Letters

New

Ben Dunne · Michael Forrester · Eugenie Kayak

Velandai Srikanth

Thomas Cueni · Elizabeth Somer

Alain Braillon · Wendy A Rogers

Helen Y Sun · Yaron Gu · Deshan F Sebaratnam

Oliver Kleinig · Christina Gao · Stephen Bacchi

To the Editor: The incidence of lung cancer and the five‐year survival of patients diagnosed with lung cancer reflect the social gradient within the Australian society. Most notably, Aboriginal and Torres Strait Islander people are twice as likely to develop lung cancer and half as likely to survive lung cancer.1 Reducing inequity in lung cancer outcomes was a key objective of Cancer Australia when it proposed a National Lung Cancer Screening Program (NLCSP) in 2020, following an enquiry that consulted both medical experts and the broader community.1 The Department of Health sought funding for Cancer Australia's proposed NLCSP in the 2021–2022 Budget but was required by the Department of Finance to refer the proposal to the Medical Services Advisory Committee (MSAC) for review.2 So, when MSAC recently announced its support for the creation of the NLCSP, there was great relief within the lung cancer community. However, what few people seemed to realise was that MSAC had in fact designed, then endorsed, their own alternative model for an NLCSP.3 MSAC's model is fundamentally different to Cancer Australia's model in terms of who is eligible to be screened and, therefore, who can benefit from the screening program. Whereas Cancer Australia intended using an individual's risk of lung cancer (as estimated by the PLCOm2012 risk calculator, which combines sociodemographic data and smoking history),4 MSAC recommended using fixed cut‐offs for age and smoking history. This is problematic in terms of both the evidence base that should have guided MSAC's decision and the ethical implications of the decision. MSAC's approach aligns with the design of historical lung cancer screening trials but it ignores an extensive body of evidence, including both a priori and post hoc analyses of trial data that consistently demonstrate that risk calculators are more efficient than fixed criteria.5 Furthermore, it also ignores international trends in the design of lung cancer screening trials and the implementation of lung cancer screening programs.1 But more importantly, the inevitable consequence of applying MSAC's eligibility criteria will be that fewer socially disadvantaged individuals will be eligible to participate in the NLCSP. This has the potential to exacerbate the existing inequity.

Jonathon B Ryan

Joshua M Inglis · Ganessan Kichenadasse · Arduino A Mangoni

Sandra C Hayes · Dimitrios Vagenas · Monika Janda

Melanie Bahlo

To the Editor: The flavivirus Murray Valley encephalitis virus (MVEV) was isolated in 1951 from the brain tissue of fatal cases of encephalitis.1 Subsequent work by Australian investigators established MVEV as the likely aetiological pathogen of the severe encephalitis “Australian X disease”.1 MVEV is enzootic in northern Western Australia and the Northern Territory, resulting in sporadic human cases.2 In south‐east Australia, however, MVEV activity can be absent for decades only to reappear with significant human outbreaks. The three most recent outbreaks in Australia were in 1951 (45 cases), 1974 (58 cases) and 2011 (17 cases).1,2,3 The case fatality rate is about 18% in hospitalised patients, reflecting the severity of disease.4 Since 1974, Victoria has employed vertebrate and invertebrate surveillance methods to detect MVEV activity before human cases.5 Until 2021, sentinel chicken flocks were placed along the Murray River and tested weekly for MVEV seroconversion during the mosquito season, which runs from November to April. The most recent seroconversions were in 2011, along the Murray River, in Greater Bendigo, and in Greater Shepparton.6 This testing strategy was limited by biological and logistic delays, diminishing the system as an early warning tool. In 2021, sentinel chickens were retired, with flavivirus testing combined into the long‐standing alphavirus mosquito trapping program when polymerase chain reaction (PCR) assays replaced labour‐intensive and insensitive cell culture methods.7 For the 2022–2023 mosquito season, in the setting of Japanese encephalitis virus activity and historic floods, the Victorian Department of Health supported 15 councils to trap mosquitoes as part of the Victorian Arbovirus Disease Control Program (VADCP). Trapped mosquitoes were pooled and submitted for PCR testing. The size and composition of these varied depending on the number of collected mosquitoes, with a preference for analysis of speciated mosquitoes if possible. Detections were confirmed with sequencing at a reference laboratory. As of 23 January 2023, we have detected MVEV in 14 mosquito traps across four local government areas (Box). The positioning and density of the traps are influenced by proximity to population centres and resource considerations, which may influence the likelihood of virus detection in different localities. The first detection was in mosquitoes collected on 4 January 2023. New South Wales and South Australia have also reported MVEV detections in multiple locations. Subsequently, on 17 February 2023 the first human case of MVEV infection in Victoria since 1974 was confirmed after lengthy investigation of a person with illness onset on 16 January 2023. This represents the first detections of MVEV in south‐east Australia in the 2022–2023 mosquito season, the first surveillance detections in Victoria since 2011, and the first confirmed human case in Victoria since 1974. The timing of these signals is notably earlier in the season than previous sentinel chicken seroconversions, which occurred in February 2011, supporting mosquito PCR testing as a rapid surveillance tool. This difference in timing may, however, be explained by inter‐year environmental or sampling factors, and a controlled comparison between mosquito and sentinel chicken surveillance, in the context of subsequent human cases, is required to demonstrate the most useful surveillance tool. Nonetheless, the presence of virus and capable vectors suggests the risk for human infection is present, and, importantly, informs public health actions. MVEV in south‐east Australia is rare and the time between outbreaks is measured in decades. These early mosquito surveillance signals have preceded a human health event which has not occurred in Victoria since 1974. In the absence of an effective vaccine, prevention relies on vector control and health promotion, while case detection requires clinician awareness. Retrospectively, a serosurvey will be essential to measure the extent of human exposure during this period of MVEV activity. Finally, given our understanding of MVEV in Victoria is limited by a paucity of historical events to analyse, researchers should engage in this rare opportunity to study MVEV epidemiology and ecology. Box – Victorian local government areas (LGA) with the first 14 polymerase chain reaction (PCR) detections of Murray Valley encephalitis virus in trapped mosquitoes in 2023 (shaded in red). LGAs where surveillance was undertaken are outlined. The inset shows the Australian state of Victoria shaded‐in and the dates of mosquito collection and notification to the Department of Health * Greater Bendigo LGA.

Maxwell Braddick · Aidan Yuen · Rebecca Feldman · N Deborah Friedman

To the Editor: Curtis and colleagues1 describe important implications for consideration as the metaverse begins to affect health care. These implications are particularly salient for individuals with specific physical impairments, especially vision loss. Emphasis on visual input in the metaverse may have implications for patients with vision loss. The lack of tactile input in the metaverse will disproportionately affect people with profound vision loss. The consequences include social isolation, motion sickness, and reduced access to services. In addition, people who lack stereopsis may also be disadvantaged in a metaverse. These individuals do not experience the stereopsis‐derived depth perception required for the three‐dimensional perception of the visual world. Efforts must be made to ensure that monocular depth cues, including linear perspective and motion parallax, are considered during metaverse development.2 Should health care be provided via the metaverse, vision impairment may limit access to these services. Difficulty accessing services may lead to deterioration in ocular conditions and potentially compound the initial vision loss precluding access.3 There are existing strategies that facilitate the use of visual media for people with vision impairment. These methods have been developed for telecommunication, cinematic and video game technologies. Mechanisms to improve accessibility, including having the capacity to increase text size substantially without disrupting user interfaces, could be employed in all screen‐based technologies.4 Effective accessibility features, such as adaptive audio description, must be available for visually impaired users. Ongoing technological development may facilitate metaverse access for people with visual impairment. There is ongoing research into the optimisation of head‐mounted and digital visual displays to facilitate use for those with vision impairment and visual field defects.5 However, this digital display technology will not facilitate access for people with profound vision loss, such as those with no perception of light. Moving forward, companies should strive to provide equal access to services to all individuals, including those with visual impairment. Regulatory frameworks may help to standardise this incorporation of accessibility. The proactive consideration of the needs of the visually impaired during the development of the metaverse may facilitate the implementation of more effective technology. Engaging disability stakeholders during testing phases of technology may help to identify issues at early stages of development.

James Pietris · Yiran Tan · Weng Onn Chan