Perspectives

During the pandemic, cancer survivors are lost in transition

Bogda Koczwara

COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020. Unemployment alone is associated with a two‐ to threefold increased relative risk of death by suicide compared with being employed,3 and sudden spikes in unemployment are associated with corresponding surges in the population rates of suicide.4 The global financial crisis, which led to the deepest recession since the 1930s and the loss of 30 million jobs worldwide, is estimated to have resulted in at least 10 000 additional economic suicides between 2008 and 2010 in Europe and North America.5 Projections using historical data suggest suicide rates may increase by 3.3–8.4% over the 2020–2021 period in the United States6 and up to 27% in Canada.7 Of course, all this is speculative and although the links between economic recessions and suicide are well documented, what is less clear is how the relationship plays out in the context of larger sociocultural and health events such as COVID‐19. The 1918–1920 influenza pandemic caused around 39 million deaths worldwide and resulted in governments implementing quarantine, public hygiene and social distancing policies, but evidence regarding its impact on world economies and suicide is limited. The severe acute respiratory syndrome (SARS) epidemic of 2003 came at the height of the Asian financial crisis, so disentangling the two is difficult. However, during this period, suicide rates in a number of Asian nations increased in tandem with unemployment, reaching historical peaks in 2003.8 As the situation continues to change daily, an accurate estimate of likely unemployment resulting from the COVID‐19 pandemic is difficult. Even current estimates under‐represent the impact, as individuals who are still employed but at significantly reduced hours are discounted. This is of particular concern when considering the global financial crisis, which saw Australian unemployment take a comparatively minor increase from 4.0% to 5.8% and coincided with an increase in suicide rates of 22% and 12% for unemployed men and women respectively.9 As the present crisis may potentially double the current unemployment rate, one can extrapolate to alarming conclusions, with some (albeit unpublished) modelling reflecting this projection.10 Despite this grim speculative forecast, this is not the whole story. There are marked differences between the present crisis and those that have come before. For instance, the current recession is supply (rather than demand) driven, and the prospect of recovery, although slow, is conceivable and may bolter optimism. Although major industries will be severely affected, there is potential for increased local spending as the borders remain closed. In addition, some hope may be found in the resilience shown by civilians in times of global unrest — for instance, the often cited “Blitz spirit”11 — and the possibility that the shared experience of the pandemic might bring a sense of social cohesion, which may prove life‐preserving. Notwithstanding considerable evidence of the psychosocial impacts of mass unemployment, we argue that the impact of the COVID‐19 pandemic on suicide rates is far from predetermined, and that early and sustained action can prevent many suicides and other adverse mental health outcomes. During prior recessions, Austria, Sweden and Finland have each displayed resilience in the face of substantially increased unemployment.5 In fact, despite sizeable rises in unemployment rates in Sweden and Finland in the early 1990s, the rate of suicide decreased.4 We suggest that, based on the available literature, there are several factors that may moderate the impacts of widespread unemployment. These include both early prevention measures and crisis care: sustained welfare spending; labour market programs and protections; and adequate funding of, and access to, mental health services, including prevention programs and engaging new technologies in the reporting and care response. Firstly, countries with sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job search initiatives for the unemployed.12 Robust social policies to ensure adequate welfare benefits for people with low or sudden loss of income are thought to be central to offsetting the impact of the recession on suicide.13 Where governments expand public welfare spending in the wake of disasters, there is good evidence for a reduction in suicide. The federal government's introduction of the JobKeeper and JobSeeker payment schemes are likely to mitigate suicide risk while simultaneously stimulating the economy and require long term investment. Secondly, countries with active labour market programs, which assist the unemployed to find work or retrain, and those with labour market protections have lower rates of unemployment‐related suicide than countries that do not.12 It has been estimated that, during European recession periods in the past 50 years, each US$100 per capita of investment in active labour market programs reduced the association of unemployment with suicide by 0.4%.4 Thirdly, it is critical that investment is made immediately in mental health, not just in terms of treatment but also in evidence‐based prevention programs. Different approaches are required to reduce attempts, and deaths, involving both public health and clinical services. In terms of direct suicide prevention interventions, there is increasing evidence for multilevel systems approaches — using components ranging from individual‐level (eg, assertive aftercare, psychosocial interventions) to public health interventions (eg, general practitioner and gatekeeper training),14 in addition to indirect interventions (targeting risk factors). Critical to effectiveness is the degree of penetration of these services, based on early population modelling, and the types of factors likely to differentially affect communities, including indigenous communities. Improving quality, availability and access to programs and crisis support services is vital to preventing suicide,14 with the current crisis both creating new challenges and compounding pre‐existing systemic issues. While the mental health sector is rapidly mobilising to improve access and the government has been quick to revise the Medicare rebate in this regard, it is vital that resource allocation and innovation continues beyond the span of the physical distancing measures. While increasing telehealth services is critical, the health professionals available to support them are unlikely to increase to meet need, and blended services that include automatised digital components may be a more efficient solution. The additional $48.1 million in mental health funding announced in May 2020 is a positive step; however, further funding for evidence‐based prevention initiatives is more important than ever to alleviate demand on treatment services. In terms of suicide prevention, digital interventions may hold some utility for both at‐risk and actively suicidal individuals, especially where other health services are lacking.15 Of course, economies undergoing recessions by their very nature have significant financial constraints, and governments will inevitably have to review spending across all services. It is critical that these limited funds are directed toward the most viable and cost‐effective services. Importantly, not all groups are affected equally, and subgroup consideration is vital. In crisis periods, it can be the most disadvantaged groups that are disproportionately affected, and marginalised and at‐risk populations require specific attention. It is also important to consider that many of the adverse consequences of job loss, including house repossession, mounting debt, mental health problems and relationship strain, are delayed and, therefore, long term investment is required.16 Finally, engaging new technologies in the fight against suicide may present a valuable new tool. This includes information technology‐enabled coordinated care and the dynamic reporting of suicide risk using immediate and real‐time data so that developing hotspots can be identified and shut down and local services can be mobilised. Although this field of study is in its infancy, the potential for concepts such as integrated, geospatial mapping, hotspot surveillance, and real‐time reporting could lead to significant advancements in predicting and intervening in suicidal behaviour.17 Ultimately, the economic fallout resulting from the COVID‐19 pandemic represents a threat, requiring urgent mobilisation and planning. There are certain steps required to moderate the mental health impacts of widespread unemployment, including sustained welfare spending; labour market programs; adequate investment in, and access to, mental health treatment and prevention services; and the dynamic reporting of suicide risk to aid regional responses and means restriction. The current economic crisis presents an opportunity to implement policies that would not only mitigate the impact of the recession on suicide but may incidentally reduce the national health and economic burden presented by emotional distress in any economic cycle. In doing so, there may be the ability to emerge from the current crisis stronger and more resilient as a nation.

Mark Deady · Leona Tan · Nathasha Kugenthiran · Daniel Collins · Helen Christensen · Samuel B Harvey

Tetrahydrocannabinol‐containing (THC) products with vitamin E additives are implicated in the pathogenesis of EVALI Electronic cigarettes, or e‐cigarettes, are battery‐powered devices that heat liquids containing nicotine and other chemicals in order to produce vapour.1 “Vaping” is the act of inhaling the vapour produced by an e‐cigarette.1 First marketed in 2005, e‐cigarette use is viewed by many as less harmful than traditional cigarette smoking, and championed as a strategy for smoking cessation.1,2,3 A detailed discussion of e‐cigarette use in smoking cessation is available in the United States Surgeon General's 2020 report, and is beyond the scope of this article; however, the report states that “there is presently inadequate evidence to conclude that e‐cigarettes, in general, increase smoking cessation”.2 Thus far, no e‐cigarette product for the therapeutic purpose of smoking cessation has been submitted to Australia's Therapeutic Goods Administration for safety evaluation or approval. Vaping in the US was initially associated with nicotine‐containing solutions. However, it is important to note that nicotine or nicotine salts may no longer be the only active ingredient in vaping solutions.1,4,5 In particular, unregulated vaping solutions or “home‐brew” products that contain tetrahydrocannabinol (THC) oil, or cannabinoids, can be obtained in the US.4,6 Vaping solutions come in a wide range of flavours, many designed to appeal to adolescents.1,2 Indeed, e‐cigarette manufacturers have used celebrity endorsements and social media‐based marketing campaigns to target adolescents, and these strategies appear to have been highly successful.1,2 There has been significant uptake of vaping among tobacco‐naive high school students, particularly in the US, where it is estimated that one in four high school students are current e‐cigarette users;7 moreover, in 2019, 14% of year 12 students reported vaping cannabis in the preceding 30 days.8 Between 2011 and 2018, e‐cigarette use increased among US high school students from 1.5% to 20.8%, even when traditional cigarette use declined from 15.8% to 8.1%.9 Consequently, from 2017 to 2018, overall use of tobacco products (traditional and e‐cigarettes combined) increased from 19.6% to 27.1%.9 In contrast, e‐cigarettes use among adults in the US has remained largely stable at 8.1 million e‐cigarette users (3.2%).10 It is possible that for young non‐smokers, e‐cigarettes may normalise smoking and serve as a gateway to nicotine dependency and traditional cigarette smoking, although this is strongly debated.1,9 In 2016, the Australian National Drug Strategy Household Survey reported that e‐cigarette use within the 12–17 and 18–29 years age brackets was about 7.1% and 16% respectively.11,12,13 The 2017 Australian secondary students’ alcohol and drug survey found that 13% of students had used an e‐cigarette at least once.14 Of the 2410 students who used an e‐cigarette, 48% reported that they had never smoked a traditional tobacco cigarette before using an e‐cigarette.14 E‐cigarettes may be perceived by young people as “a cool new gadget” and “safer than smoking”.1 Unfortunately, it has become abundantly clear that the use of illicitly sourced e‐cigarettes can be dangerous.10 In 2019, disturbing reports emerged of an acute and, for some, deadly outcome from vaping.15 Across the US, e‐cigarette users began to be admitted to hospitals with acute respiratory failure. In August 2019, the first fatality was documented in Illinois, while 200 other cases across 22 states were under investigation by the Centers for Disease Control and Prevention (CDC).15 This epidemic has spread very rapidly. There have been over 2800 hospitalised cases reported from every US state and territory and a total of 68 deaths.16 Patients were predominantly male (66%) and under 35 years of age (76%).6 [Correction added on 2 July 2020 after first online publication: Information has been updated on the second last sentence.] The CDC has termed this new disease “e‐cigarette or vaping product use‐associated lung injury” (EVALI)17 and has proposed four obligatory criteria for its diagnosis: use of an e‐cigarette (“vaping”) in the 90 days before symptom onset;18 pulmonary infiltrates or ground glass opacities on x‐ray or computed tomography scan; absence of pulmonary infection (defined by negative respiratory viral panel, negative influenza polymerase chain reaction, negative urinary pneumococcal antigen and sputum culture including Legionella, and bronchoalveolar lavage [BAL] culture); and no evidence of an alternative plausible diagnosis such as a cardiac disease or a neoplastic process.17,18 Patients with EVALI typically present with both respiratory (dyspnoea, cough, fever) and gastrointestinal (nausea, vomiting, diarrhoea, abdominal pain) symptoms.15,19 Usually, there is no prior history of respiratory disease. Diagnosis may be challenging, as EVALI can mimic infective pneumonia and gastrointestinal symptoms may sometimes precede respiratory symptoms.15 Respiratory failure may be severe enough to require invasive ventilation and intensive care support.15,19 Imaging findings include ground glass opacities on chest imaging,20 suggesting diffuse lung injury with bronchiolitis obliterans and cryptogenic organising pneumonia.19 Pathologically, limited lung biopsies have shown acute lung injury, acute fibrinous pneumonitis and diffuse alveolar damage.21 “Foamy” or lipid‐laden macrophages are often seen, suggestive of lipoid pneumonia.15 Aetiology and pathophysiology of EVALI: reasons for its recent emergence Careful epidemiological investigation has revealed two key findings explaining the recent emergence of EVALI after more than a decade of e‐cigarette use. Firstly, 80% of hospitalised patients with EVALI have admitted to using THC vaping products.6 Eighty‐four per cent of the reported THC products were acquired via informal channels and were probably manufactured outside of regulated facilities.15 The CDC identified “Dank Vapes” — a group of largely counterfeit THC‐containing products — as the most commonly reported THC brand across the US and used by 56% of patients with EVALI admitted to hospital.6 In contrast, only 13% of hospitalised patients with EVALI reported exclusive use of nicotine‐containing products; however, traces of THC were found in BAL samples.6,19 There may be unreliable self‐reporting and it is possible that the nicotine e‐cigarettes may have been contaminated by black‐market THC additives. Most patients reported using combination products containing either THC, cannabidiol or nicotine.6 Secondly, there is mounting evidence that a specific additive to vaping solutions — vitamin E acetate — played a major role in the 2019 EVALI outbreak.19,20 It is hypothesised that vaping the vitamin E acetate oil causes direct lung injury and lipoid pneumonia.21 Supporting this, BAL fluid from 51 patients from 16 states diagnosed with EVALI yielded vitamin E acetate in 94% (48/51) of the BAL samples.19 In an analysis of the THC‐containing e‐cigarette products used by 12 patients, vitamin E acetate was found in products from 11 patients.19 It is likely that this substance was added as a diluent or filler, and this practice appears to be a very recent development.19 The same chemical analysis performed on THC e‐cigarette products seized in 2018 did not find vitamin E acetate.19 Current evidence shows that THC‐containing products with vitamin E acetate additives are implicated in the pathogenesis of EVALI.21 Given the outbreak has only manifested in the past 18 months, it is likely that the addition of these substances into e‐cigarette solutions is a very recent occurrence. The CDC outlines three broad tenets for treating suspected EVALI: cover possible infective agents with empiric broad‐spectrum antibiotics; administer systemic steroids (optimal dose unknown); and provide best supportive care with oxygen therapy and close monitoring.15,17,20 In mild to moderate cases, the decision to start steroids can be delayed until culture results exclude or identify potential infectious pathogens.17 In severe cases, systemic corticosteroids should be given early due to the potential life‐threatening nature of EVALI.20 There have been reports of progressive ventilatory failure despite administration of high dose steroids (methylprednisolone 1 mg/kg), with patients requiring extracorporeal membrane oxygenation.20 So far, there are no confirmed reports of EVALI in Australia. Unlike in the US, nicotine‐containing liquids are illegal in Australia and can only be obtained on medical prescription for personal use.11 The sale of e‐cigarettes to people aged under 18 years is also illegal.11 In practice, however, a 2015 survey of Australian e‐cigarette use found that 90% of users purchased e‐cigarettes and liquids from unregulated online stores.11 Even legal nicotine‐free liquids sold in Australia have been found to contain traces of nicotine and other toxic substances, with no regulation of products.22 Most Australian e‐cigarette users are therefore vulnerable to the possibility of potentially dangerous substances being added to solutions, as has occurred in the US. Conclusion Vaping THC oil contaminated with vitamin E acetate is linked with severe lung injury and death. With more than 2800 cases of EVALI reported and 68 deaths, e‐cigarettes are definitely not risk‐free. Australian clinicians should maintain vigilance and ask every patient about e‐cigarette use. Adults using nicotine‐containing e‐cigarettes as an alternative to cigarette smoking should not revert to tobacco smoking.2 A reasonable and precautionary strategy is to advise patients that little is known about the long term effects of e‐cigarettes, and also to inform users that severe lung disease and death have occurred mainly with unregulated solutions. We recommend further research and ongoing field monitoring of e‐cigarette usage patterns in Australia.

Maitri Munsif · Mark Hew · Eli Dabscheck

Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable. Our subacute sector is presently able to deal with patients requiring rehabilitation. However, rehabilitation needs following COVID‐19 are broad, complex and include cognitive, motor and respiratory sequelae to the infection, acute respiratory distress syndrome, and the thromboembolic response. Planning and anticipatory action has been Australia's strength so far. In the same vein, an active planning approach is now required for the post‐acute and rehabilitation response. This pandemic will inevitably have its waves, and will continue to threaten until a vaccine is rolled out. Not having a plan for possible surges is unconscionable, particularly when the consequences of the relaxation of restrictions are unknown. Currently, Australian numbers are at a trickle; however, the challenge has been front and centre in countries such as Italy,1 Spain, the United Kingdom and North America.2 In Wuhan, China, 36% of those with severe COVID‐19 had neurological complications such as stroke, critical care neuropathy, and the complications of prolonged bed rest (eg, venous thromboembolism, disseminated intravascular coagulation, acute kidney injury, delirium anxiety, post‐traumatic stress disorder).3 In Italy, rehabilitation physicians have been treating post‐extubation dysphagia, impaired mobility, critical care myopathy and neurocognitive losses,1 while the British Society of Rehabilitation Medicine has established a framework of partnership with acute services to improve patient flow, outcomes and access to ventilators.4 In the United States, hospitals have had to rapidly transition acute patients to rehabilitation hospitals. In New Orleans, a 1000 bed post‐acute hospital was dedicated to post‐COVID‐19 disability, with rehabilitation teams treating patients battling persistent hypoxia, stroke and mental illness.5 The majority of patients who are ventilated for more than 7 days suffer complications that require rehabilitation, 60% are unable to walk, and 17% die within a year.7 One‐third suffer neurological complications, many require inpatient rehabilitation for over 3 weeks, and some take over 150 days to regain their capacity to walk independently.8 Others with stroke or cardiac complications of COVID‐19 will require rehabilitation for up to 6 weeks, with some requiring lifelong support. Australia needs to plan now, not just for survivors in the initial post‐acute stage, but also to manage individuals affected in subsequent waves. Such patients may require rehabilitation, along with those, fearful of infection, who present to hospital late with non‐COVID‐19 conditions like stroke, and those with deteriorating chronic diseases who have not had access to hospital based services. That means not only estimating the patient population but also ensuring that subacute health workers have sufficient access to personal protective equipment, staffing and training. In the Australian Government's emergency response plan,9 the recovery phase devolves to the states, but there is no mention of the post‐acute phase. In April, the New South Wales Ministry of Health established a rehabilitation community of practice to advise it. This follows international experience, as the International Society of Physical and Rehabilitation Medicine's disaster committee lead, Australia's Fary Khan states: “early rehabilitation reduces disability and improves clinical outcomes”.10 Currently, many rehabilitation units are not prepared. Inpatient rehabilitation units (public and private) are almost always working to capacity. COVID‐19 patients will be expect to be accommodated in addition to usual patients (eg, strokes, spinal injuries, amputations). The NSW Rehabilitation Community of Practice has developed a staged COVID‐19 escalation plan,11 but the plans turn on one integral point — contagion. When COVID‐19 survivors come to rehabilitation wards will they no longer be infected? While a national statement exists,12 local de‐isolation protocols are yet to be implemented or updated in many hospitals and local health districts. Many people with severe COVID‐19 have positive nasal swabs for up to 37 days13 but are not considered infectious once 10 days have elapsed from after first symptoms. Attention to this timetable is critical should we need to make ICU beds readily available by shifting patients to rehabilitation. In some US rehabilitation hospitals, patients are assumed to always be infectious, which has a significant impact on personal protective equipment usage. To ensure de‐isolation, moderate and severe COVID‐19 patients transferring to rehabilitation must have negative swabs on 2 consecutive days, be symptom‐free for 2–3 days and be at least 10 days from symptom onset. In NSW, these criteria are currently being put in place and such a protocol will require discussion, review of the evidence, and leadership to execute. Once we have a de‐isolation protocol, we can confidently activate a staged escalation plan. While our ICUs are coping with current numbers, our subacute sector has been managing with innovative models of care, such as mobile rehabilitation teams.14 The NSW Rehabilitation Community of Practice's COVID‐19 response principles11 refer to mobile rehabilitation teams, variously called ART (acute care rehabilitation team) or SMART (specialist management with acute rehabilitation treatment) teams. They provide rehabilitation and discharge planning services to patients in the acute hospitals. It is a parallel care model in partnership with acute care that has been successful in decreasing length of stay and facilitating early discharge or transfer to inpatient rehabilitation facilities. These teams have discharged almost 50% of their patients directly home, avoiding inpatient rehabilitation admissions, and have been active in many NSW hospitals since 2009. Once home, tele‐rehabilitation physician consultations, supported by community‐based allied health practitioners, can be delivered, although additional resources are still being sought. Similar models exist or are under development in other jurisdictions as well. In the event that our acute hospitals start to face challenges in accommodating those needing COVID‐19 or ICU beds, the subacute sector will need to escalate to the next stage to create access. Options include decanting non‐COVID‐19 patients to the private sector, increasing resources to acute or mobile rehabilitation teams, scaled up tele‐rehabilitation services, and preparation for public hospital rehabilitation inpatient units to manage COVID‐19 patients. However, in order to decant to the private sector we need completed agreements with private hospitals, as flagged on 31 March by the Minister of Health.15 Many private hospitals have facilities that are well suited for rehabilitation patients. This would require delineating private hospitals as COVID‐19‐free facilities and would be dependent on appropriate triage and testing facilities. Managing the logistics will be a challenge in the subacute sector, particularly if planning is left as an afterthought. The efficient flow of disabled COVID‐19 patients from acute to rehabilitation care will likely produce better patient outcomes and improve safety. Egress from acute hospitals means access to intensive care and ventilation for the community. If Australia and New Zealand's success at flattening the curve continues, our existing subacute sector will manage. If not, mobile rehabilitation teams will need to be expanded, systems for patient flow to the private sector will need to be operational, and enhanced tele‐rehabilitation services will need to be working. This will require the same vision and leadership that made our acute COVID‐19 response world leading, collaborative and publicly supported. In the UK and the US, we see the brutality of this pandemic, with mass burials and the tragic toll on health care workers. Australia and New Zealand have avoided this so far, but it is because we have planned well. We now need to prepare for the recovery phase because surviving may not be the same as living.

Steven G Faux · Kathy Eagar · Ian D Cameron · Christopher J Poulos

Australia needs to improve vigilance in the global endeavour to eradicate poliomyelitis In 1988, there were over 350 000 cases of paralytic poliomyelitis globally.1 In 2018, there were 29 cases and in 2019 there were 112 cases2 — all in the only two remaining countries in the world where wild poliovirus (WPV) is endemic (Afghanistan and Pakistan). We are tantalisingly close to global eradication. What is poliomyelitis? Poliovirus is an enterovirus and exists as three serotypes: WPV types 1, 2 and 3. Spread via the faecal–oral route, poliomyelitis results in subclinical or self‐limited infection in most patients, but causes acute flaccid paralysis (AFP) due to anterior horn cell damage in about one in 200 cases.3 Ubiquitous distribution of polioviruses and epidemics of paralysis caused widespread panic throughout the world in the early 20th century. With an ambitious and unprecedented level of international public and private collaboration and funding, the Global Polio Eradication Initiative (GPEI) was launched in 1988.2 In recent years, significant achievements have been recorded (Box 1), but the target of global eradication is yet to be reached. The GPEI currently faces two main global issues. Firstly, addressing the eradication of WPV1 in Afghanistan and Pakistan, and secondly, dealing with the growing issue of vaccine‐derived poliovirus (VDPV).1 Vaccine strain virus can slowly accumulate mutations over time, which eventually result in reversion to neurovirulence — these strains are known as VDPV. Although extremely uncommon, this phenomenon becomes increasingly prominent in areas where there are long term low vaccination rates, allowing continued circulation of the attenuated poliovirus contained in the Sabin vaccine. Ironically, the modern prominence of VDPVs is a consequence of the GPEI's successful endeavours to reduce WPV. Poliomyelitis close to home VDPVs are appearing in areas with low immunisation rates in Africa, and recent emergence in closer neighbours puts poliomyelitis back on our doorstep. In 2018, there was an outbreak in Papua New Guinea involving 26 VDPV type 1 AFP cases, including a death.4 In late 2019, the Philippines reported 15 VDPV cases, and Malaysia reported three cases in 2019 and one in 2020.5 These countries had previously been declared poliomyelitis‐free.6 Between 2012–13 and 2017–18, the median number of annual arrivals for Philippine citizens to Australia was 141 813, with 8% of these arrivals being children younger than 15 years.7 Screening individuals at our borders is not an economically viable option to prevent poliomyelitis, thus highlighting the importance of optimal immunisation and high quality surveillance. Australia's commitment to World Health Organization targets Australia and all other Western Pacific region countries were certified as poliomyelitis‐free on 29 October 2000.6 As a signatory to the World Health Organization's International Health Regulations (2005),8 Australia reports annually on its compliance, with obligations to prevent and respond to acute public health risks of international consequence. This includes observing temporary recommendations issued when the WHO declared the risk of international spread of poliovirus a public health emergency of international concern in 2014, poliovirus containment activities, and reporting to the WHO Regional Certification Commission providing evidence that Australia's poliomyelitis‐free status has been maintained. This evidence requires Australia to meet WHO‐specified surveillance standards. The Australian National Enterovirus Reference Laboratory plays an important role in providing enterovirus testing and environmental surveillance for Australia and the Western Pacific region to meet these requirements. Environmental surveillance for polioviruses is costly and labour‐intensive and involves sampling sewage for detection and then characterisation of enteroviruses. There is currently inadequate capacity to routinely conduct environmental surveillance throughout Australia. Therefore, this capacity is currently directed at monitoring during high risk episodes; for example, when there is a cluster of AFP cases or after the importation of a confirmed case. The detection of any poliovirus in Australia is considered a likely importation event, as Australia stopped the use of the oral polio vaccine in 2005. Adequate clinical surveillance is based on two key WHO indicators. Firstly, achieving an AFP detection rate of at least one case per 100 000 children younger than 15 years. Secondly, the WHO requires enterovirus culture on two stool samples collected at least 24 hours apart, both within 14 days of onset of paralysis, for at least 80% of reported AFP cases.9 Submission of two samples ensures adequate sensitivity, required due to intermittent viral shedding.10 Meeting these targets provides national and international reassurance that there is timely investigation that excludes poliomyelitis as the cause of AFP. However, for Australian clinicians, awareness of this surveillance and its purpose is often not well understood. An overview of the AFP surveillance structure is provided in Box 2. Importantly, AFP cases need to be notified and investigated even if another diagnosis (eg, Guillain–Barré syndrome) is likely. Australia's performance in meeting World Health Organization targets While Australia has met the surveillance target for AFP notification for the past 11 years, we consistently fail to reach the WHO benchmark for stool submissions (Box 3).11 This is in marked contrast to many of our closest neighbours. Only New Zealand, the small Pacific Island countries and Papua New Guinea have a similarly low performance over recent years. In 2018, adequate stool collection was achieved in only 44% of Australian AFP cases and 2019 results are currently at 65%.12 The most populous states of New South Wales and Victoria consistently underperform, with rates of 33% and 42% respectively for 2018 (Bruce Thorley, Head of Victorian Infectious Diseases Reference Laboratory, Australia, personal communication, September 2019). In 2018, three cases of AFP and anterior horn cell abnormality on magnetic resonance imaging in young children were reported to WHO by Australia as “poliomyelitis compatible” because of a lack of adequate clinical information and appropriate stool sample collection (David Isaacs, Chair of Polio Expert Panel, Australia, personal communication, September 2019). In addition to providing robust public health surveillance, ensuring adequate investigation of AFP can produce relevant diagnostic information for an individual. A 3‐year‐old child with permanent significant disability following AFP in 2018 had the neuropathic enterovirus D68 (EV‐D68) in faeces sent for AFP surveillance purposes.13,14 The converse may also apply. Detection of a non‐polio enterovirus by polymerase chain reaction (PCR) in a clinical sample does not preclude the possibility of dual infection with poliovirus. Co‐infection and subsequent recombination of species C non‐polio enteroviruses with Sabin‐like poliovirus is an important precursor event in the development of VDPVs.15 Barriers to improvement A number of logistical issues affect successful stool sample collection; for example, late presentation of patients, discharge before sample collection, and constipation may all have an impact on stool collection rates.16 In some instances, pre‐examination by microbiology laboratories using enterovirus reverse transcriptase PCR (RT‐PCR) may occur. This does not exclude poliovirus infection and testing at the WHO reference laboratory is still required. Due to the extended viral shedding in the gastrointestinal tract, stool samples are the specimen type most likely to facilitate enterovirus identification. The collection of rectal or throat swabs is discouraged by WHO due to reduced sensitivity compared with faeces samples. Pragmatism may dictate that the former may be preferable to no testing at all in a particular child if barriers to faeces collection exist. Recognising poliomyelitis in a low prevalence community Cases of poliomyelitis present as acute and often painful weakness in affected limbs. The weakness is often asymmetrical, affecting lower limbs more frequently than upper limbs, with rapid onset and usually no further progression after 48 hours. Sometimes patients may present atypically, reinforcing the need for any AFP to be reported and investigated. Alternative presentations may include dyspnoea or dysphagia due to weakness of bulbar or respiratory muscles. Cerebrospinal fluid findings are suggestive of viral meningitis. There are usually no systemic symptoms, although a recent history of a mild upper respiratory tract infection with or without headache may be elicited.3 A history of exposure to a high risk area (eg, Central Africa, Pakistan, Papua New Guinea or Afghanistan) and/or lack of previous immunisation is important. A history of distant past immunisation will not exclude the diagnosis, particularly if this was received overseas.10 Call to action There appears to be a level of complacency among physicians due to the rarity of clinical poliomyelitis in Australia. In addition, there is a lack of awareness in the diagnostic chain regarding the importance of laboratory surveillance. In 2020, a comprehensive action plan was implemented by the Paediatric Active Enhanced Disease Surveillance (PAEDS) network to improve faeces collections across the country. Clinicians should not fear that they are being alarmist in notifying AFP cases that they believe have negligible risk of poliomyelitis. The emphasis on detection and investigation of AFP cases despite an alternative diagnosis may seem pointless for an individual case, but at a national level, it allows confidence in the integrity of surveillance and, ultimately, achievement of poliomyelitis eradication. Conclusion The recent VDPV outbreaks in Papua New Guinea and the Philippines and the ongoing WPV1 circulation in Pakistan and Afghanistan emphasise the possibility of poliomyelitis re‐introduction into Australia. Clinical acumen is unlikely to provide a timely diagnosis. Clinicians are reminded that poliomyelitis as a diagnosis should be excluded in all cases of AFP; faeces collection from all AFP cases independent of age should be viewed as a priority to ensure the country remains poliomyelitis‐free and as an opportunity to maintain surveillance, even when another diagnosis is confirmed or highly likely. Box 1 – Selected achievements relevant for Australia in the history of the Global Polio Eradication Initiative2 Year Milestone 2000 Australia declared poliomyelitis‐free 2005 Inactivated polio vaccine replaces oral polio vaccine in Australia 2014 South‐East Asia declared poliomyelitis‐free 2015 Wild poliovirus type 2 declared eradicated 2017 99% of poliomyelitis eradicated globally 2019 Wild poliovirus type 3 declared eradicated Box 2 – Schematic overview of acute flaccid paralysis surveillance structure in Australia APSU = Australian Paediatric Surveillance Unit (www.apsu.org.au); PEP = Polio Expert Panel; PAEDS = Paediatric Active Enhanced Disease Surveillance Network (www.paeds.org.au); VIDRL = Victorian Infectious Disease Reference Laboratory (https://www/vidrl.org.au/surveillance/afp-surveillance1); WHO = World Health Organization. Box 3 – Percentage of acute flaccid paralysis notification with adequate stool sample collection, Australia, 1995–2018* WHO = World Health Organization. * Data reproduced, with permission, from Roberts et al.11

Meryta May · David Durrheim · Jason A Roberts · Rhonda Owen

A rigorous and well supported primary care response to COVID‐19 is essential to protect the most vulnerable people in Australia In late December 2019, a pneumonia caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) was reported to the World Health Organization following identification in Wuhan, China. The outbreak was declared a public health emergency of international concern on 30 January 2020 and a pandemic on 11 March 2020. The respiratory disease complex was officially renamed coronavirus disease 2019 (COVID‐19) on 11 February 2020. On 27 February 2020, the Prime Minister of Australia announced the activation of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID‐19).1 Australia has a strong system of primary care provided by doctors, nurses and other health care workers, including allied health professionals, midwives, community pharmacists, dentists, and Aboriginal health workers. Comprehensive primary care services are available to all members of the community through general practice and Aboriginal community‐controlled health services, provided by general practitioners, primary care nurses, allied health and other health care professionals working at the forefront of the health system. Many of the nation's most vulnerable people also access services through aged care, home care and disability care services. Australia's primary care response to COVID‐19 acknowledges the need to protect vulnerable populations,2 to continue the provision of regular primary care services to the whole community for acute and chronic conditions, preventive care and mental health concerns,3 and the need to support and protect health care workers in community settings4,5 as well as in the nation's hospitals.6 In early March 2020, a targeted action plan was initiated by the Australian Government Department of Health to develop and refine the national COVID‐19 primary care response (Box 1). This action plan acknowledged the essential, first‐contact role of general practice in the nation's pandemic response,7 and was informed by lessons from previous epidemics and pandemics where primary care had limited involvement in both planning and response8,9 and by focused consultation with primary care stakeholder organisations. Consultation included a Primary Care COVID‐19 Preparedness Forum, led by Australia's Chief Medical Officer and held on 6 March 2020 with representatives from general practice and other medical specialties, nursing, allied health, pathology, pharmacy, practice management, rural workforce, Aboriginal and Torres Strait Islander health, the disability sector, Primary Health Networks, and federal, state and territory governments. The Australian Government also established the National Aboriginal and Torres Strait Islander Advisory Group on COVID‐19, co‐chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO). Issues considered in the framing of the primary care response included measures required to protect both the public and the primary care workforce from infection, the management of people presenting to general practice with fever and/or respiratory symptoms, the continued health care management of vulnerable people at increased risk of COVID‐19, concerns about seasonal influenza in winter, arrangements for pathology testing in the community, and the impacts on business continuity for community‐based health services. The primary care response was supported by a funding package of $2.4 billion announced by the Australian Government on 11 March 2020, which included $1.1 billion specifically allocated to support the COVID‐19 response in primary care.10 Key components of the primary care response included: funding of a whole of population model of telehealth (using telephone or video consultations); establishment of call centres to triage people with fever or respiratory symptoms, provide advice and direct them to the most appropriate health services; establishment of a nationwide network of respiratory clinics based in the community to complement state‐ and territory‐run fever clinics; development and delivery of online infection prevention and control training for all care workers; measures to safeguard the health of the members of remote Aboriginal and Torres Strait Islander communities across the continent; and ensuring consistent messaging to members of the nation's primary care workforce. Telehealth New funding provided through Australia's Medicare Benefits Schedule (MBS) enabled a shift to the use of telehealth modalities for all appropriate consultations between patients and their health care providers. Telehealth initiatives were rolled out in a rapid, staged approach: beginning with support for the use of telehealth for members of the nation's most vulnerable populations; followed by items specific to obstetrics and midwifery, nurse practitioner care, and mental health care provision; then measures to enable vulnerable health care providers to continue providing care through telehealth; and then moving to whole of population telehealth consultations for all patients by all health care providers funded under the MBS (Box 2). On 30 March 2020, bulk‐billing incentives for people with concession cards and children aged under 16 years being seen in general practice were doubled to ensure there were no barriers for the population needing to access health care services and advice, and additional payments were introduced to support the ongoing viability of the nation's general practices.11 At the time of writing (2 June 2020), over 11 million telehealth services had been delivered to the people of Australia. National call centre People with fever or respiratory symptoms, or with concerns about possible exposure to COVID‐19, were encouraged to call Healthdirect — the Australian Government‐funded national call centre that provides free health information and advice. Healthdirect activity peaked at around 37 000 calls from members of the public per week in mid‐March 2020. The Healthdirect website also provided an online COVID‐19 symptom checker, which can be downloaded as an application for mobile phones and other devices (www.healthdirect.gov.au). Since 25 March 2020, up to 370 000 people per day have used the symptom checker. General practice‐led respiratory clinics Evidence from prior epidemics has demonstrated that neglect of usual care can be an unintended consequence of prioritising the emergency response, resulting in increased morbidity and mortality related to other causes.3,12 The establishment of a network of more than 120 general practice‐led respiratory clinics has redirected people with fever and/or respiratory presentations away from general practices and emergency departments. Primary Health Networks have had a crucial role in supporting general practices and Aboriginal community‐controlled health services, working with their local hospital networks to identify and help establish respiratory clinics. In addition to protecting other patients and health care staff from potential infection, the respiratory clinics allowed other general practices across the country to continue providing regular essential primary care services to their patients. Online infection prevention and control training A series of online education modules was created to provide consistent, evidence‐based information to health care workers and others working in community settings with vulnerable people. This series included eight modules targeting residential aged care workers and a 30‐minute online course, targeting all care workers, including those working in hospitals, primary care, aged care and disability care.13 It provided education on aspects of infection prevention and control for COVID‐19 and has been completed by over 800 000 health care workers at the time of writing. Protection of remote Aboriginal and Torres Strait Islander communities The primary care response recognised that Aboriginal and Torres Strait Islander people, as well as other people living in remote communities, are at increased risk of COVID‐19, due to pre‐existing health issues, difficulties with service access and high population mobility. Building on the strength of Aboriginal and Torres Strait Islander leadership and on measures initiated by many communities themselves, on 26 March 2020, the Australian Government enacted biosecurity restrictions on entry and travel to remote communities. Grants were provided to support remote communities in self‐determining appropriate planning and preparedness activities, adapting national plans and protocols for local use to enable early retrieval and evacuation of suspected cases, and establishing the mechanisms to support responses to any outbreak, including the deployment of appropriate health care workers. Communication with members of the primary care workforce Regular webinars with primary care doctors, nurses, mental health and allied health professionals were initiated, along with regular teleconferences with the representatives of national primary care professional organisations, with the aim of providing consistent and ongoing two‐way communication with the nation's primary care workforce.14 Since 19 March 2020, there have been over 100 000 live views of online webinars and over 130 000 accesses of online newsletters, along with use of the content by medical media outlets and reproduction by national professional organisations in their own newsletters and emails to their membership. The primary care response was supported by a series of government fact sheets and other COVID‐19‐specific resources developed to assist the primary care workforce in knowing how to protect their patients and themselves from COVID‐19. These have been made publicly available at www.health.gov.au. Primary Health Networks supported these initiatives through the provision of updates about the management of people with suspected or diagnosed COVID‐19. Conclusion Lessons from previous epidemics and pandemics have emphasised the critical importance of engaging early and effectively with primary care4 and the need for a single source of trusted information from health authorities for both clinicians and members of the public.5,15 Australia's primary care response has sought to achieve this, through early collaborative planning and ongoing two‐way communication with the nation's primary care workers. The Australian Government's investment in primary care during the COVID‐19 pandemic is an investment in essential elements of the nation's health system, enabling optimal frontline care while mitigating spread and protecting the ongoing health of the nation's most vulnerable citizens. Box 1 – Aligning Australia's coronavirus disease 2019 (COVID‐19) response with existing knowledge The known: Lessons learnt from previous epidemics and pandemics emphasise the frontline role of primary care and the need for strong, consistent communication with the primary care workforce and the wider community The new: Australia's primary care response to COVID‐19 has seen rapid implementation of initiatives to protect the nation's most vulnerable citizens, preserve existing health system function, support and treat people with COVID‐19, and optimise workforce capacity The implications: Australia's investment in the primary care response to COVID‐19 is enabling effective frontline care while mitigating spread, and protecting the ongoing health of the nation's most vulnerable people Box 2 – Staged introduction of Australia's coronavirus disease 2019 (COVID‐19) telehealth response Stage/date Description Stage 1 (13 March 2020) General practitioner consultations using telehealth for patients aged at least 70 years, Indigenous people aged at least 50 years, pregnant women, parents of children under 12 months of age, and those who are immunocompromised or have a chronic medical condition resulting in increased risk from coronavirus infection Stage 2 (16 March 2020) Supporting telehealth consultations by obstetricians, midwives, nurse practitioners, and some mental health providers Stage 3 (23 March 2020) Enabling vulnerable GPs and other medical specialists (in the same categories as in Stage 1) and providers authorised to use telehealth item numbers to provide care for their patients using telehealth Stage 4 (30 March 2020) Extending existing telehealth items to all Australians. This included a substantial investment in mental health support, with specific commitments to children and young people, older Australians, and health care workers Stage 5 (6–20 April 2020) Supporting expanded telehealth for many specialist medical services and allied health services, including consultant physicians, psychiatrists, geriatricians, public health physicians, neurosurgery, chronic disease management by nurses and Indigenous health workers, and group psychotherapy

Jane Desborough · Sally Hall Dykgraaf · Lucas Toca · Stephanie Davis · Leslee Roberts · Catherine Kelaher · Michael Kidd

A fresh examination of potentially preventable hospitalisation rates gives new insights and strategic direction Australia lies at a critical juncture for health reform. In August 2019, the Minister for Health, the Honourable Greg Hunt MP, released Australia's Long Term National Health Plan,1 a 24‐page document anticipating the imminent initiation of a 10‐year Primary Health Care Plan. In October 2019, the Minister announced experts to provide independent advice for this purpose.2 With their counsel, this 10‐year Primary Health Care Plan will set a path to guide future primary health care reform. This undertaking behoves laser‐like focus on population‐based system‐level indicators. Potentially preventable hospitalisations (PPHs) comprise a nationally agreed set of 22 specific conditions selected through precise rationale.3 Hospitalisation for any one of those diagnoses is potentially prevented through effective community‐based primary health care.3 Total PPHs reflect a holistic system‐level indicator calculated by combining hospital admissions for all 22 agreed conditions from routinely collected data. As national coding requirements ensure consistency across jurisdictions, age‐standardised PPH rates per 100 000 people permit comparisons over time and place. While it is tempting to focus on one or several individual conditions, it is the total age‐standardised PPH rate that best reflects the integrated functioning of primary health care in that location.4 We accessed 2017–2018 age‐standardised total PPH rates for all 331 Statistical Areas Level 3 (SA3).5 As geographical footprints, SA3s provide a regional breakdown of Australia. Each SA3 has a population between 30 000 and 130 000 people and often closely aligns with the local government area.6 Total PPH rates are inequitably distributed in Australia, with the highest rates clearly visible in SA3s in remote and very remote regions (Box 1). We note the national median PPH rate is 2742 per 100 000, but PPH rates by SA3 are highly skewed (Box 2). The ten SA3s demonstrating the worst PPH rates each feature rates more than double the national median. Indeed, the highest PPH rate (26 661 per 100 000 population in Barkly, Northern Territory) is more than 16 times the lowest (1662 per 100 000 population in Stonnington East, Victoria). We then ranked PPH rates by deciles, noting the first decile comprises the 10% of SA3s across Australia with the best (lowest) PPH rates, while the tenth decile comprises the 10% with the worst (highest) rates. This distribution is also inequitable, exhibiting marked variation between states and territories (Box 3). Median PPH values for Queensland and the NT fall in the eighth and tenth worst deciles respectively (Box 3). Given that 75% of the SA3s in the Australian Capital Territory rank in the best two deciles for SA3s nationally, bureaucrats residing in the nation's capital may have limited awareness of the daily reality of system‐level health inequity elsewhere. Unabated continuation of inequities in the performance of primary health care compromises the health and wellbeing of Australians living every day in these locations. High total PPH rates also place relentless pressure on hospitals already showing strain. In response, recapitalisation of comprehensive primary health care as the foundation of the Australian health care system requires serious, proportionate and long term resource reallocation within health budgets across Commonwealth, state and territory governments. A fair and functional frontline primary health care system was assumed as a viable platform for the nation's coronavirus disease 2019 (COVID‐19) response.7 PPH rates provide much‐needed insight into geographic health inequity and emphasise the importance of strategic focus. A meaningful national mandate to reduce the size of the gap in age‐standardised total PPH rates between the lowest and highest SA3 deciles should be implemented through the 10‐year Primary Health Care Plan. It is also important to identify mechanisms to shift skew and median values by jurisdiction towards the best attainable rate. In addition, an explicit goal could be set in every SA3 to deliver a specific time‐based trajectory for total PPH rates. These strategic imperatives are the Minister's to set. Health care reform requires political leadership. In the Plan, there should be arrangements for continuous public monitoring of significant quantitative improvement in total PPH rates. At the very least, substantial new funding for local rejuvenation of primary health care in all SA3s in the worst decile should be prioritised. If not, we fail Australians living in these locations yet again. Box 1 – Distribution of potentially preventable hospitalisation (PPH) rates by Statistical Area Level 3 (SA3) in Australia Box 2 – National distribution of age‐standardised potentially preventable hospitalisation (PPH) rates per 100 000 population by Statistical Area Level 3 (SA3) Box 3 – Distribution by decile of age‐standardised total potentially preventable hospitalisation rates at Statistical Area Level 3 (SA3) by state and territory Decile (%) Total SA3s Jurisdiction 1 2 3 4 5 6 7 8 9 10 ACT 3 (38%) 3* (38%) 1 (12%) 1 (12%) 0 0 0 0 0 0 8 (100%) NSW 15 (17%) 15 (17%) 10 (11%) 10* (11%) 6 (7%) 8 (9%) 12 (13%) 5 (5%) 7 (9%) 1 (1%) 89 (100%) WA 4 (12%) 4 (12%) 5 (15%) 6* (18%) 4 (12%) 4 (12%) 2 (5%) 0 2 (5%) 3 (9%) 34 (100%) Tas 3 (20%) 1 (7%) 0 4* (27%) 4 (27%) 1 (7%) 0 2 (5%) 0 0 15 (100%) SA 2 (7%) 3 (11%) 5 (18%) 2 (7%) 7* (25%) 1 (3%) 4 (15%) 1 (3%) 0 3 (11%) 28 (100%) Vic 4 (6%) 6 (9%) 8 (12%) 6 (9%) 8 (12%) 13* (20%) 10 (15%) 7 (11%) 3 (4%) 1 (2%) 66 (100%) Qld 2 (3%) 1 (1%) 3 (4%) 4 (5%) 5 (6%) 6 (7%) 5 (6%) 18* (22%) 20 (24%) 18 (22%) 82 (100%) NT 0 0 1 (11%) 0 0 0 0 0 1 (11%) 7* (78%) 9 (100%) Total number of SA3s in each decile 33 33 33 33 34 33 33 33 33 33 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; Qld = Queensland; SA = South Australia; Tas = Tasmania; Vic = Victoria; WA = Western Australia. * Indicates the decile in which the jurisdiction's median potentially preventable hospitalisation rate lies.

Gemma C Ma · Jeanette E Ward

OECD data indicate that Australia is a comparatively high user of residential aged care The Royal Commission into Aged Care Quality and Safety interim report highlighted many concerns about aged care in Australia.1 These include that “the system designed to care for older Australians is woefully inadequate”, and that “aged care services … have simply not been seen as a priority by successive Australian Governments”. To inform the Royal Commission, we undertook a review of international approaches to the provision of aged care.2 As a component of our review, we examined data reported to the Organisation for Economic Co‐operation and Development from 13 countries.3 The list of countries included in the review was developed in consultation with experts and with input from representatives from the Royal Commission. Countries were selected based on the availability of information, applicability to the Australian aged care system, and to ensure a diverse range of countries were represented. Long term care is the provision of services for medical needs, personal care and assistance in living independently for people with long term dependencies due to their health care needs. Long term care can be provided in institutions (eg, nursing homes or residential aged care facilities) or by providing services to assist people to remain living in their own homes, including community services such as respite care. The OECD defines long term care institutions as specifically designed nursing and residential care facilities that provide accommodation and care as a package, with the predominant service being care. Institutional long term care recipients are those receiving formal long term care in institutions other than hospitals. We compared numbers of older long term care recipients in institutional care (12 countries) and estimates of long term care expenditure for older people (12 countries) (Box). Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations (Box). The relative use of institutional care, as opposed to home or community care, was also highest for Australia, with 52.5% of long term care recipients aged ≥ 65 years and 58.6% of long term care recipients aged ≥ 80 years in institutional care. This is in comparison to a range of 21.6% in Japan to 34.6% in the Netherlands for recipients aged ≥ 65 years, and 23.1% in Japan to 41.8% in Canada for those aged ≥ 80 years (Poland is an exception, with institutional care provided for 94.1% of long term care recipients aged ≥ 65 years, and 100% aged ≥ 80 years, based on 2006 data; however, long term care is highly limited, with only 1.6% of the population aged ≥ 80 years receiving care). Our estimates of gross domestic product (GDP) expenditure on long term care for older people comprise the health component of government/compulsory long term care expenditure (not age‐specific) plus social expenditure on old age benefits in kind, as reported to the OECD. This approach best captures Australia's long term care expenditure on older people. Benefits in kind are services such as the home care packages program. However, this estimate does not capture cash benefits such as the carer allowance in Australia or direct cash payments that are a component of aged care benefits in some other nations (eg, Germany, England, Poland). In the OECD database, these payments cannot be separated from non‐care related cash provisions for older people, such as the age pension. The expenditure estimates indicate that many other nations spend a much greater proportion of their GDP on long term care for older people (Box). Different approaches to funding are used in other countries, including the provision of universal social care insurance, some of which includes compulsory contribution schemes such as in Japan and Germany.5 Limitations in these international comparisons include possible differences between nations in reporting or definitions of institutions, lack of data on the dependency levels of care recipients, and comparisons being limited to OECD nations reporting institutional care use. Nevertheless, the data indicate that in Australia a comparatively high proportion of older people live in institutions, with a relatively low financial investment in the whole aged care sector. While many countries have wait lists for home care services, the wait times of over 12 months for home care packages at the approved level (for level 2 and above; ie, beyond basic care needs, providing low to high level care) may lead to premature admission to institutional care for some people.6,7,8 In November 2019, the Australian government announced funding of an additional 10 000 home care packages at a cost of $496 million.9 However, in September 2019, there were about 63 000 people waiting for an approved home care package, and an additional 49 000 people were offered, while waiting, a package at a level lower than that approved.6 Some countries focus on keeping older people at home, with greater emphasis on preventive and rehabilitation approaches.10,11 In Denmark, for example, legislation obliges local municipalities to assess all older people applying for home care for their suitability for reablement: short term home‐based training programs aiming to increase people's independence.11 To reduce the number and proportion of older Australians living in residential aged care, there needs to be an increase in investment across the sector, particularly in home‐ and community‐based care. Box – Estimates derived from OECD data2 on proportion of older population receiving long term care (LTC) in institutions (A), and LTC estimates for expenditure on older people as a proportion of gross domestic product (GDP) (B) Notes: Data refer to 2015 or nearest year. A: Data not available for UK; it is unclear whether or not older people living in skilled nursing facilities are counted in US data. B: Data not available for New Zealand. Old age benefits in kind were not reported for Canada or Poland; Germany reports zero expenditure as benefits in kind. US expenditure may only include institutional care.4 Data extracted on 6 May 2019 (A) and 15 September 2019 (B) from https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.3

Suzanne M Dyer · Madeline Valeri · Nimita Arora · Dominic Tilden · Maria Crotty

How to deal with diabetes and COVID‐19 — do we just dial in? The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the subsequent announcement by the World Health Organization of a global pandemic, has altered health care across the public and private sectors. Clearly, coronavirus disease 2019 (COVID‐19) is having a huge impact on general practitioners, emergency physicians, respiratory physicians, intensivists and related staff, and is also impacting the day‐to‐day delivery of chronic health care. Conditions such as type 1 and type 2 diabetes require regular, usually face‐to‐face contact with GPs, endocrinologists, diabetes educators, dieticians and podiatrists to optimise glycaemic control. However, with recommendations regarding social isolation to minimise spread of COVID‐19,1 the delivery of such health care is increasingly being delivered using telehealth. This has been greatly facilitated in Australia with the announcement of temporary Medical Benefits Schedule telehealth (videoconference and telephone) item numbers during the COVID‐19 pandemic.2 The eligibility criteria for bulk‐billing include individuals who are immunosuppressed or with chronic health conditions, which include diabetes mellitus. Significantly, the eligibility criteria also include pregnancy. At a time when individuals are being asked to socially isolate to minimise exposure to SARS‐CoV‐2, many who greatly need ongoing health care are avoiding these appointments out of fear of infection from those also attending the clinic and perhaps from clinicians, who are recognised to be at high risk of infection. It is therefore crucial that telehealth care services are offered (and if not available, fast tracked). This may be via videoconference, or a phone call for those who are less able to use newer technologies or if videoconferencing services are not available. Services traditionally offered in a group setting, such as group education for those with gestational diabetes or type 2 diabetes, may also be delivered via this technology. The use of diabetes management technology can benefit health care and telehealth consultation. Continuous or flash glucose monitoring can be used with both type 1 and 2 diabetes with therapeutic benefit. Many of these devices upload automatically to cloud‐based software. Other devices such as insulin pumps and blood glucose meters can be uploaded by the user before the consultation, which places a greater burden on the individual. Involvement of parents, carers and diabetes educators before the appointment may be of benefit. This may lead to improvements in individual diabetes self‐management. The electronic medical record is vital in updating changes to medications, results and scheduled appointments. Many pathology providers facilitate electronic access to test results, but anecdotally some patients may avoid having pathology tests taken in order to minimise travel and exposure to others. The individuals who are at greatest risk of complications from COVID‐19 are still being determined. It seems clear that those with diabetes and other chronic comorbidities are at increased risk of morbidity. A number of small observational studies have analysed comorbidities in individuals with severe SARS‐CoV‐2 infection from China. Rates of diabetes (type unspecified, but most likely to be type 2 diabetes given the low incidence of type 1 diabetes in China3) are reported between 7.4% in confirmed cases infection,4 and up to 17% in cases with severe pneumonia.5 A recent meta‐analysis of six studies (including 1527 people) analysed the prevalence of comorbidities among individuals with severe and non‐severe COVID‐19.6 Diabetes complicated 11.7% of severe cases compared with 4% of cases of non‐severe COVID‐19. This did not reach statistical significance; however, this is clearly limited by a lack of statistical power and further analyses are required. Retrospective analysis of survivors and non‐survivors of the 2002–2003 SARS coronavirus outbreak suggested that diabetes was a predictor for mortality.7 This association seemed to be driven by glycaemic control, with an independent association with elevated fasting plasma glucose. This further highlights the need to maintain ongoing medical care to optimise glucose control throughout the current COVID‐19 pandemic. All people who currently smoke should be advised to cease smoking. In addition, receiving the recently available influenza vaccine, which is usually recommended for people with diabetes, would be advisable, although patients should be aware that this will not protect against COVID‐19. Individuals with both type 1 and type 2 diabetes need to have clear action and sick day plans in the eventuality that they become unwell, and should be encouraged to seek face‐to‐face care for complications such as myocardial infarction or high risk foot ulcer. This should be emphasised even for individuals with long standing diabetes, whose initial diabetes education may have occurred years ago. Individuals with type 1 diabetes should have ketone monitoring strips available (preferably blood continuous subcutaneous insulin infusion ketone test strips), know when to test for ketones, and be aware of the need for additional insulin doses (via injection or continuous subcutaneous insulin infusion) during an intercurrent illness. Excellent sick day management resources are available on the websites of the Australian Diabetes Educators Association (https://www.adea.com.au) and National Diabetes Services Scheme (https://www.ndss.com.au). Individuals using hybrid closed loop insulin pumps should be educated that during illness the wearer may need to exit automatic mode to enable more rapid correction of hyperglycaemia with manual correction boluses of insulin and a temporary increased basal rate.8 The algorithm within the hybrid closed pump may otherwise not adapt quickly enough to manage hyperglycaemia during acute illness. With the increased use of sodium–glucose cotransporter type 2 (SGLT2) inhibitors in Australia and internationally, all individuals treated with SGLT2 inhibitors should be educated on the need to withhold these drugs during illness to minimise the risk of ketoacidosis.9 This should be reiterated to GPs and emergency physicians to screen for SGLT2 inhibitor use in patients presenting with COVID‐19 or any illness. There have been mixed anecdotal reports as to whether non‐steroidal anti‐inflammatory drugs (NSAIDs) may predispose patients to COVID‐19. There has been suggestion that NSAIDs may upregulate angiotensin‐converting enzyme 2 (ACE2),10 and therefore potentially predispose by a similar mechanism suggested for angiotensin receptor blockers (ARBs). Currently there are no guidelines to avoid the use of NSAIDs. In relation to COVID‐19, there is also increasing interest in the use of ACE inhibitors and ARBs in individuals with type 1 or type 2 diabetes and other chronic care conditions, such as diabetes. SARS‐CoV‐2 binds to ACE2, allowing entrance into the host cells.11 ACE inhibitors and ARBs can result in upregulation of ACE2 in some tissues in both human and animal models.10,12,13 However, not all investigators have found a link between these antihypertensives and upregulation of ACE2.14 It has been proposed that ACE inhibitors and ARBs may theoretically increase susceptibility to COVID‐19 by increasing ACE2 levels. However, there is currently no evidence to link the use of these agents to increased risk or severity of COVID‐19. Indeed, other research groups have hypothesised that the use of ARBs may be a potential therapeutic modality.15 Following SARS‐CoV‐2 binding to ACE2, there is downregulation of ACE2 with subsequent increased angiotensin levels and exacerbation of COVID‐19 related lung injury. It has been proposed that the downregulation of ACE2 by ARBs might protect against such injury.15 Other groups have suggested that ARBs may stabilise the binding of ACE2 to the type 1 angiotensin receptor and may therefore reduce available binding sites for SARS‐Cov‐2.16 Currently, there is no evidence to suggest changing antihypertensive therapy, and multiple national and international bodies including the Australian Diabetes Society, Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and the American College of Cardiology and European Society of Hypertension have recommended that ACE inhibitors and ARBs should not be ceased.17 Trials are currently underway to assess the impact of these agents during COVID‐19 infection (https://clinicaltrials.gov). Patients should be encouraged to continue their ACE inhibitor or ARB drugs, and if not prepared to do so, be offered alternative drugs for blood pressure control. This is a time of great concern to all individuals, and perhaps more so to those who have been informed they are at greater risk of COVID‐19 and its complications. This may necessitate a greater state of preparedness. The current advice is that there will be no shortage of insulin supplies or consumables needed for insulin pump therapy or blood glucose monitoring equipment, yet anecdotally, local pharmacy shortages of insulins, ketone strips and oral hypoglycaemic drugs have been reported and are being addressed by government prescription limits. Should patients be unable to obtain their usual prescriptions, suitable alternatives can be recommended to them by their diabetes care clinicians. It is critical that individuals with diabetes and other chronic conditions do not hoard these medical supplies and inadvertently create a critical supply shortage. Continuation of health care to at‐risk individuals is crucial throughout the pandemic. Telehealth is the key for the delivery of such care. It is important that people with diabetes are educated regarding the management of their condition during acute illness, including medication changes. It is also critical that there is no deterioration in the medical management of glycaemia and other complications of diabetes, which, if neglected, may result in increased morbidity and mortality independent of COVID‐19.

Emma S Scott · Alicia J Jenkins · Gregory R Fulcher

COVID‐19 ARDS is a predictable serious complication of COVID‐19 that requires early recognition and comprehensive management “This disease is still too strange to us, and there are too many doubts”, says Dr Ling Qin (LQ), after reviewing more than 400 patients with coronavirus disease 2019 (COVID‐19) pneumonia in Wuhan Union Hospital, China. COVID‐19 is a novel disease. We are familiar with acute respiratory distress syndrome (ARDS); however, when it occurs as part of COVID‐19, it has different features and there remain unanswered questions. So if someone has COVID‐19 ARDS, how does it compare and contrast with ARDS from other causes? To answer this question we provide a summary of the published literature (based on a PubMed search using the terms “COVID‐19” and “ARDS”, 17 April 2020) and current clinical experience from managing patients with COVID‐19 ARDS in Singapore (SHP) and Wuhan (LQ). Severe COVID‐19 represents viral pneumonia from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection leading to ARDS. Its manifestations can be viewed as a combination of the two processes, namely viral pneumonia and ARDS. COVID‐19 is a novel disease recognised initially in Wuhan, China, in December 2019, and is now pandemic. It is likely caused by zoonotic spillover of a β‐coronavirus type 2b that is now transmitted between humans. Along with the other serious coronavirus infections of severe acute respiratory syndrome and Middle East respiratory syndrome, which also cause ARDS, COVID‐19 represents an ongoing global threat as this virus family has the potential to mutate and infect non‐immune populations. Australia's living guidelines provide the latest recommendations and evidence.1 Diagnosis SARS‐CoV‐2 infection can be confirmed by positive detection of viral RNA in nasopharyngeal secretions using a specific PCR test. COVID‐19 illness can be confirmed by a consistent clinical history, epidemiological contact, and a positive SARS‐CoV‐2 test. COVID‐19 ARDS is diagnosed when someone with confirmed COVID‐19 infection meets the Berlin 2012 ARDS diagnostic criteria2 of (i) acute hypoxaemic respiratory failure; (ii) presentation within 1 week of worsening respiratory symptoms; (iii) bilateral airspace disease on chest x‐ray, computed tomography (CT) or ultrasound that is not fully explained by effusions, lobar or lung collapse, or nodules; and (iv) cardiac failure is not the primary cause of acute hypoxaemic respiratory failure. ARDS is underdiagnosed in intensive care settings.3 ARDS develops in 42% of patients presenting with COVID‐19 pneumonia, and 61–81% of those requiring intensive care.4 COVID‐19 ARDS follows a predictable time course over days, with median time to intubation of 8.5 days after symptom onset in Singaporean patients.5 This is similar to previous reports where ARDS developed at day 8 or 9 after symptom onset. It is therefore important to monitor patients for the development of ARDS as their COVID‐19 infection progresses. Respiratory rate and SpO2 are two important parameters for judging patients’ clinical condition and allowing early recognition of ARDS. A patient who fits any one of the following conditions may have severe disease and require further evaluation: respiratory rate ≥ 30 breaths/min; SpO2 ≤ 92%; and PaO2/FiO2 ≤ 300 mmHg. Blood tests can also be helpful. In Singapore, it was noted that raised C‐reactive protein levels and blood neutrophil counts along with lymphopenia were more common in patients requiring invasive mechanical ventilation for COVID‐19 ARDS.5 Lung pathology ARDS causes diffuse alveolar damage in the lung. There is hyaline membrane formation in the alveoli in the acute stage, and this is followed by interstitial widening and by oedema and then fibroblast proliferation in the organising stage. COVID‐19 ARDS causes the typical ARDS pathological changes of diffuse alveolar damage in the lung.6,7 As patients move through the course of their illness, the longer term outcomes of ARDS are being reported, with lung fibrosis appearing as part of COVID‐19 ARDS.8,9 A study reported that 17% of patients had fibrous stripes in chest CT scans,9 and considered that the fibrous lesions may form during the healing of pulmonary chronic inflammation or proliferative diseases, with gradual replacement of cellular components by scar tissues. Thrombosis Pulmonary thrombosis is common in sepsis‐induced ARDS. Coagulation dysfunction appears to be common in COVID‐19, and is detected by elevated D‐dimer levels. In fatal cases there is diffuse microvascular thrombosis, suggesting a thrombotic microangiopathy, and most deaths from COVID‐19 ARDS have evidence of thrombotic disseminated intravascular coagulation.10 This may explain some of the atypical or unexpected manifestations seen in the lung, such as dilated pulmonary vessels on chest CT, and episodes of pleuritic pain. Vascular enlargement is rarely reported in typical ARDS, yet was seen in most cases of COVID‐19 ARDS.9 Mortality COVID‐19 ARDS appears to have worse outcomes than ARDS from other causes. The intensive care unit and hospital mortality from typical ARDS are 35.3% (95% CI, 33.3–37.2%) and 40.0% (95% CI, 38.1–42.1%), respectively.3 For COVID‐19 ARDS, mortality ranged between 26% and 61.5% if ever admitted into a critical care setting, and in patients who received mechanical ventilation, the mortality can range between 65.7% to 94%.4 Risk factors for poor outcomes include older age; presence of comorbidities such as hypertension, cardiovascular disease and diabetes mellitus; lower lymphocyte counts; kidney injury; and raised D‐dimer levels. Death from COVID‐19 ARDS is due to respiratory failure (53%), respiratory failure combined with cardiac failure (33%), myocardial damage and circulatory failure (7%), or death from an unknown cause.4 Radiology The radiology of ARDS is distinctive, yet COVID‐19 pneumonia appears to have unique features. This likely results from the co‐occurrence of viral pneumonia and ARDS, and allows radiologists to be fairly specific in diagnosing COVID‐19 pneumonia. The most discriminating features for COVID‐19 pneumonia in China compared with viral pneumonia in the United States included a peripheral distribution of opacification (80% v 57%; P < 0.001), frosted glass opacities (91% v 68%; P < 0.001), and vascular thickening or enlargement (58% v 22%; P < 0.001).11 These imaging features appear to be typical for COVID‐19 pneumonia and can be helpful in early screening of highly suspected cases and in evaluation of the severity and extent of disease. As COVID‐19 lung disease progresses, the lesions are more likely to be bilateral, lower lung predominant and multifocal. They often have the appearance of rounded opacities, termed “COVID balls”. With the development of ARDS, the extent of lung involvement increases, and there is a consolidative component.12 The opacities resolve with recovery from COVID‐19;13 however, with ARDS, the lesions increase in their extent and density, and evolve to fibrotic bands. Ventilation The strategy of breathing support is very important in treating COVID‐19 ARDS, as is the case with typical ARDS caused by other pathogens.14 The key elements are: use oxygen by nasal cannulae to achieve SpO2 > 92%; use of high flow nasal oxygen is controversial and highly dependent on the treatment location; avoid non‐invasive ventilation; prone ventilation appears to be beneficial; and consider extracorporeal membrane oxygenation for rescue. Because of concerns about viral transmission to other patients and health care workers,15 the use of high flow nasal oxygen and non‐invasive ventilation (such as bi‐level positive pressure ventilation) for COVID‐19 ARDS is highly dependent on the health care setting. Australian COVID‐19 guidelines1 strongly recommend against the use of high flow nasal oxygen in emergency departments, but provide a strong recommendation for its use in negative pressure single rooms. Non‐invasive ventilation may be used in negative pressure rooms with appropriate viral transmission precautions.1 Clinical experience has found inconsistent benefit from non‐invasive ventilation and there is concern about aerosol generation and increased risk of viral transmission. Prone ventilation appears to be beneficial for COVID‐19 ARDS.1 Placing a person in prone position promotes more homogenous aeration of the lung in ARDS and can improve oxygenation. While prone ventilation is used in only about 16% of patients with typical ARDS,3,16 in COVID‐19 it is being used successfully earlier in the course of ARDS, and suggested use is for > 12 hours per day.16 Venovenous extracorporeal membrane oxygenation can be used as rescue for mechanically ventilated adults with COVID‐19 and hypoxaemia that persists despite optimised ventilation, use of rescue therapies and prone ventilation. Among critically ill patients treated in Wuhan, prone ventilation and extracorporeal membrane oxygenation treatment were not found to be as effective as for ARDS caused by other pathogens. Possible reasons include: COVID‐19 pneumonia was still progressing and was not under control; lung lesions were not completely gravity‐dependent under ultrasound, so the effect of the prone position was limited; the patient's immune status was not restored, and a secondary hospital‐acquired infection worsened the condition; and when case numbers are high from the epidemic, the management mode and human resource arrangement of the isolation wards still need to be discussed and strengthened. Anecdotal observations in Singapore (SHP) and investigations in the Netherlands17 suggested that patients ventilated for COVID‐19 ARDS tended to have plateau pressures < 30 cmH20 and driving pressures < 15 cmH20 despite high oxygen requirements. The lung protective ventilation strategy used in typical ARDS involves a low tidal volume (6 mL/kg) and higher positive end expiratory pressure targets. For COVID‐19 ARDS, a change to more generous tidal volume targets allowing up to 8 mL/kg and lower positive end expiratory pressure levels is suggested to prevent patient self‐inflicted lung injury. Adjunct treatment In typical ARDS, continuous neuromuscular blocking agents, high dose corticosteroids and recruitment manoeuvers were the most frequently used adjunctive therapies. In COVID‐19 ARDS, the evidence for systemic steroids is still scarce and they are only recommended in patients with concomitant shock which has been unresponsive to vasopressors. There are concerns that steroids may increase viral shedding and possibly lead to a higher mortality rate. Antiviral therapy Many patients with COVID‐19 receive antiviral or immunosuppressive therapy. In Australia, the National COVID‐19 Clinical Evidence Taskforce1 recommends administering antiviral medications or other disease‐modifying treatments in the context of clinical trials. Singapore was using empiric lopinavir–ritonavir plus subcutaneous interferon‐β 1b initially, but is now randomising patients to receive remdesivir. In Wuhan, a broad range of antiviral and immune therapies are being used. All patients also received treatment with Chinese medicine. COVID‐19 ARDS is a predictable serious complication of COVID‐19 that requires early recognition and comprehensive management. Research programs such as the Medical Research Future Fund 2020 Respiratory Medicine Clinical Trials Research on COVID‐19 grant opportunity are required to answer the important questions that remain about therapies for COVID‐19 ARDS.

Peter G Gibson · Ling Qin · Ser Hon Puah

The current reduced capacity of post‐release services may compound offender vulnerabilities, increasing their risk of harm to themselves and others The coronavirus disease 2019 (COVID‐19) pandemic has affected many countries internationally and has been implicated in more than 445 000 deaths worldwide.1 The speed at which this infectious disease is transmitted has led to calls to immediately release prisoners from custody in some countries, including Australia, and has already led to the release of some prisoners in others. The reasons for these calls to action are intuitively rational. Custodial environments are susceptible to a COVID‐19 outbreak given the confined conditions and potential for overcrowding.2 Moreover, prison populations are often vulnerable, having poorer physical and mental health and other social challenges (eg, substance misuse, homelessness) compared with the general population.3 At the time of writing, Australian governments have yet to immediately release select prisoners into the community as part of efforts to mitigate the spread of COVID‐19, despite recent advocacy to do so. Experts across a number of sectors have recommended the early release of prisoners from vulnerable groups if possible, including Indigenous Australians, women, children, older prisoners, victims of domestic violence, and those with chronic health issues.4 However, the proposed early release strategy requires a nuanced assessment of its potential societal consequences and, most importantly, its immediate impact on the health and wellbeing of candidate prisoners for release. Victoria and New South Wales — Australia's most populous states — provide a useful case in point. Stage 3 restrictions — home confinement except for restricted essential activities5 — have been in effect for approximately 2 months. Some restrictions were eased in late May, although limits on public and private gatherings remain in place. Prisons in both Victoria and NSW have yet to record a single case of COVID‐19 within the inmate population. In Victoria, a number of safety mechanisms have been introduced by correctional centres to help manage the potential transmission of the virus.6 These include: temperature testing of all staff before entry to the facility; sending staff home who present with high temperatures and other flu‐like symptoms, and requiring them to undertake a COVID‐19 test before returning; isolating all new prison admissions for up to 14 days; isolating prisoners who display cold or flu‐like symptoms; adjusting programs to abide by physical distancing; and enabling prisoners to connect with family members via video calls on tablet devices (“video visits”) as an alternative to in‐prison visitation. Moreover, conventional medical, psychological and cultural support services continue to be available to prisoners. Similar precautions have been implemented in NSW correctional centres,7 which hold the largest proportion of prisoners in Australia. With no confirmed cases in both Victorian and NSW correctional centres and ongoing efforts to restrict the materialisation of COVID‐19 in custodial settings, the potential costs of releasing vulnerable prisoners into the community necessitates scrutiny. Any prisoners released under anti‐COVID‐19 preventive measures will return to a general community enduring social restrictions and society‐wide economic contraction. The post‐release community support services ordinarily available to released offenders are currently compromised or are experiencing significant delays.8,9,10,11 Moreover, government social security services (ie, Centrelink), which are heavily relied upon by individuals after release, are currently overwhelmed as they service thousands of newly unemployed clients.12 Mental health and crisis support services are also strained as they adjust to remote service delivery and contend with an elevated spike in community‐wide help seeking.13 The reduced capacity for intensive case management, monitoring and re‐entry assistance for released prisoners is a serious concern given their higher levels of complex mental and physical health needs, as well as histories of unemployment, addiction, social disadvantage and homelessness.3 Australian research points to high rates of mortality and self‐harm shortly after release from custody.14 Key predictors of post‐release mortality include mental disorder, suicide and substance misuse — concerns that transitional support programs and other post‐release interventions will be unable to optimally manage during the national lockdown. This scenario poses an increased health risk for released prisoners, compounding their vulnerability and increasing the likelihood of problem behaviour and recidivism. Without readily available coping strategies and assistance with pro‐social functioning, released prisoners with histories of violence, aggression, impulsivity and serious mental illness may put themselves and others (particularly cohabitants) at risk. Calls to release prisoners who are survivors of domestic violence must also consider the heightened risk of revictimisation after release. The social isolation, economic stress and reduced options for support during stage 3 restrictions may exacerbate unhealthy relationship dynamics, especially among those with complex needs. Moreover, physical distancing may not be adhered to by those whose behavioural and psychological needs are untreated. Proposals to immediately release vulnerable prisoners to avert the ostensible threat of COVID‐19 in Australian custodial environments warrant consideration. The potential for a COVID‐19 outbreak in custody is a genuine concern, notwithstanding proactive measures employed in Victorian and NSW correctional centres. However, this advocacy must consider the broader social context. A focus on early release cannot be uncoupled from the current compromised community environment prisoners will face after detainment. Community support services are increasingly strained at a time when released prisoners will have a greater need for them. As such, it is important to balance the relative health and safety trade‐offs of remaining in custody — in Victorian and NSW prisons, there are no confirmed cases of COVID‐19 and health supports remain available — with early release into a resource‐depleted community. The real prospect of harmful outcomes for immediately released vulnerable prisoners must be weighed heavily during this challenging period.

Stephane Shepherd · Benjamin L Spivak

Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.

Emma Spencer · Eswaran Waran

Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm. There are five components of the Safer Baby Bundle: supporting women to stop smoking in pregnancy; improving awareness of a safe maternal sleeping position; improving decision making about timing of birth; improving the detection and management of fetal growth restriction (FGR); and raising awareness and improving care for women with decreased fetal movements (DFM). Of these five components, the latter two have the potential to increase early delivery. FGR is the strongest contributor to the burden of stillbirth. If detected and managed, the risk of stillbirth is 20‐fold lower than if FGR remains undetected.5 Improving the detection of FGR is central to any program aiming to reduce stillbirth. But increasing FGR detection may also cause harm. In a French population, half of the babies suspected of FGR antenatally had normal growth.6 In Victoria, a greater focus on improving the detection of FGR quadrupled the number of babies delivered early for suspected FGR, from 741 in 2000 to 2996 in 2017.5 The number and proportion of these babies with a birthweight in the 10th centile or greater increased from 307 (41%) to 1597 (53%).5 Striving to increase the sensitivity of FGR detection decreased specificity. This is a problem because unwarranted early delivery is harmful to both immediate perinatal5,6 and longer term developmental outcomes.7 Similar risks exist for increasing awareness of DFM. It has long been recognised that there is a relationship between DFM and stillbirth. Women who report DFM have a 2.4‐fold increased risk of stillbirth.8 However, translating this into an effective intervention has been challenging. Thirty years ago, it was shown that the use of formal fetal movement counting charts failed to reduce stillbirth.9 More recently, a large randomised controlled trial — the AFFIRM trial — assessed a care package for women presenting with DFM. In over 400 000 women attending 33 health services in the UK, increasing the awareness of DFM and standardising the care of those women presenting with DFM did not significantly reduce stillbirth.10 Moreover, there was evidence of harm to both mother and baby. Despite clear guidance for clinicians about what investigations to offer women with DFM and under what circumstances delivery was merited,11 there was an increase in the rates of induction of labour and caesarean delivery,10 with an additional 500 babies born between 32 and 34 weeks’ gestation and 5000 more born between 34 and 37 weeks’ gestation. The number of babies requiring admission to a neonatal unit also increased.10 The fact that most women with DFM will go on to give birth to a healthy baby suggests that the care package assessed by AFFIRM needs to be better targeted to women at risk. So what lessons can be drawn from these experiences for the Australian Safer Baby Bundle? Foremost, it is to be aware of the potential harm of any intervention and to look for this harm. This is possible with the use of balance performance measures12 —essentially, measures of unnecessary early delivery such as the proportion of babies delivered for suspected FGR but who were normally grown, or the number of neonatal unit admissions of term babies. Stillbirth programs elsewhere did not embed balance measures as part of their planned evaluation. Benefiting from the lessons learned by others, the Australian Safer Baby Bundle will include these measures to ensure that strategies designed to reduce stillbirth are targeted towards babies who are at most risk.1 The ultimate goal of balance measures is to reduce the unintended harm of our interventions. At present, no strategy has been shown to increase the sensitivity of FGR detection without causing harm. Neither is there a reliable tool to differentiate patterns of fetal movement that correspond to adverse outcome from those that are just a normal event. It is likely that more discriminatory screening tools reside in improved use of ultrasonography and biomarkers that assess fetoplacental function13 or in a better understanding of circadian patterns of fetal movements.14 Until then, caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies. It is crucial that the potential for unintended harm is made explicit and that measures of unnecessary early delivery are used to monitor progress of the Safer Baby Bundle implementation in Australia.

Roshan Selvaratnam · Mary‐Ann Davey · Euan M Wallace

A false impression of technological panacea may see much needed interventions overlooked and may introduce unintended consequences and risks In the face of coronavirus disease 2019 (COVID‐19) limiting free movement, experts are scrambling to mitigate the profound impact that the disease is having on our lives. For many countries, this approach involves increased testing, isolation, and education about hygiene practices until a vaccine is found. To varying degrees, without much evidence as to their efficacy, countries are turning to technology to solve some of the current challenges.1 Increasingly, smartphone applications (apps) are being contemplated for tracking proximity of people to determine possible sources of transmission, with elements of technological solutionism. Such technical solutions require trust, and without honest and clear information about the possibilities and limitations of technologies, an app's benefits may be undermined by low adoption, or conversely a false impression of a technological panacea may see much needed interventions overlooked. For example, the Australian Government's target of a 40% uptake of the COVIDSafe app may or may not be effective in helping to control the disease, while 60% uptake is supported by independent modelling from the United Kingdom.2 Furthermore, such summary statistics do not clarify to the public the wide range of other factors and assumptions that must be considered in predicting the app's efficacy. Much is being written about the different technological models and whether they trace, track and comply with privacy and human rights frameworks, including whether this information can, in fact, ever be anonymised.3 Fully effective anonymisation is unlikely when collecting data as granular as regular interaction with others in addition to age, gender and postcode demographics, as has been demonstrated by previous attempts to de‐anonymise data.4 If these data are accidentally or deliberately linked with other datasets, such as births in hospitals or the public Myki public transport dataset,5 anonymity is virtually impossible to guarantee. Successful uptake of new technologies requires trust. When adoption is insufficient, collective benefits are not guaranteed. Civil society in the United Kingdom called for clear and comprehensive primary legislation to regulate data processing in symptom tracking and digital contact tracing applications, including with a strict purpose, access and time limitations.6 Such regulation may improve trust. Technology embeds values Even when people are told of the limitations of technology, they may have magical thinking about its capabilities.7,8 In early May 2020, the Australian Government furthered this magical thinking by direct messaging Australians that downloading the COVIDSafe app would help to keep people safe and ease restrictions, linking the two directly and potentially conflating the capability of COVIDSafe. Contact tracing apps may assist in manual tracing, in turn slowing the virus’ spread, but usage of an app does not render the individual protected from infection nor does it guarantee successful tracking without intensive manual efforts. Yet statements by those in authority have made strained assertions about COVIDSafe, likening the use of the app to the use of sunscreen9 or a digital vaccine: “You could think about contact tracing as a digital vaccine with our contact data being the virtual antibodies”.10 Such statements are incorrect representations of the app's capabilities.11 Even the technical details of the app are not immune from false messaging. For example, the app records all Bluetooth contacts, not just those that last 15 minutes or that are within 1.5 m. The filtering occurs after contacts are uploaded. Furthermore, there are some inaccurate statements on the official COVIDSafe website; for example, the frequently asked questions section states that “all information that is stored on the phone is digitally encrypted;” however, metadata, such as the device make and model for each contact, are stored unencrypted.12 Communication must be fact‐based, transparent and consultative, any short term gains in support from the use of emotive and persuasive messaging may be undone when they are ultimately demonstrated to be false. Centralised versus decentralised data collection The fundamental difference between centralised versus decentralised tracking is in who learns what. In the centralised approach, the central authority learns who an infected person has interacted with, whereas this does not occur in the decentralised system. Decentralised systems are no more challenging to implement but they better protect privacy. In a centralised approach (Box 1), such as TraceTogether (Singapore) or COVIDSafe (Australia): encrypted identifiers are issued by the central authority to each device; devices broadcast the encrypted identifiers via Bluetooth, and nearby devices listen for such broadcasts and record any that they receive; if a person tests positive, they report to the central authority all the identifiers they have received within a predetermined timeframe; and the central authority decrypts the identifiers and maps them to the individuals they were issued to and duly notifies them if they are deemed to be at risk. The above is a very high level description and there are many technical challenges in implementing such a system securely.13 In a decentralised approach (Box 2), as proposed by decentralised privacy‐preserving proximity tracing (DP‐3T), Covid Watch, Apple and Google: devices generate random identifiers that are not linked to an individual; identifiers are broadcast via Bluetooth and recorded by nearby devices; a person who tests positive publishes a list of the identifiers they have broadcast; and all apps on user devices download such lists and check if they received positive identifiers so as to identify likely contacts. While there are variations in the details, in the decentralised approach, the central authority does not map identifiers to individuals. Although the distinction between centralised versus decentralised tracking may seem small, from a privacy perspective, there is a significant difference. In the case of COVIDSafe, the identifiers are generated and provided to the phone individually rather than as a daily batch: the central authority can monitor whether the app is being used in at least 2‐hourly increments, and possibly as frequently as every 9 minutes, due to regular checks for new identifiers. Models reflect differing societal priorities. In Germany, where there are legal protections for both individual and group privacy, the decentralised app has been chosen. In fact, it has been suggested that a decentralised smartphone contact tracing system — as contemplated by DP‐3T, Apple, Google, and governments across Europe — would be likely to comply with human rights and data protection laws. In contrast, a centralised smartphone system would pose a greater risk to fundamental rights and would require significantly greater justification to be lawful.6 Even when consent for central data collection has been sought, it is unclear what users are consenting to in the absence of fully open code that includes server‐side code, a clear regulatory framework, and with omissions, such as the COVIDSafe's Privacy Impact Assessment and Privacy Policy failing to mention the collection of the devices’ make and model.14 In comparison, Singapore's TraceTogether is based on the same codebase and its frequently asked questions section notifies of such data collection.15 Efficacy and risks of using Bluetooth Bluetooth Low Energy (BLE) is designed to be a low power communication technology, it was not designed to facilitate range finding. Accurately measuring the distance between two devices based only on the received signal strength is a challenge, with error margins often in the metres.16 The signal strength is relative not absolute, and thus, the scale of the reported values differ by manufacturer. Furthermore, the signal strength is influenced by many external factors, including the angle at which the device is held, whether it is in a pocket or a bag and any objects around or between it and the other device. Whether BLE can deliver the necessary accuracy remains an open question. While the use of Bluetooth avoids direct location tracking, many other risks remain. There are vast networks of Bluetooth beacons distributed around cities, which facilitate location tracking. Security advice is to disable Bluetooth when not in use. While the public might be expected to compromise for the common good, legislation could also move to limit Bluetooth beacons during the crisis. However, the Privacy Amendment (Public Health Contact Information) Act 202017 passed on 14 May provides no such protections.18 It provides an exemption to those accidentally collecting COVIDSafe data as part of a wider collection of non‐COVIDSafe data. This appears to be aimed at protecting commercial tracking, rather than protecting privacy. Legal and social implications are as important as the technical ones Given the many risks of using technology, the contemplation of any technological solutions to alleviate the impacts of COVID‐19 needs to be not only technical but also legal and social. Making the code open for audit provides some technical guard rails, much as providing open and transparent proof of test results ensures that no risks are overseen. But beyond technical questions there are also legal questions, including with whom the data may be shared. A recently published article refers to the multiple legal regimes potentially applicable to the app in Australia, as experts scramble to review the legal protections for individuals using COVIDSafe.19 Enacting emergency measures in the face of catastrophes is easy. Rolling back changes to technology, habits and even culture is far more difficult. If they are to be used, technological tracking solutions must have sunset clauses to ensure that human rights are protected. But even with sunset clauses, the large quantity of data collected are effectively out in the world, where they can be accessed and misused. Protections and limits for these data and their providers need to be contemplated before use, not only to protect individuals but also for group privacy. Increasingly, there is a risk of data being accessed by overseas agencies, which could have an impact on national security. It is vital that the technical, legal and social challenges are addressed in coordination. Any new legislation must be written within the context of existing technological practices, particularly around Bluetooth tracking. Likewise, where technical compromises are made, they must be justified to the public with clear, concise explanations, in a manner that is transparent and open to scrutiny. While many liberties have been curtailed during COVID‐19, all modifications to existing rights are required, under law, to be legal, necessary and proportionate. These same standards apply to the use of technology. Legal protections need to be in place to ensure that rights are protected, including the right to privacy. Without sound legal protections and safeguards, tracing apps will not only fail but will embed values that may not be those that represent the society we wish to be. Box 1 – The centralised approach of contact tracing wherein the central server learns user contact details Box 2 – The decentralised approach to contact tracing wherein no central authority learns user contact details

Kobi Leins · Christopher Culnane · Benjamin IP Rubinstein

All countries must increase medical capabilities and adopt a concerted whole-of-government approach to combat COVID-19

Ray Junhao Lin · Tau Hong Lee · David CB Lye

Combatting the resurgence of measles requires vigilant clinicians and sustained, high level vaccination coverage At the beginning of 2020, Samoa was in a state of emergency due to a measles outbreak. It resulted in over 5700 cases and over 80 deaths, the majority being in children under 5 years of age.1 There were concurrent outbreaks regionally, in New Zealand, Tonga, American Samoa and Fiji. Globally, there has been a massive resurgence of measles with over 360 000 cases reported to the World Health Organization between 1 January and 31 July 2019 — almost three times the number reported over the same period for 2018. We have also seen the re‐establishment of endemic measles in some countries, such as the United Kingdom, where it was previously eliminated.2 In 2019, Australia had 285 confirmed measles cases, the highest number reported since 2014, the year that it was verified by the Regional Verification Commission for Measles Elimination in the Western Pacific to have eliminated measles.3 Most infections occurred in, or were secondary to, unimmunised or underimmunised individuals returning from countries where measles is endemic or that have active outbreaks.4 Australian doctors cannot afford to become complacent about measles, particularly while large outbreaks affect popular tourist and business destinations in the region. Why must we care about measles? Measles is the most highly communicable human virus known, and has a basic reproduction number (R0; the average number of secondary cases generated from a single case in a fully susceptible, freely mixing population) between 9 and 18 — double that of smallpox and quadruple that of Ebola virus.5 It can therefore result in devastating and explosive outbreaks where immunity gaps exist. It is transmitted by respiratory droplets, and aerosolised particles can remain airborne for up to 2 hours, making infection possible well after a patient has left an enclosed space such as a clinic waiting room. Cases are infectious from 24 hours before prodrome onset until 4 days after onset of rash. As the characteristic, maculopapular rash does not appear until 3–7 days into the illness (Box 1), each case may unwittingly expose hundreds of contacts by the time of diagnosis.5,6 Although the majority of patients recover from measles, up to one child in every thousand infected in wealthy countries will die, usually due to pneumonia or encephalitis.5 The immunosuppression caused by the measles infection may last months to years, and rare but devastating neurological complications include acute disseminated encephalomyelitis, measles inclusion body encephalitis and subacute sclerosing panencephalitis.5 The dramatic decrease in subacute sclerosing panencephalitis in Australia since 1990 is a testament to the impact of effective immunisation programs.7 There is no specific antiviral therapy for measles. Management remains supportive, with fluids, vitamin A, and antibiotic therapy if secondary bacterial infections arise.5 The importance of preventing measles through vaccination cannot be overstated. Breakthrough infection While most measles cases still occur in underimmunised individuals, some countries, including Australia, have seen a small but increasing proportion of cases occurring in adults reporting previous measles vaccination.5,8,9,10 At the time of elimination verification in Australia, the estimated efficacy of measles vaccine was 96.7% for one dose and 99.7% for two doses.11 Thus, about one in 300 fully vaccinated people who are exposed to measles are vulnerable to “breakthrough” infection, resulting from either an inadequate response at the time of vaccination or waning of immunity over time.8,9 The latter is particularly seen in post‐elimination settings where regular immune‐boosting from circulating wild strain virus is absent, and there is concern that this may become more common as the time since elimination increases.10,12 Measles should therefore be considered in all patients presenting with fever and rash, particularly if there is a history of travel, exposure to a confirmed case, or when measles is known to be circulating locally, even if the patient has received two doses of measles vaccine. Breakthrough infections often present as modified measles with a mild to moderate rash and less pronounced prodrome.8,9,10 Virus burden and transmissibility appear to be lower in modified cases than in a typical infection; however, onward transmission may still occur, making isolation of cases and public health responses still necessary.8,10 Attenuated symptoms, alongside often undetectable IgM antibody levels, make diagnosis considerably more challenging and definitive laboratory testing using polymerase chain reaction all the more relevant. Advances in laboratory testing Detection of measles IgM antibodies through serological testing is a commonly used diagnostic method but relies on optimally timed specimens. IgM is detectable in 75% of cases 3 days after rash onset, and in almost 100% after one week, but may not be present early in the illness or in the setting of waning immunity.4,8 Specificity varies from 60% to 97% and serology cannot distinguish wild‐type infection from recent vaccination.13 Nucleic acid testing of respiratory and urine specimens using polymerase chain reaction has revolutionised measles diagnosis. Sensitivity and specificity approach 100% from the first day of rash but decrease after 2 weeks, at which point serology remains useful.4,13 Preliminary results may be available within 4 hours of receipt by an accredited laboratory, and can distinguish between wild‐type virus and vaccine strain (genotype A).6 Nucleic acid testing is now the preferred method of diagnosis (often in conjunction with serology), and has the additional advantage that swabs are often easier to collect than blood in young children.4 Virus genotyping enables source and cluster identification, tracking of global transmission and detection of emerging strains, and provides supportive evidence to confirm elimination of endemic measles. For epidemiological purposes, breakthrough infections may be differentiated by avidity analysis of IgG antibodies in serum.8 Avidity is the strength with which antibodies bind to antigens. Low avidity suggests an inadequate immune response at the time of vaccination, while high avidity suggests an initially adequate response to vaccination followed by waning immunity.14 Public health management If measles is suspected, the patient should be isolated at home or under airborne precautions in a health care facility until the diagnosis is excluded by laboratory testing or the case is no longer infectious. A public health unit should be notified on clinical suspicion of measles before laboratory confirmation is received.4 Public health management includes vaccination of susceptible contacts within 72 hours following exposure, and passive immunisation of susceptible high risk contacts (immunocompromised patients, pregnant women and infants under 12 months of age) with intramuscular normal human immunoglobulin within 144 hours of exposure.4 With such a highly transmissible virus, any delay in notification and initiation of public health actions can result in large scale outbreaks. Vaccination importance and update Vaccination remains the key to control and prevention of measles cases and complications. A population immunity of 95% is required to eliminate ongoing measles transmission, and every year a new, susceptible cohort is born, mandating that high quality immunisation efforts be maintained.12,15 While childhood vaccination coverage in 2019 was above 90% for all Australian states and territories, few met the 95% target for measles (Box 2).16 Further, national and state/territory rates can conceal pockets of low vaccination coverage where the introduction of a single case can be the catalyst for an outbreak. As of April 2019, infants travelling to a high risk setting can be given measles vaccine from 6 months of age. They still require the further two doses routinely given at 12 months and 18 months of age as part of the current National Immunisation Program.4 Previously, measles vaccination was not recommended for infants aged under 12 months because of the presence of maternal antibodies, which provide protection in early life and render the vaccine less effective. This immunity now appears to wane earlier in infants born to vaccinated mothers in an elimination setting.5 In Australia, the second dose of measles vaccine was first recommended in 1993, initially for 10–16 year olds, and introduced into the National Immunisation Program for 4–5 year olds in 1998.15 Thus, adults born between 1966 and 1982 may be susceptible, being born after circulating measles began to decline but unlikely to have received two doses of vaccine. Measles vaccine should therefore be offered to anyone aged 12 months or older (or 6 months or older as detailed above), born after 1965, who does not have formal documentation of immunity or receipt of two doses of measles vaccine, particularly before travelling overseas. It is safe to give an additional dose if it is unclear whether two doses have been previously administered. Because it is a live attenuated vaccine, measles vaccine is contraindicated in pregnancy and in immunocompromised patients.4 Although vaccine hesitancy is a concern and receives substantial media attention, access to services and other practical factors remain important barriers to vaccination uptake.17 Conclusion Measles virus is the ultimate opportunist and will capitalise on any gaps in immunity. National programs are important, but measles control cannot be achieved without effective local prevention and control measures, including diligent vaccination and prompt diagnosis by alert clinicians. With outbreaks occurring regionally, concerted effort is required to maintain Australia's elimination of measles and continue progress towards the goal of global measles eradication. Box 1 – Typical measles rash Photograph showing skin rash on a patient's abdomen 3 days after the onset of measles infection. Image captured at New York Hospital–Cornell Medical Centre. Photograph courtesy of CDC/Heinz F. Eichenwald, MD from Centers for Disease Control and Prevention Public Health Image Library ID# 3168 (https://phil.cdc.gov/details.aspx?pid=3168). Box 2 – Australian state and territory immunisation coverage rates for 1‐year‐olds at 31 December 2019 Data source: Australian Immunisation Register. Infographic courtesy of Australian Government Department of Health.16

Kirsten M Williamson · Tony Merritt · David N Durrheim

The number of tests for vitamin D deficiency in Australia rose steeply between 2000 and 2011, from 0.4 to 36.5 tests per 1000 population; the cost to Medicare increased from $1.1 million in 2000 to $95.6 million in 2010,1 and peaked at $151 million in 2012–13.2 Consequently, the Medical Benefits Schedule (MBS) items for testing (66608, 66609) were replaced in November 2014 by new items (66833–66837) with the aim of restricting testing to people at particular risk of vitamin D deficiency, including those with a history of osteomalacia or osteoporosis, elevated alkaline phosphatase levels, hyperparathyroidism, hypo‐ or hypercalcaemia, hypophosphataemia, malabsorption, chronic renal failure, deeply pigmented skin or chronic and severe lack of sun exposure, or a diagnosis of vitamin D deficiency, and people who used medications that reduce 25‐hydroxyvitamin D levels.3 The immediate effect of the new criteria was that the rate of vitamin D tests was 47% lower during 2014–16 than during 2013–14.4 However, the proportion of people tested who met none of the new MBS criteria increased from 71.3% to 76.5%, while the proportion with moderate to severe vitamin D deficiency increased only from 5.4% to 6.5%.4 Medicare data5 indicate that the testing rate has since increased, by 34% between 2015 and 2019, from 119 to 159 tests per 1000 population; the cost to Medicare rose 42%, from $73.7 million to $104.7 million (Box). The testing rate increased in all states; the rate for women increased by 30% (from 164 to 214 tests per 1000 population), and for men by 40% (from 74 to 105 tests per 1000 population) (Supporting Information, figures 1A,B). The most marked increases were for people aged 85 years or more, for whom the 2019 testing rate (women, 447 tests per 1000 population; men, 364 tests per 1000 population) exceeded the 2012 levels (women, 388 tests per 1000 population; men, 276 tests per 1000 population). Testing rates for people aged 0–25 years did not markedly change between 2015 and 2019 (Supporting Information, figures 1C,D). The Royal College of Pathologists of Australasia,6 like most medical authorities, does not recommend screening for vitamin D deficiency. The marked overall increase in testing since 2015 is not explained by changes in demographic or clinical factors, suggesting that at least some screening is unnecessary and that ordering doctors are either unaware of or do not support the new MBS vitamin D testing criteria. Evidence‐based guidelines6 and MBS policy, accompanied by education and audit activities, have failed to contain the level of vitamin D testing. Further, people who are socio‐economically disadvantaged or at particular risk of vitamin D deficiency, including Indigenous Australians, are still tested less frequently than other Australians.4 Finally, people at clear risk of vitamin D deficiency could be treated without testing, especially as the cost of supplementation ($2.25 per month) is only a fraction of that of a vitamin D test ($30.05). High quality research is needed to provide evidence for informing interventions that curb the use of low value tests in a health system that encourages a high volume of services, but not necessarily better value care. Box – Cost to Medicare of vitamin D testing (MBS items 66608 and 66609, 66833 to 66837), January 2000 – December 2019 MBS = Medical Benefits Schedule. Source: Medicare item reports.5 Our estimated rates for 2001 (2.3 per 1000 persons) and 2011 (140 per 1000 persons) differ from those estimated by Bilinski and Boyages1 using a different source of Medicare data. * The MBS items 66833 to 66837 were listed on 1 November 2014.

Louisa Gordon · Mary Waterhouse · Ian R Reid · Rachel E Neale

Investment is urgently needed in repurposed drugs which could ease the burden of the COVID-19 pandemic

Jennifer H Martin · Nikola A Bowden

The existing system is failing to deliver the care that Australia expects Australia's aged care has changed considerably in recent decades. In response to consumer demand, old institutional‐style nursing homes have been progressively phased out in favour of better facilities. Home‐like furnishings and decor and single bedrooms personalised with residents’ own belongings have increasingly become the norm. In the process, they have become residential aged care facilities (RACFs), and there is no longer a distinction between low and high care.1 At the same time, older people want to stay in their own homes longer and have increasingly been able to do so because more community care is now available. Along with significant accommodation bonds and other charges, this has also served government objectives of reigning in the costs of Australia's ageing population.1 Contemporary residential care is no longer a lifestyle choice, it is now primarily for people who can no longer live at home. However, funding and staffing have not kept pace with this change.1 Aged care residents’ needs People living in RACFs now are typically very frail and have complex physical, cognitive and social care needs. During 2018, we independently assessed 5000 people living in RACFs.2 Only 15% of residents were independently mobile, one in two (50%) required mobility assistance, and over a third (35%) were not mobile. The bedridden group was at greatest risk of pressure injuries. People living in RACFs are vulnerable; the typical resident lacks energy and struggles with everyday activities. Most residents (> 80%) need help with activities such as showering, getting dressed or using the toilet. Moreover, many residents have memory, understanding and communication problems. Almost half of the residents find it difficult to interact with others and may become distressed when care staff try to assist them with personal hygiene, for example. Mental health problems are rife. Agitation is the most prevalent problem (43%), followed by depression (35%) and irritability (35%).3 There are about 180 000 residential care beds in Australia occupied on any one day by permanent residents.4 About 60 000 permanent residents die each year and about the same number take their place.5,6 The number of residents who die in their RACF is unclear. What is known is that many thousands are transferred to hospital due to staff not having the skills, confidence, capacity, resources or back‐up to provide the care they need.7 Neglect, the recently released interim report of the Royal Commission into Aged Care Quality and Safety, concluded that “substandard care is much more widespread and more serious than … anticipated”.7 Staffing in residential aged care facilities To inform its work, the Royal Commission requested a research study be carried out into residential care staffing.1 This involved a review of staffing standards internationally and an assessment of current Australian staffing levels against international and national standards. Australian staffing levels were calculated based on a time and motion study we conducted in 2018.3 Residents in Australia receive on average 188 minutes of care per day, which includes 36 minutes by registered nurses, 8 minutes by allied health professionals (mostly physiotherapists) and 144 minutes by personal care assistants.1 Anecdotally, registered nurses and allied health professionals are required to spend a disproportionate amount of time on paperwork for funding purposes, leaving even less time to spend on care. Adequate care time and staffing mix and levels So how can we tell if a RACF is providing adequate care time and has the right mix of staff? Our Royal Commission research considered these questions.1 The international literature consistently reports that staff time requirements are driven by resident function, cognition, behaviour and technical nursing requirements, and our 2018 research confirmed that these same drivers apply in Australia.3 The clear evidence in the international literature of a direct causal relationship between staff numbers and skill mix and resident safety and quality outcomes is equally applicable to Australia.8,9,10 Over 150 studies documented in systematic reviews, primarily from the United States, Canada, the United Kingdom and northern Europe, confirm a “strong positive impact of nurse staffing on both care process and outcome measures”.11 Organisational factors, such as professional staff mix (ratio of registered nurses to total staffing levels), staff turnover rates, use of agency staff, and consistency in staffing also have an impact on quality. We found that the five‐star rating system used in the US by the Centers for Medicare and Medicaid Services (CMS) is the most relevant system internationally for judging aged care in Australia. It has a strong evidence base and has been in widespread use for nearly 20 years.12 While it does not address allied health staffing levels, it could be developed to do so if such an approach were adopted in Australia. The CMS considers the amount of care time provided to residents by nursing and personal care staff and adjusts this according to the needs of residents in each home. The outcome is a rating of between one and five stars. The more stars the better. The five‐star threshold is the point at which there is no evidence of any additional quality improvements for residents (Box).12 As seen in the Box, Australian RACFs rate poorly compared with US RACFs. They also do badly compared with the standards in place in Germany and Canada and with the standards set down by the state governments of Victoria and Queensland.1 Research into the CMS system found that homes are more likely to “experience quality concerns” when staffing levels fall below a certain level.12 This threshold is equivalent to the minimum requirement for a three‐star rating (ie, 30 minutes of registered nurse time and 215 minutes of total time). Therefore, we determined that anything less than three stars is inadequate for Australian RACFs.1 Using these metrics, more than half of all Australian aged care residents (57.6%) are in RACFs that have inadequate (one or two stars) staffing levels. A little over a quarter (27.0%) are in RACFs that have three stars, 14.1% of residents are in RACFs with four stars, and 1.3% are in RACFs with five stars, which we consider best practice.1 Bringing all RACFs in Australia up to at least three stars would require an average staffing increase of 37.3% in those RACFs currently rated one or two stars, which would result in an overall increase of 20% in total care staffing across Australia. Achieving four stars would increase total staffing by 37.2% and five stars by 49.4%. Importantly, these increases are total numbers for the sector as a whole and need to be adjusted according to the mix of residents when applied to individual RACFs.1 The best international benchmark for allied health staff currently is from the Canadian province of British Columbia, which recommends a minimum of 22 minutes of allied health services per resident per day. Only 2% of Australian aged care residents currently receive this level of care. An additional 175% in allied health staffing is required to achieve this international standard.1 The evidence is clear Our research was requested by the Royal Commission against a background of numerous examples of poor quality care experienced by older people living in RACFs.1 A recurring theme has been the lack of staffing to meet the wide‐ranging and increasingly complex needs of residents — assertions that have been supported by the results of our research.1 It is clear from our research and from the evidence presented to the Royal Commission that there is a compelling case for additional resources in RACFs. This includes improving the staffing mix and increasing staffing levels to an acceptable standard. As the Royal Commission's interim report notes,7 the existing system has failed to ensure residents receive quality care. It is no longer acceptable to describe RACFs simply as a person's home or for advocates to argue that what is required is a social model of care delivered with a wellness philosophy.13,14,15 While on the surface it sounds attractive and in line with what consumers want, the evidence from the Royal Commission is that these arguments are now being used as a justification for inadequate care.7 Conclusion Residents in Australian RACFs have a right to be safe and to receive clinically competent and adequate care. This care needs to be provided within a non‐institutional environment that is respectful of individual choices and affords every resident the opportunity to be meaningfully engaged to the extent possible. There does not need to be a trade‐off between a social model of care and a clinically competent model. Aged care residents have a right to both and do not have the time to wait. Box – Star rating system for aged care facilities: comparison between Australia and the United States

Kathy Eagar · Anita Westera · Conrad Kobel

An integrated approach that includes a central role for pathology laboratories is necessary Mass casualty events (MCEs) are defined as events or other circumstances “where the normal major incident response of one or several health organisations must be augmented by extraordinary measures to maintain an efficient, suitable and sustainable response”.1 Haemorrhage is a leading cause of mortality in MCEs, accounting for almost 50% of deaths in the first 24 hours,2,3 and transfusion emergency preparedness is increasingly recognised as a critical element of an integrated approach to MCEs,4 with timely availability and appropriate delivery of blood components being an essential part of management. On 20 January 2017, an MCE occurred in Melbourne, Victoria, when a car struck pedestrians in the Bourke Street Mall in the central business district, killing six people and injuring more than 30. The injured were taken to various adult and paediatric hospitals around Melbourne, including designated trauma centres and non‐trauma hospitals, both public and private. A Code Brown was activated at some of these hospitals. This is a hospital alert activated internally when notification of an external incident is received, usually by emergency services or health departments, which requires mobilisation of additional capability and capacity within that facility to receive an influx of patients.5 In Victoria, the users of blood products, including public and private hospitals and pathology laboratories, are represented by the Victorian Blood User Group. The Blood User Group meets quarterly with Australian Red Cross Lifeblood (previously Australian Red Cross Blood Service) to discuss issues relevant to the use and supply of blood products. In February 2017, Blood User Group members highlighted concerns with communication during the Bourke Street incident. Poor communication from hospitals to their pathology laboratories was noted during activation of hospital Code Brown alerts. There was also uncertainty and lack of transparency surrounding supply of blood components from Lifeblood to hospitals in Victoria, not only to those involved in the incident but also those awaiting delivery of routine blood inventory. In response to these concerns, the Blood User Group held a forum in August 2017 to discuss these issues and to make recommendations to assist planning for future incidents. Blood User Group representatives and invited guests, including National Blood Authority representatives, heard presentations from the Victorian Department of Health and Human Services, Lifeblood and four hospitals that received patients, outlining issues and learnings from the incident, followed by further discussion. A summary of recommendations was circulated to forum attendees. This article highlights issues and recommendations pertinent to hospitals and associated pathology laboratories, in particular their haematology and transfusion laboratories. Recommendations Pathology staff must form part of hospital critical incident management teams In some hospitals, the associated pathology laboratory is not part of the critical incident management team, and when these hospitals were notified of the Bourke Street MCE by emergency services, this was only communicated to the pathology laboratory via public address systems or other informal means. Updates received by hospitals from emergency services throughout the event were similarly not always communicated in a planned way. Key pathology representatives in some hospitals also attended their emergency departments in person, which was invaluable for communication but occurred on an ad hoc basis rather than being part of a documented protocol. Without streamlined communication, pathology representatives can often only respond to blood component requests and transfusion specimens when they arrive, leading to potential delays in blood product provision. As transfusion support remains a core component of management in MCEs, a key recommendation is that pathology staff must form part of any hospital's critical incident management team. This should be documented in the critical incident protocol, and involves active pathology staff participation during critical incidents. Further formalised pathology roles, such as physical attendance at critical sites in the hospital (eg, emergency department) to streamline communication with the laboratory, are also encouraged. This ensures that pathology services receive adequate notification of critical events, and enables direct involvement in ongoing management of the incident in a systematic way with clear lines of communication. It also allows pre‐emptive action such as pre‐thawing of clinical plasma, and review and management of current inventory including appropriate use of emergency blood components. Implement safe, non‐sequential allocation of unit record numbers for consecutive emergency patients One hazard noted at the forum was a lack of specific labelling protocols for identifying patients presenting to some emergency departments, resulting in potentially dangerous patient identifiers being used; for example, consecutive unit record numbers for consecutive patients, or the same prefix on all patients. This may facilitate clerical errors and patient misidentification. It is recommended that institutions ensure that allocation of unit record numbers for consecutive unknown patients is performed in a safe way, which minimises the risk of patient misidentification. Ensure adequate levels of pathology staff familiar with critical event management Staffing levels were an issue at some sites during the Bourke Street MCE, owing to senior staff being on leave. Similarly, when critical incidents occur after‐hours, staffing is often limited and senior personnel may not be on site, resulting in less experienced staff enacting their critical incident management plans. Extra staff may be required and there may be difficulty of access to workplaces if the incident results in road closures. Working during the incident can be physically and emotionally tiring, and replacement staff will be required after the event.4,6 Therefore, it is recommended that all staff, irrespective of experience, should be familiar with their local critical incident management plan, and that consideration be given to how staffing levels are managed during and after a critical incident. Include pathology staff in practice disaster scenarios All hospitals should practise responses to disaster scenarios and involve pathology representatives. During the Bourke Street event, hospitals other than the major trauma centres received multiple casualties. “Walking wounded” may also present at nearby hospitals, irrespective of whether these have emergency departments. Performing practice scenarios is therefore important to familiarise staff with their critical incident plans. Limitations of these scenarios are recognised, as they often do not encompass the practical issues faced by pathology teams, such as time taken to run multiple pathology samples, perform multiple crossmatches and accept into inventory large numbers of blood products. Despite these limitations, it is recommended that hospitals perform practice disaster scenarios and involve pathology staff to highlight areas of potential weakness. Consider standby phase in Code Brown responses One hospital activated their Standby Code Brown during the Bourke Street MCE, when it was first notified by emergency services of the possible arrival of casualties, but before patient numbers or severity of injuries were known. This standby phase alerted the critical response areas of the hospital, including the emergency department and pathology services, to an external incident, allowing review of department response plans such as staffing levels and blood product inventory without activating a full Code Brown response. The standby code remained in place until the hospital was advised of further details of presenting patients. It is recommended that hospitals incorporate such a standby phase in their emergency response plan. This alerts relevant departments to plan and prepare for escalation of an event when a critical incident is first notified to the hospital, but before further details are known or casualties have presented, without activating the full series of Code Brown activities which can be disruptive. Discussion Effective communication during MCEs is critical. It is common for many more blood components to be requested than are eventually transfused, and the overall requirement for products in these events is often lower than expected.7,8 Most blood use in MCEs occurs within the first 24 hours, particularly in the first 4 hours as the majority of severe casualties arrive within this time frame.2,7 Therefore, the key to managing these chaotic and rapidly evolving events is early, accurate and ongoing updated communication between emergency services, state health departments, hospitals, pathology laboratories and Lifeblood to ensure that blood components are urgently allocated to appropriate patients while limiting unnecessary ordering and cross‐matching of products. Local communication between hospital departments and pathology laboratories can be improved by implementing the above recommendations, in particular by involving pathology laboratories in critical incident management. Hospitals may use existing communication channels including email, intranet and paging or other messaging services; however, the protocol for using these should be clearly documented in the critical incident management plan. Broader statewide communication via health departments and Lifeblood would also allow other health care services to respond appropriately; for example, by managing blood inventory conservatively until the extent and impact of the MCE is known. This requires effective communication between health departments and Lifeblood, and it is imperative that information circulated via state jurisdictions and Lifeblood is consistent to avoid confusion. Forum attendees recommended that the National Blood Authority enable Lifeblood to disseminate information to pathology services through a web‐based blood product ordering system, BloodNet, which is used by transfusion laboratories throughout Australia. Health departments should similarly ensure that existing channels for communicating emergency information to hospitals, such as hospital personnel contact details, are current. Any communication must also be effective outside standard business hours. Fax or email messages are unreliably received after‐hours, and phone contact with appropriate hospital personnel may be more effective. The Bourke Street Mall MCE highlighted the challenges involved in supplying blood components during such events. The recommendations are similar to those published in a previous review on transfusion preparedness for MCEs4 and recognise the requirement for an integrated approach that includes a central role for pathology laboratories. Incorporating the lessons learnt from this incident will allow for more organised responses and streamlined communications between all departments and institutions.

Linda Saravanan · Amanda Ormerod

During the COVID‐19 pandemic, people with heart disease are likely abandoning usual medical advice As the world watches the spread of the coronavirus disease 2019 (COVID‐19) pandemic, affecting the health of millions of people and the lives of everyone, common health conditions including heart disease, stroke, cancer and other chronic diseases continue. While there is no doubt that there are direct consequences for morbidity and mortality of COVID‐19, including its direct cardiovascular effects, it will be important to ensure that these are not matched by the indirect consequences. Countries are at different stages in the natural history of the pandemic, but there is a clear pattern. Overloaded health systems necessitate the hasty development of new protocols and pathways for common conditions that deviate from established guidelines and that may be caused by changes in community behaviour, either imposed or arising from fear. Unproven therapies are being tested in the field and, in the absence of evidence, there is the potential for theory to drive practice to an extent that is generally not seen in conditions with an established evidence base. During the COVID‐19 pandemic, emergency department (ED) attendances fell dramatically in England, with 89 584 attendances in the week after the lockdown (23–29 March 2020), down 25% compared with the 120 356 attendances during the previous week and almost 50% down on attendances in February 2020.1 This decrease in ED attendances has also been reported in Europe, Canada and Australia.2 ST elevated myocardial infarction (STEMI) rates fell by about 40% in reports from Austria3 and the United States.4 It is possible that COVID‐19 is associated with plaque stabilisation and lower rates of STEMI, but it seems more likely that people with heart disease are abandoning usual medical advice at a time when they may need it the most. In New York, US, a 50% decrease in ED visits for acute coronary syndromes has been reported at the same time as an eightfold increase in out‐of‐hospital cardiac arrest calls in the first week of April 2020.5 It is not clear how many of these calls are COVID‐19‐related, but there seems to be no doubt that people have a reluctance to attend hospital during the peak of the epidemic, which is having a significant cost in mortality. The angiotensin‐converting enzyme inhibitors and angiotensin II receptor blockers controversy In the midst of all this, a controversy has emerged about the safety and value of angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) — commonly used for the treatment of hypertension and heart failure — in the context of the COVID‐19 pandemic. In ordinary times, these are considered to be among the safest, best tolerated and most effective drugs for the management of both hypertension and heart failure, with a strong evidence base showing a reduction in morbidity and mortality from these conditions.6,7 To date, there is insufficient clinical evidence that ACEIs, ARBs or other inhibitors of the renin angiotensin system are either harmful or beneficial in the acquisition of COVID‐19 or its subsequent clinical course in individual patients. A number of clinical trials of losartan and recombinant angiotensin‐converting enzyme 2 (ACE2) are underway, such as the Losartan for Patients with COVID‐19 Requiring Hospitalization trial (ClinicalTrials.gov, NCT04312009). The debate has arisen because of circumstantial arguments based on COVID‐19 pathophysiology and renin angiotensin system physiology.8,9 It is argued that ACEIs and ARBs may be harmful because: hypertension is overrepresented among people who develop the most severe complications of COVID‐19;10 severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) gains entry to a cell using ACE2 and type II transmembrane serine proteases;11 ACE2 is highly expressed in the cardiovascular system, gut, kidneys and lungs (in the cardiovascular system, ACE2 is expressed in cardiomyocytes, epicardial adipose tissue, cardiac fibroblasts, vascular smooth muscle and endothelial cells);11 ACEIs or ARBs upregulate ACE2 in heart cells in some experimental models;12 these factors in theory may lead to a greater viral load and more serious infection. Several important links in this logic chain are contested. Early reports of high rates of hypertension in people dying of COVID‐19 or presenting with severe COVID‐19 were not adjusted for age. However, it is clear that most of these patients have comorbidities, including hypertension, heart failure and diabetes, all of which are more common in an older population. The mortality rate in the intensive care unit in 72 regional hospitals in Lombardy, Italy, was 26%. Most patients were male (82%) and had extensive comorbidities, especially hypertension (49% overall and 62% of deaths).10 ACE2 and COVID‐19 pathophysiology The relationship between COVID‐19 and the renin angiotensin system has been reviewed extensively.11 Although there is no doubt that ACE2 is a receptor for COVID‐19 and that the gene is widely expressed in the body, there is mixed evidence on whether it is upregulated by ACEIs or ARBs in animal models, and there is no evidence that it is increased de novo in tissues that have low expression.13 COVID‐19 suppresses ACE2.11 If ACE2 expression is increased by ACEIs or ARBs, it does not necessarily imply that this enhances the ability of SARS‐CoV‐2 to infect cells. The affinity of the virus for ACE2 is very high, and it is not clear that a small increase in expression due to renin angiotensin inhibition would increase intracellular viral load. Another counterargument to this hypothesis is that an increase in ACE2 expression would provide a counter to the suppression due to SARS‐CoV‐2 and allow the beneficial effects of ACE2, including anti‐inflammatory activity, to manifest; that is, ACEIs or ARBs may be beneficial. Trial design to resolve the matter In considering the possibility of interactions between COVID‐19 and medications, it is important to take into account the different stages in the evolution of the disease in an individual. The earliest stages are characterised by mild or absent upper respiratory symptoms and lymphopenia. A minority of people infected with SARS‐CoV‐2 subsequently develop pneumonitis and pulmonary complications. Even fewer people develop the most severe complications with hyperinflammation — also called “cytokine storm” — often with myocarditis and other major organ failures. It is quite likely that the renin angiotensin system and, by implication, drugs that interact with it, such as ACEIs or ARBs, have different actions at various stages of the condition according to the tissues affected. For example, ACE2 is protective in acute lung injury, suggesting that, although it facilitates viral entry through the epithelium, the ACE2 and its product, the angiotensin (1‐7) axis, could be used to reduce tissue injury caused by SARS‐Cov‐2, a potential target for therapy.11 This will be an important consideration in the design and setting of clinical trials. What clinicians can do in the meantime There are highly circumstantial arguments for and against the use of ACEIs and ARBs in patients with COVID‐19 and there are many more in the literature — as preprints and on social media. In the absence of good epidemiological and clinical trial data, there is no immediate and definitive resolution to the debate. What is clear is that people with hypertension and heart failure benefit from ACEIs and ARBs where indicated, and withdrawing treatment is likely to have serious consequences in some people. We are thus left with a situation where stopping ACEIs or ARBs in some people has known and potentially serious sequelae, whereas continuing them in people with or vulnerable to COVID‐19 has unknown consequences that, depending on how the experimental evidence is interpreted, may be negative, neutral or even positive. International and national authorities on cardiovascular disease, including the High Blood Pressure Research Council of Australia, the World Health Organization, the American Heart Association and the European Society of Cardiology, have been united in their recommendation that treatments with ACEIs or ARBs should be continued during the present pandemic pending evidence from clinical studies to the contrary.14,15 In a number of patient groups, ACEIs or ARBs are first line choices; for example, in patients with hypertension and proteinuria or in people with heart failure. Given the clear benefits they have provided over several decades, a decision to withdraw first line therapies should only be based on reasons supported by a strong evidence base. In other groups, such as in patients with uncomplicated essential hypertension, there are alternatives, including calcium channel blockers or diuretics. However, changing medications in patients with well controlled blood pressure requires careful monitoring and there is a risk in the short term that blood pressure will fall outside the optimal range. This may prove challenging during a period when telemedicine is the norm and given that not all households have home blood pressure monitoring equipment and training. As the ACEIs and ARBs controversy has been wisely canvassed in the media, health professionals will need to have a conversation with patients about the benefits or otherwise of continuing their present therapies. It is important that people understand that no concerns have been raised about other medications they may be taking, such as statins, antithrombotic agents, or treatment for diabetes. In recommending continuation of ACEIs or ARBs, physicians can draw comfort that they are backed by almost every cardiovascular health authority in the world. Nevertheless, the clinical trial results of both administration or withdrawal of ACEIs or ARBs cannot come quickly enough, and in the best case, they will allow us to turn practice into the right theory.

Garry LR Jennings

Usual care must be rapidly adapted to isolate, assess and test large numbers of patients during the COVID‐19 pandemic Coronavirus disease 2019 (COVID‐19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), emerged in China in late 2019.1 COVID‐19 is an example of a high consequence infectious disease that may present to an Australian hospital. These infections are uncommon in Australia and, in most cases, were imported from overseas. Less frequently, there is onward local transmission, such as during the influenza A(H1N1)pdm09 pandemic in 2009. High consequence infectious diseases present unique challenges to Australian hospitals. Their rarity leads to unfamiliarity and loss of institutional knowledge between events. Many hospitals operate at near maximal capacity between outbreaks and have limited surge capacity.2 Protocols designed to manage single patients require adaptation to situations where larger numbers of patients require isolation, assessment and testing for infection. While every Australian hospital has a mass casualty or disaster protocol, these are developed for all hazards and may not address problems specific to high consequence infectious diseases, including: the need to rapidly identify and isolate potentially infectious patients to prevent nosocomial transmission; the complexity of rapid triage and assessment on frequently evolving epidemiological and clinical grounds; the difficulty of differentiating high consequence infectious diseases from more common but clinically similar conditions;3 the absence of rapid diagnostic tests to aid clinical decision making; and the potential for a prolonged surge for weeks to months during which time the workforce may be affected by both infection and absenteeism. Here we describe the strategic approach of the Royal Melbourne Hospital to triage and screen patients who have presented at risk (or concerned that they are at risk) during the early phases of COVID‐19. Our resources may be of value to other organisations refining their triage and clinical algorithms. The Royal Melbourne Hospital response The Royal Melbourne Hospital is an adult tertiary referral centre and the designated state‐wide provider for quarantinable diseases. The emergency department (ED) treats over 80 000 patients annually. From 6 January 2020, we instituted tools to identify at triage those patients with risk factors for COVID‐19 and rapidly isolate them. Initially, there was capacity to assess patients in one of three existing negative pressure rooms. On 25 January, the first patient with COVID‐19 in Australia, who had arrived in Melbourne on a flight from Guangzhou, was confirmed. The Victorian Department of Health and Human Services informed all passengers on the flight of their possible contact with the patient, leading to a significant surge in presentations to the Royal Melbourne Hospital. Box 1 presents an overview of the challenges in managing high consequence infectious diseases and details of our coordinated approach. Key components that can be used by other services are detailed below. Governance Unlike other major incident responses, which tend to be short‐lived, response to an outbreak requires a sustained response that will inevitably have an impact on other clinical services. A governance process that includes executive sponsors and senior clinical leaders is essential. The Royal Melbourne Hospital COVID‐19 response leveraged an existing code brown (external emergency) pandemic subplan and clinical code yellow (internal infectious disease emergency) plans as a governance framework. A governance group including medical and nursing executives and senior clinicians from the ED, infectious diseases, infection prevention services and microbiology meet regularly. A single standard operating procedure exists on our hospital intranet that provides all clinically relevant information for frontline health care workers (eg, personal protective equipment guidelines, current case definitions, patient assessment algorithms). It is updated frequently given the dynamic situation and, thus, functions as a living document for staff. This document provides 24/7 access to an authoritative source that supports junior and senior staff alike to feel confident in their practices and approach. Infrastructure Establishment of a fever clinic. A particular design feature that may be adopted by other facilities is the rapid establishment of an out‐of‐department fever clinic. In response to the first surge of patients, we rapidly repurposed the nearby hospital transit lounge, which was closed for the weekend, into a fever clinic (Box 2). The clinic received its first patient within 2 hours of notification from the Victorian Department of Health and Human Services of the first local case. In its first 7 days, we assessed 109 patients. We discharged over 90% of patients within 4 hours of arrival. We retain this model as patient numbers continue to increase. In this model of care, patients are physically segregated from the rest of the ED into a dedicated rapid assessment and treatment space from their arrival, limiting exposure to other patients. The main benefit of this approach is that cases yet to be identified can be an important contributor to nosocomial transmission; therefore, early separation and detection are vital.4,5 However, immediate recognition of cases is difficult due to unfamiliarity with the disease, overlap in clinical presentation with more common illnesses, and due to patient wait times. Our fever clinic model of care was based on the success of this model in Toronto and Taiwan during the severe acute respiratory syndrome (SARS) outbreak,6 where no transmission was reported in these facilities despite hospital exposure being implicated in the majority of cases in these regions (eg, it was the presumed source of exposure for 72% of patients in Toronto7,8). It has also been reported as an effective strategy for triaging patients in Wuhan for COVID‐19.9 Similar approaches appear to have been used in other countries, but detailed descriptions are not yet available in the literature. In Australia, segregation of major incident patients was exemplified by the Royal Darwin Hospital, which functioned as the forward receiving hospital for medically evacuated patients during the 2002 Bali bombings.4 The benefits of establishing a fever clinic include: protecting an existing environment for the maintenance of business continuity; facilitating protocolised interventions for spatially clustered groups of patients; providing a physical location to send additional disaster resources without cluttering areas of core business; and enhancing record‐keeping. Limitations of our approach include the additional staffing required, operational impact of loss of transit lounge, staff unfamiliarity with the location of resources (such as resuscitation trolleys), and a slightly further distance from resuscitation bays if patients deteriorate. Moreover, we were also concerned about the risk of stigmatisation of patients who are seen to be segregated from the main ED waiting room cohort. Implementation of electronic self‐registration and self‐screening. A surge related to an emerging infectious disease provided our clerks’ department with a confluence of unique administrative and logistical challenges. These included: a high proportion of patients came from a non‐English speaking background; contact tracing and follow‐up requires accurate registration and an extended suite of contact details, but usual disaster response medical records protocols generate only anonymised patient registrations; non‐clinical staff (ward clerks) unfamiliar with personal protective equipment would be required to extensively interview patients to confirm details at some point; patients came in bursts, producing delays in registration; manual screening paperwork and registration papers provide a potential fomite for disease transmission; and our ED is paper‐free under usual circumstances. We developed a novel solution to this problem, leveraging the fact that over 91% of Australian citizens and over 96% of Chinese citizens own a smartphone5,10 and converted an initial paper‐based bilingual screening tool to an online one. This is hosted using the research electronic data capture (REDCap) tool (www.projectredcap.org).11 Patients are directed to a secure website optimised for use on a smartphone. The registration portal is free to use. They answer questions regarding their epidemiological risk (such as a detailed travel history, or being a health care worker), clinical risk factors (such as being immunocompromised) and symptoms. Results are immediately fed to remote clinical computers where ward clerks can register the patient without direct patient contact and clinicians can see screening information before their clinical encounter. While not yet tested under a pandemic scenario, we anticipate this method of self‐registration may be particularly useful in the event of a significant surge in patient numbers. Triage sieve and sort of patients can be rapidly undertaken by clinicians who are fed real‐time registration data. Compared with usual mass casualty principles, the inclusion of epidemiological data in the electronic tool is valuable for triage in this setting to screen out the relatively high proportion of patients with perceived, but not actual epidemiological risk factors. Our REDCap infrastructure is available in the Supporting Information for adaptation by other health services. Conclusion The importation of emerging infections into Australia is rare, and onward transmission is rarer still. As the Royal Melbourne Hospital received a surge in patients who required screening for COVID‐19 relatively early during the current outbreak, our recent observations may provide opportunities for other hospitals to enhance their preparedness and response plans. We prioritise prevention of nosocomial transmission (using a scalable, separated fever clinic) early planning for worsening surge (adopting scalable solutions) and clear clinical governance (providing malleable and accessible centralised resources). Box 1 – Elements of the Royal Melbourne Hospital clinical response Element of response Challenges Approach used Clinical governance Multiple clinical units involved, with tangible impacts on business as usual activity and frequent changes to the model of care and the expectations Where possible, we operated within existing plans and policies. Daily executive and head of unit level huddles were instituted initially, and then stepped down to weekly as needed, producing hospital agreement on messaging and expectations of all teams and sharing of information between executive, infectious diseases (ID), infection prevention services (IPS) and emergency medicine (EM). COVID‐19 multidisciplinary working groups were formed within the ED and ID clinical units Infrastructure A space was needed to accommodate the extra patients while maintaining infectious isolation among them, and between them and the rest of the ED census A graduated response used with existing ED negative pressure rooms used for small numbers, a cohort subwaiting area was created when several patients were present in the ED at once, and a separate fever clinic was created in the nearby transit lounge used for surge response Infection prevention and control practices Transmission dynamics are incompletely understood and there is a risk of nosocomial amplification (especially during aerosolising procedures) Education sessions, posters, and videos used to reinforce PPE training; nebulisers removed from dedicated treatment space; hand sanitiser stations; PPE stations and infectious waste bins deployed; and a SOP employed for aerosolising procedures (Supporting Information) Clinical care (including triage, assessment and testing) There is rapidly evolving understanding of clinical and epidemiological characteristics of the disease. Staff lack familiarity with the disease and with the roles performed (concierge nurse, fever clinic doctor), while the normal ED and hospital functions need to continue alongside Creation of a SOP including clinical algorithms for triage, assessment and biological sampling as a living document hosted on the hospital intranet, and updated as needed and used as a single source of truth for clinical staff. Gradual transition to algorithm‐driven assessment by junior medical staff to free up senior staff for unwell patients. Action cards with role descriptions were provided in the SOP for all fever clinic staff Communication with patients Initially, most patients were Mandarin‐speaking Bilingual signage (English and Mandarin) deployed in the fever clinic, and bilingual patient resources and screening questionnaire generated. Discharge information sheets specific to different tiers of risk were translated into Mandarin and provided to all patients discharged from the fever clinic Human resources Maintenance of staff competence and confidence essential for safety and prevention of absenteeism Regular education sessions to provide updated clinical information and epidemiology, train in PPE, and answer questions COVID‐19 = coronavirus disease 2019; ED = emergency department; PPE = personal protective equipment; SOP = standard operating procedure. Box 2 – Floor plan of the Royal Melbourne Hospital fever clinic and guiding principles for a fever clinic COVID‐19 = coronavirus disease 2019; PPE = personal protective equipment; SOP = standard operating procedure.

Amanda M Rojek · Martin Dutch · David Camilleri · Emma Gardiner · Emma Smith · Caroline Marshall · Kirsty L Buising · Nicola Walsham · Mark Putland

The maintenance of sustainable low cost physical distancing and enhanced hygiene may decrease the number and severity of cases It is estimated that about two‐thirds of cases of coronavirus disease 2019 (COVID‐19) exported from China between 1 and 13 January 2020 were undetected globally.1 Most of these exported cases were mild and were only detected after several hundred cases had accumulated and severe or fatal cases were recognised 5–8 weeks later, as likely occurred in the COVID‐19 outbreaks in Iran, South Korea, Italy and Seattle, United States.2 The spread of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission globally has been very rapid. The basic reproduction number (R0) is estimated at between 2 and 3.3,4 The mode of transmission is thought to be droplet and contact infection, although opportunistic or close range airborne infection may be involved.4 The transmission dynamics of the early cases of COVID‐19 were significantly different to those during the severe acute respiratory syndrome (SARS) epidemic in 2003. In particular, the proportion of COVID‐19 cases from health care settings was low and the proportion with no known risk exposures was high.4 Another significant factor is that viral loads in nasopharyngeal and respiratory secretions are highest soon after symptom onset in patients with COVID‐195 compared with a peak of around 10 days in patients with SARS,6 making transmission before entering health care facilities and in the pre‐symptomatic phase more likely.7 Even though the understanding of transmission dynamics is at an early stage, they do suggest that the stepwise introduction of stringent measures will be necessary to control this epidemic and highlight the importance of early community control. Australia and other countries have experienced a first wave of disease and managed to effect a decline in cases.8 Quarantine; city lockdowns; complete childcare, school, university and workplace closures; and cancellation of mass gatherings and events have a significant social and economic impact and were not often implemented until significant transmission was confirmed — when they may be less effective. Countries are now challenged with identifying which of these various controls can be relaxed to allow some routine societal and economic activities to return. However, there are low cost, sustainable interventions that may be maintained over what may be many years of continued mitigation9 (Box 1). These low cost enhanced hygiene and physical distancing measures are applicable pre‐emptively before confirmation of local community transmission or where transmission of SARS‐CoV‐2 appears to be under control. The purpose of these interventions is to slow the transmission of disease and limit the impact on health services, particularly on hospitals and intensive care units, to ensure access to high level care when needed. The interventions are based on the following assumptions, which require further exploration: community‐wide SARS‐CoV‐2 transmission may be occurring undetected or may only be recognised after containment is no longer feasible; interventions implemented after community‐wide transmission is detected will be less effective; reduction of the force of infection, particularly early, will delay the epidemic peak, blunt the epidemic peak, spread cases over a longer time, and help limit the potential for critical care services to be overwhelmed, which may be lifesaving;12,13 low cost sustainable interventions will assist in the relaxation of more economically costly interventions, and enhanced hygiene and physical distancing interventions should: ▸decrease the total number of cases per week; and ▸decrease the severity of cases through reducing viral inocula. Box 2 illustrates the concept of limiting the peak in cases so that health services are less likely to be overwhelmed and there is less unmet health service need. Unmet need may include inability to admit patients to a hospital or to provide hospitalised patients in critical condition access to intensive care. Interventions to reduce infection lead to longer but less peaked epidemics. A slower evolution in the epidemic also allows time for health care staff to provide better care, for recovery of infected health care workers, for learning and adapting to the evolving situation by administrators, and for vaccines and treatments to be developed. This principle is validated in simulations for influenza14 and appears to be validated with the reduction in COVID‐19 cases in Australia and the relative lack of overburden on clinical services.8 Measures to decrease the number and severity of cases Pre‐emptive and ongoing maintenance of low cost interventions (such as enhanced hygiene and physical distancing measures) (Box 1) may not only decrease the total number of cases but may also decrease the severity of cases. The R0 is the average number of secondary cases of an infectious disease that arise from cases in a totally susceptible population and reflects the epidemic potential of a pathogen.15R0 is a function of the number of contacts an infectious person has, the risk of transmission per contact, and the duration of infectiousness. Physical distancing mostly acts on the first factor by reducing the number of contacts each person makes. Hygiene measures mostly act on the second factor, as they reduce the risk of transmission if a contact occurs. It is difficult to disentangle the effectiveness of the multiple control measures implemented in pandemic‐affected areas. The World Health Organization–China Joint Mission on COVID‐19 determined that widespread community transmission and outbreaks occurred in Wuhan before the implementation of comprehensive control measures.4 However, in other parts of China, community transmission has been limited and after public gatherings were cancelled and people were restricted to their homes, most transmission occurred in families. For example, among 344 clusters involving 1308 cases (out of a total 1836 cases reported) in Guangdong Province and Sichuan Province, 78–85% have occurred in families.4 Community‐wide interventions may decrease the average viral exposure dose encountered in the community. People exposed to a higher viral dose (inoculum) are more likely to become infected and have more severe disease. Animal models for other coronavirus infections demonstrate that increased viral inocula lead to more severe disease and higher viral loads in the lungs and other organs and fluids.16 The SARS outbreak in Amoy Gardens, Hong Kong, in 2003 provided evidence that patients with presumed higher exposure to the index case had higher nasopharyngeal viral loads and more severe illness.17 SARS‐CoV‐2 cases with more severe disease have been found to have around 60 times higher viral load than those with mild disease.18 Modelling of the 2009 influenza pandemic also supported a hypothesis that severe illness was due to a higher infectious dose of the virus mediated by the number of simultaneous infectious contacts.19 Viral loads in severe patients with Middle East respiratory syndrome (MERS) were higher than those in a mild group, and the patients in the severe group had more prolonged viral shedding in respiratory secretions, beyond 21 days after the onset of symptoms, whereas viral RNA was no longer detected by 21 days in the mild group.20 Therefore, it is proposed that early measures that lower the number of contacts, the likelihood of transmission, and average viral infective dose in an area of transmission may have a multiplier effect leading to fewer cases and fewer severe cases that are less infectious. Maintaining the early reduction of the R0 would result in fewer cases overall and have a significant negative multiplier effect on the overall impact of the epidemic, including the number of deaths (Box 3). The higher case fatality rate in Wuhan, compared with other provinces in China, may partially relate to health care resource availability and shortages in the face of overwhelming community transmission as well as greater severity of disease due to higher infection doses.12,17 These interventions will be particularly important for people over 60 years of age and those with underlying medical conditions. The costs of intervention The suite of low cost interventions, other than a working from home policy, is unlikely to affect work productivity and may provide the community with some reassurance that all is being done to prevent the epidemic and that maintenance of the low cost measures may allow earlier opening of some workplaces. WHO is supportive of pre‐emptive interventions to prevent COVID‐19 in workplaces.21 Some may see it as being overreaching, but thus far, communities seem to voluntarily adopt low cost interventions, and acceptance may be enhanced through consultation and trust building.22,23 Influenza co‐benefits For regions approaching their influenza season, optimal prevention and control of seasonal influenza, such as vaccination, in the face of potential COVID‐19 cocirculation is also crucial to minimise the double burden on health services. The measures discussed here (enhanced hygiene and physical distancing) are also effective against influenza, resulting in potential co‐benefits for both pathogens. Early indications from Flutracking.net (https://info.flutracking.net/reports-2/australia-reports) indicate that physical distancing and hygiene enhancements have markedly decreased influenza‐like illness in Australia. Limitations While physical distancing and enhanced hygiene interventions in Australia appear to be working, the evidence on the effectiveness of individual interventions in preventing COVID‐19 is not yet available. However, there is evidence from observational and simulation studies for the effectiveness of physical distancing measures in controlling seasonal influenza.13 Other measures, such as hand hygiene and cleaning surfaces, have a long history of use in infection prevention and control.24 Despite the lack of robust evidence of effectiveness for these measures, their relative low cost means that there is little harm and much potential benefit in maintaining and optimising them. We have made no recommendations in regard to masks. The use of masks outside of health settings is controversial and it is important that medical grade masks not be diverted from health care supplies. Nevertheless, surgical masks are protective of large droplet spread, have about half the effectiveness of N95 masks for small droplet transmission, and are suggested to be cost‐saving in some modelled pandemic influenza scenarios.25 The use of masks may have a role in the community setting if there are adequate supplies.10 There is evidence suggesting that community use of masks may have reduced the risk of contracting SARS.26 It is clear that masks should be used in households caring for patients with COVID‐19 at home. Policy development and scientific review of the literature on community use of masks is very dynamic at this time. The US Centers for Disease Control and Prevention has made a recent recommendation that cloth masks be used at the community level and many recent reviews have come to divergent conclusions about the usefulness and risks of community mask use.27,28,29,30 Coherent policy development in this space will rely on transparently articulating the scientific evidence on community mask use with a public conversation on the potential risks in implementation. The interventions discussed here should be tailored to individual settings and communities, in partnership with members of those communities. In particular, these interventions should be adapted to the unique circumstances of groups, such as Indigenous communities; vulnerable groups, including homeless populations; and culturally and linguistic diverse communities. Conclusion SARS‐CoV‐2 continues to disseminate globally and there are likely to be recurrent waves of infection into the foreseeable future. We would argue that these low cost interventions, although formulated at an earlier stage of the epidemic, have increasing relevance. They will protect against the emerging concern for pre‐symptomatic transmission and their optimisation will better enable the more restrictive and economically damaging constraints to be relaxed.7 Box 1 – Low cost hygiene and physical distancing interventions Settings Interventions Workplace No handshaking policy Promote cough and sneeze etiquette, but focus is on excluding ill staff Videoconferencing as default for meetings Defer large meetings Signage for all offices/meeting rooms advising of maximum occupancy based on 4 m2 per person and 2 m distancing Enforced sanitisation of hands at entrance Regular hand sanitation schedule reminders via email Avoid gathering in lunch and break rooms Gamifying hygiene rules, for example, to discourage touching face Ill* people should stay at home and ill workers immediately isolated Hold necessary meetings outside in open air if possible Staff with ill household contacts should stay at home† Disinfect high touch surfaces regularly and between users Work from home where possible and consider staggering of staff Consider opening windows and adjusting air conditioning to increase air flow and maintain warmer more humid environments‡ Limit food handling and sharing of food in the workplace Assess staff business travel risks§ Enhance hygiene and screening for illness among food preparation (canteen) staff and their close contacts Analyse the root cause of crowding events on site and prevent through rescheduling, staggering or cancelling Mark floor areas to indicate 2 m distancing points in areas where staff spontaneously gather to prompt distancing Minimise the number of employees in a work vehicle at any one time School Supervised sanitisation of hands at entrance and at regular intervals Defer activities that lead to mixing between classes and years Promote cough and sneeze etiquette, but focus on excluding ill persons Strict stay at home policy if ill Gamifying hygiene rules, for example, to discourage touching face Regular handwashing schedule Disinfect high touch surfaces regularly and between users Outdoor lessons where possible Consider opening windows and adjusting air conditioning Enhance hygiene and screening for illness among food preparation (canteen) staff and their close contacts Review after‐school care arrangements that lead to mixing of children from multiple classes and ages Commercial, entertainment and transport Sanitisation of hands at building entrance encouraged Tap and pay preferred to limit handling of money Disinfect high touch surfaces regularly Avoid crowding through booking and scheduling, online pre‐purchasing, limiting attendance numbers Enhance hygiene and screening for illness among food preparation staff and their close contacts Enhance airflow and adjust air conditioning to increase air flow and maintain warmer more humid environments Public transport workers, taxi and ride share drivers — vehicle windows opened where possible, increased air flow, high touch surfaces disinfected Household All households Enhanced hand sanitisation Gamifying hygiene rules, for example, to discourage touching face Disinfect high touch surfaces regularly “Welcome if you are well” signs on front door Increase ventilation rates in the home by opening windows or adjusting air conditioning Promote cough and sneeze etiquette Households with ill members Measures listed above Confirmed cases of COVID‐19 should be isolated away from susceptible household members if there are not completely separate bedroom, bathroom and kitchen facilities If care must be provided at home, ill household members are given their own room and only one person cares for them The door to the ill person's room is kept closed10 Wearing simple surgical or dust masks by both infected persons and other family members caring for the patient if needing to be in the same room Consider extra protection or alternative accommodation for household members aged over 65 years or with underlying illness COVID‐19 = coronavirus disease 2019. *Ill person refers to someone with symptoms of respiratory illness or fever, who is not yet under investigation for COVID‐19 but could be an unrecognised case. †This could be costly unless used judiciously while awaiting exclusion of COVID‐19 in the suspected case and should be introduced based on likelihood of local transmission. ‡Evidence that low temperature and low humidity in air‐conditioned environments may enhance the survival of coronaviruses such as severe acute respiratory syndrome (SARS).11 §When international travel restrictions are lifted, sites such as the Centers for Disease Control and Prevention travel risk assessment site may be useful (https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html). Box 2 – Intended impact of enhanced hygiene and physical distancing measures on the coronavirus disease 2019 (COVID‐19) pandemic* *Figure adapted from Fong et al.13 Box 3 – Conceptual model of how pre‐emptive interventions with a negative multiplier effect could affect an impending epidemic

Craig B Dalton · Stephen J Corbett · Anthea L Katelaris

Victorian legislation will help the health sector reduce emissions and adapt to climate change

Brett Sutton · Vanora Mulvenna · Daniel Voronoff · Tiernan Humphrys

The origins, scope and significance of the 2019–2020 Climate Health Western Australia Inquiry

Tarun S Weeramanthri · Sarah Joyce · Revle Bangor‐Jones