates for bulk‐billed telephone consultations,3 but this is problematic for people who are homeless without a phone. Similarly, technological solutions such as video or virtual consultations are digitally prohibitive for people without a home let alone a computer. Outreach health services are among the most effective ways of enabling people who are rough sleeping to access health care.4 Homeless Healthcare, for example, runs clinics at drop‐in centres and crisis accommodation settings and has nurses out on the streets each day and doing home visits to those recently housed. However, implementing the use of personal protective equipment is difficult in these settings, and in the absence of primary care outreach, emergency department presentations are likely to escalate. Cancelling outreach GP clinics and other outreach services for this population to reduce exposure risks would have severe unintended consequences. If risk factors for COVID‐19 or patients with COVID‐19 are untreated in this highly susceptible population, the mortality risk is high.1 Moreover, many people will not receive critical treatment for other medical conditions, such as depot medications for psychotic illness and, as articulated in a recently published article, “lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration”.1 The higher risks of COVID‐19 for people experiencing homelessness and, consequently, for those working closely with them present an enormous challenge that has no easy answers. As new precautionary measures are being announced daily, it is critical that further marginalisation for this group is not an unintended consequence.

Lisa J Wood · Andrew P Davies · Zana Khan