Letters

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

Debra J Rickwood · Jason Trethowan · Patrick D McGorry

Brendan Harney · Michael Curtis · Peter Higgs

To the Editor: The impact of the coronavirus disease 2019 (COVID‐19) pandemic continues to affect institutional care, both acute and aged care services. More hidden is the impact on community care, especially community palliative care. Community palliative care aims to enable people to die where they wish. About 70% of the population seek to die at home, but between 4% and 12% actually do.1 During the COVID‐19 pandemic, however, data from three Melbourne community palliative care services indicated a rise in deaths at home of between 30% and 50% (personal communication, John Doran, Manager, Melbourne City Mission Palliative Care; Janet Phillips, Chief Executive Officer, Peninsula Home Hospice; and Kelly Rogerson, Chief Executive Officer, Palliative Care South East; December 2022). This increase has not been recently reported in Australia. One factor may be family reticence to admit their family member for inpatient care because of continued visitor restrictions2 — also reflected in international literature.3,4 Consequentially, the client profile has changed as more people present with complex needs and a higher number need terminal care. This requires lengthier visits from clinical staff — one service employed a registrar to support general practitioners (personal communication, Janet Phillips, December 2022). More emphasis is placed on telehealth, now routine, often substituting every second scheduled visit; and many staff work from home (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). The use of in‐home overnight respite has markedly increased, providing additional support to family carers (personal communication, Janet Phillips, December 2022). Perhaps because of increased workload, locum doctors are less available, meaning that palliative care staff are increasingly called on to support terminal care, including complex symptom management, and to verify death (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). Staff are still required to do regular risk assessment, including COVID‐19 testing, and to wear personal protective equipment, aligned with Department of Health guidelines for health care workers.5 A significant number of inpatient bed‐days are saved when people are supported to die at home, which may reduce the burden of care in institutional settings.6 Further work is required to measure the impact of home‐based care on outcomes for terminally ill people and their families and to understand the value of that care to the health care system.

Margaret O'Connor

To the Editor: Haining and colleagues discuss compensation for medical practitioners in supporting patients through the voluntary assisted dying process, which requires much time and effort.1 We want to inform you how the Netherlands, where euthanasia has been performed since 2002, has dealt with this challenge. A Dutch physician who performs euthanasia must evaluate whether a patient is suffering hopelessly and unbearably, is adequately informed, has no reasonable alternatives available, and is making a voluntary and well considered request. A second independent physician also needs to evaluate the patient, which often requires multiple house visits. Six weeks after the procedure, a review committee establishes whether all due diligence requirements were fulfilled. In 2021, 7666 people underwent euthanasia in the Netherlands, mostly performed by general practitioners for patients suffering from a malignancy.2 Everyone who lives or works in the Netherlands is legally required to have health insurance. Insurance companies finance the health costs through premiums and an income‐related contribution, collected through the government's tax on wages. On a side note: for religious reasons, it is possible to choose an insurance company that does not reimburse the costs of euthanasia or abortion. Every patient needs to be registered with a specific GP, who receives a registration payment every three months from the health insurer of between €18.76 and €51.86 (AU$30.37 and AU$83.96 at 3 April 2023), depending on age. When the patient visits the physician, an additional €11.51 (AU$18.63) is paid.3 However, as euthanasia is a time and effort consuming trajectory, the physician is entitled to additional compensation. Several home visits are required to investigate and explore the euthanasia request, for which the physician receives €88.85 (AU$143.84) per visit. On the day euthanasia is performed, the GP receives €269.99 (AU$437.09) from the health insurer. The second, independent physician receives €602.27 (AU$975.01) for their efforts. The pharmacist who prepares and processes the return delivery of the euthanasia drugs can invoice €274.00 (AU$443.58). Here, we have provided some insight into the compensations for physicians and pharmacists who facilitate euthanasia in the Netherlands, and we hope this can contribute to the discussion on the remuneration of this important work in Australia.

Stefan Leus · Jan Bollen

To the Editor: We thank Gibney and Steer for their editorial1 in response to our research letter,2 supporting further public health action and research into invasive group A streptococcal (iGAS) disease. However, we are concerned about the statement that the 30‐day risk of iGAS disease for contacts of someone with an index infection is about 2000‐fold higher than background risk. This figure is derived from an English population‐based study3 and cannot be universally applied across circumstances varying in background incidence of GAS‐related disease, which is driven predominantly by socio‐environmental factors. Applying this 30‐day secondary attack rate of iGAS infection in Northern Territory household contacts would translate to about 177 cases per 1000 population (18%) in Indigenous Australian contacts and 2738 per 1000 population (274%) in people receiving haemodialysis.2 In contrast, rates of iGAS infection in household contacts were 3.2 per 1000 population in Canada4 and 0.7 per 1000 population in the United States.5 As described in the NT public health guidelines for iGAS, previous NT and Queensland studies have demonstrated large diversity of iGAS genotypes,6 with less clonality and a greater proportion of sporadic cases rather than transmission directly from another case of iGAS infection. This reflects the stark contrasts in iGAS and other consequences of GAS infection between central and northern Australia and southern states, as seen with so many other health issues linked to socio‐economic disadvantage. Gibney and Steer also note that some authorities recommend antibiotic prophylaxis for close contacts, and others do not.1 We wish to highlight that the NT guidelines for the public health response to iGAS include specific guidance around antibiotic prophylaxis for close contacts (for mother–neonatal pairs, contacts of severe iGAS disease cases, and in other special circumstances), informed by a literature review in the Appendix.6 National guidelines for iGAS are currently being developed and these need to include advice tailored for the vastly different epidemiology seen across Australia, reflecting a contrasting diversity of endemicity of GAS‐related disease. This has also been necessary for the Australian guidelines for diagnosing acute rheumatic fever, with low risk and high risk populations defined.7

Johanna M Birrell · Bart J Currie · Vicki L Krause

To the Editor: Paradoxically, both vitamin B6 deficiency and excess are associated with peripheral neuropathy. Increasingly, patients are presenting with peripheral neuropathy associated with elevated vitamin B6 whole blood levels, as previously presented by our laboratory.1 With a societal push towards wellness, there has been a greater uptake of over‐the‐counter vitamins in recent years. Magnesium is taken by patients for muscle, nerve and digestive issues, as well as for stress, anxiety and overall wellness. For some of these listed indications, the evidence is dubious. Vitamin B6 (as pyridoxine hydrochloride) is common among magnesium supplements based on the theory that the cellular uptake of magnesium is enhanced.2 These supplements are readily available in pharmacies, supermarkets and online, and contain up to 60mg of vitamin B6 per tablet. When purchasing magnesium supplements, patients may be unaware that they are also getting vitamin B6 and the quantity included could be hazardous to health. A patient taking two magnesium tablets per day could be unintentionally consuming 120mg of vitamin B6, now considered a large dose. This is far greater than the recommended dietary intake of vitamin B6 for adults in Australia and New Zealand of 1.3–2.0mg/day with a maximum of 50mg/day.3 The pharmacokinetics of pyridoxine hydrochloride are complex. Despite being water soluble, it has a half‐life of up to 30 days. Repetitive small doses taken over a period of months can accumulate, resulting in high blood concentrations. Vitamin B6 is associated with peripheral neuropathy when whole blood levels exceed 250nmol/L.4 Our laboratory recently presented a study showing that about 39% of our patients had elevated vitamin B6 whole blood levels (>190mol/L, the upper limit of our reference interval). The study included data from 88655 samples.1 A recent regulatory change from the Therapeutic Goods Administration mandated that products containing vitamin B6 in daily doses above 10mg now require a label warning.5 This previously applied to products containing over 50mg per daily dose. The Therapeutic Goods Administration has also reduced the maximum permitted daily dose from 200mg to 100mg for adults. It also noted cases where peripheral neuropathy developed in patients taking less than 50mg daily.5 This change applies to products produced after 1 March 2023 and therefore does not apply to products purchased before this date. In addition to being present in magnesium supplements, vitamin B6 (as pyridoxine hydrochloride) is contained in many multivitamins and energy drinks. Community awareness is key.

Gemma M Daley · David Kanowski · Lee Price

To the Editor: O'Shea and colleagues1 have highlighted the importance of precision medicine and recognised that health care systems are struggling to adapt to new genomic innovations. New technologies are frequently distributed unevenly and follow socio‐economic gradients, and health care systems have a responsibility to ensure equitable access.2 In South Western Sydney, there is a significant population of culturally and linguistically diverse people whose genetic risk factors for cancer development and treatment are different to those of the greater Sydney population. Consequently, the Department of Anatomical Pathology at Liverpool Hospital has offered next generation sequencing (NGS), using the 50‐gene Oncomine Precision Assay (ThermoFisher Scientific) for multiple tumour streams, including non‐small cell lung cancer (NSCLC) and colorectal cancer. A nine‐month internal audit of 400 patients has found that 77% of patients with stage IV NSCLC and 82% of patients with stage IV colorectal cancer had at least one gene mutation identified using this panel. Currently, the European Society of Medical Oncology has put forward a clinical scale of actionability of molecular targets, ESCAT, to help clinicians understand the utility of genetic variations in cancer.3 The guidelines define mutations from tier I to tier X based on degree of actionability. The NGS results found that 56% of patients with colorectal cancer and 50% of patients with NSCLC had tier I mutations, defined as those with clear evidence of clinical actionability. Twenty‐one per cent of patients with colorectal cancer and 28% of patients with NSCLC had tier II or III mutations with potential actionability. In addition to providing access to standard of care treatments, NGS provides a means for patients to access novel clinical trials. In our cohort, about 45% of both NSCLC and colorectal cancer patients had additional mutations on the 50‐gene panel that are currently being investigated in early phase clinical trials. Standardisation and funding of testing across Australia is critical to prevent inequities of access to testing, especially in patients in South Western Sydney with lower rates of private health insurance, high rates of socio‐economic disadvantage and low rates of health literacy. Currently, there are a limited number of centres available in New South Wales to provide NGS testing and, thus, now is the right time to get it right for all Australians.

Udit Nindra · Abhijit Pal · C Soon Lee

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community. Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4 Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5 Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3 Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3

Rosalie Schultz

To the Editor: Kamini Vidrawan Ras (Kamini) is an opiate‐containing Ayurvedic preparation with multiple purported functions.1 Kamini comes in the form of handmade tablets or balls, with varying quantities of opium within the tablets ranging from 2mg to 20mg.2 Chemical analysis of Kamini tablets revealed a variety of opioid alkaloids and heavy metals such as lead, mercury and arsenic.2 There are reports of patients suffering significant harms from heavy metal poisoning after ingestion of Ayurvedic medicines.3 Evident risks of the use of Kamini include the development of de novo opioid use disorder, use of the preparation as an additional opioid source by current opioid users, and contribution to potential harms including overdose, particularly when combined with other opioids or drugs. In Australia, Kamini poses a public health concern as an unregulated opiate‐containing medication available in certain Indian grocery stores.4 Australia is trying to curb the harms associated with opioid medications through real‐time prescription monitoring and various other interventions. As opioid medications are being increasingly scrutinised and rationalised, importation of Kamini into Western countries could increase. In 2016, the Therapeutic Goods Administration prohibited the importation of Kamini, but patients are still presenting with opioid use disorder‐associated with this Ayurvedic preparation.1,2,4 The limited evidence regarding treatment and management of opioid dependence related to Kamini shows that the majority of patients can be stabilised with opioid substitution therapy, remain engaged in treatment, and cease Kamini use.1,4 Most patients (22/24) in the two largest case series on Kamini use were of Indian background and a large proportion were of Punjabi origin.1,4 Some sociological studies about Punjabi men and the cultural norms within this community state that it is appropriate to use substances to deal with stress and to increase productivity.5 Traditional views on the role of medications can be precipitating and perpetuating factors for ongoing substance use and could lead to poorer health outcomes. Treatment for patients with Kamini dependence should include culturally appropriate and specific education.

Thileepan Naren · Jon Cook

To the Editor: Nursing homes need enough qualified, skilled staff to care for residents with diverse clinical needs and preferences. Even though most staff are personal care workers, registered nurses and enrolled nurses represent the majority of registered health care professionals. The Royal Commission into Aged Care Quality and Safety heard that, by 2050, best practice nursing home care will require about 7170 more enrolled nurses.1,2 Despite this, the importance of enrolled nurses in the sector is overlooked. Newly legislated minimum time standards and requirements for registered nurses’ presence 24/7 do not explicitly include enrolled nurses.3 This means employers are incentivised to use other staff, particularly personal care workers. There are already reports of providers making enrolled nurses redundant despite staff shortages, risking further workforce deprofessionalisation and possible worse outcomes for both residents and staff.4 Although evidence specific to enrolled nurses is limited and must increase,5 they are valuable, regulated staff members in nursing homes and their role represents an important step in career progression between personal care workers and registered nurses. If Australia is to develop a world‐class aged care sector that prioritises the best possible resident outcomes and experiences and matches staffing levels and skills to the needs of residents, then enrolled nurses must be valued multidisciplinary team members. Necessary legislative change should mandate a minimum time standard for direct care staff that includes clear specification of the enrolled nurses’ role and contribution.

Micah DJ Peters

To the Editor: Over 26000 Australians experience out‐of‐hospital cardiac arrest (OHCA) each year, with almost nine in ten of these patients not surviving to hospital discharge or 30 days.1 Although it is known that swift defibrillation increases the possibility of patient survival in these situations, and that initial defibrillation by first responders (regardless of training) is associated with greater survival than initial defibrillation by emergency medical services,2 in Australia, less than 2% of OHCA cases receive defibrillation by a bystander.1 It is likely that this is driven by the limits to publicly accessible automated external defibrillators (AEDs) in Australian communities.3 On 30 November 2022, South Australia took a major step to deal with this problem and reduce death from OHCA. The SA Parliament passed the Automated External Defibrillators (Public Access) Bill 2022,4 making SA the first state or territory in Australia, and one of few in the world, to mandate the public provision of AEDs. The legislation, introduced by Member of the Legislative Council, the Hon Frank Pangallo of the SA‐BEST party, had bipartisan political support and backing from various organisations, and follows a recent public health campaign to install AEDs in Adelaide. The Bill will come into effect for government and public buildings in 2025 and a variety of private buildings in 2026, with awareness campaigns, grant programs, and communication with organisations being the focus of the interim period. The expected cost to the SA government of $7.2 million across four years is weighed against the $2 billion gross domestic product loss that Australia incurs annually as a result of sudden cardiac arrest.5 The health and economic benefits of public access defibrillation to Australian society are large. For the benefit of all Australians, other states and territories should follow the example set by SA and move to implement similar laws mandating the public availability of AEDs in their communities.

Joshua G Kovoor · Gregory J Page · Pramesh Kovoor