Article Types

Research letters

Infectious diseases Research letters 12 July 2021 Free

Re‐defining the dengue‐receptive area of Queensland after the 2019 dengue outbreak in Rockhampton

On 23 May 2019, the Central Queensland Public Health Unit received a confirmed laboratory notification of a dengue virus serotype‐2 (DENV‐2) infection in a Rockhampton resident. On 5 May, a 71‐year‐old man without a history of travel overseas or to Far North Queensland had developed symptoms consistent with a zoonotic disease, and presented later that month to his general practitioner because his symptoms had not abated. Between 23 May and 7 October 2019, 21 locally acquired cases of DENV‐2 were identified in Rockhampton: 13 laboratory‐confirmed cases and eight probable cases detected by active surveillance. This was the first outbreak of locally acquired dengue in Central Queensland for 65 years.1 In 14 cases (67%), the infected persons sought medical attention; two required hospitalisation. A formal outbreak response was initiated by the Central Queensland Public Health Unit on 23 May 2019, including extensive mosquito surveillance and active and passive human surveillance within 200 metres of the residences of each identified infected person. Particular attention was directed to surveying locations that might facilitate increased dengue transmission in the community (such as schools, a plant nursery, and aged care facilities) for artificial and natural containers that could serve as breeding areas for infected mosquitoes (Aedes aegypti). Such containers were either removed or emptied of residual water and treated with pellets of the insect growth regulator (S)‐methoprene, and the premises and buildings were sprayed inside and out with the residual insecticide Temprid 75 (Bayer; includes imidacloprid and β‐cyfluthrin). In addition to the house‐to‐house human surveillance, a novel “lure and kill” approach was adopted for vector control: lethal ovitraps were deployed within 200 metres of the residence of any person with a probable or confirmed infection. Ae. aegypti was found in 105 of 1107 inspected residential premises (9.5%), or more than half of the 205 premises found to contain mosquitoes. Enhanced serological surveillance was undertaken to detect patients with viraemia early, enabling prompt public health and mosquito control interventions. The complete DENV‐2 genome sequence (GenBank accession number, MN982899.1) indicated that the implicated virus was most closely related to Southeast Asian strains of DENV‐2. Given the presence of Ae. aegypti in Central Queensland and the increasing numbers of travellers and visitors returning from countries in which dengue is endemic, it is important that Rockhampton be recognised as a dengue‐receptive area. As locally acquired cases of dengue are being reported outside Far North Queensland, the state map of dengue‐receptive areas2 should be updated; specifically, the broad geographic area from Townsville south to Rockhampton should be considered dengue‐receptive.

Jacina Walker · Alyssa Pyke · Paul Florian · Rachael M Rodney Harris · Gulam Khandaker

Mja2 51151
General medicine Research letter 12 July 2021 Free

Prostate‐specific antigen testing of asymptomatic men in Australia: an observational study based on electronic general practice data

Measuring prostate‐specific antigen (PSA) levels is widely used for screening for the early diagnosis of prostate cancer.1 However, the value of PSA testing for reducing prostate cancer‐specific or all‐cause mortality in asymptomatic men is uncertain.2 The Prostate Cancer Foundation of Australia and the Cancer Council of Australia recommend that men aged 50–69 years be offered biennial PSA testing if they make an informed decision to be tested.1 We investigated age‐specific patterns of PSA testing and PSA levels in men aged 40 years or more without symptoms of prostate cancer. We analysed routinely collected data from 180 Victorian general practices, pooled by the data custodian, Outcome Health.3 We included all men who had attended the same practice at least three times during October 2016 – September 2018. We identified tested men and testing frequency from recorded PSA test results. PSA testing prevalence was defined as the number of men tested at least once divided by the total number of men in an age group. We evaluated the relationship between log‐transformed PSA levels and age as a continuous variable in a linear regression model. The Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee (17‐008) and the Macquarie University Human Research Ethics Committee (5201700872) approved our study. A total of 142 016 male patients were identified. The proportion who underwent PSA testing at least once (prevalence) or at least twice during the study period increased with age: prevalence peaked with the 65–69 year age group (8132 men tested, 54% of age group), and the proportion of men tested at least twice with the 70–74 year age group (3159 men, 46% of age group) (Box 1). A total of 78 818 PSA test results were recorded during the study period; about one‐third were for men aged 60–69 years (25 496 tests, 32%). The median PSA level increased from 0.7 ng/mL (interquartile range [IQR], 0.5–0.9 ng/mL; 95th percentile, 1.7 ng/mL) for men aged 40–44 years to 1.9 ng/mL (IQR, 0.8–4.5 ng/mL; 95th percentile, 11.7 ng/mL) for men aged 85 years or more (Box 2). The median PSA level increased by 3.2% per year of age (95% confidence interval, 3.1–3.3%). We found that PSA testing prevalence, the proportion of men tested more than once within 24 months, and median PSA levels each increased with age. For men over 69 years of age, this could lead to further invasive tests and treatments, some of which may be unnecessary or cause harm. The high PSA testing prevalence among older men was similar to previous Australian reports (48% of men aged 70 years or more reported they had PSA tests in the preceding two years4), and the PSA levels matched current age‐specific 95th percentile reference ranges.5 Why patterns of testing are different to those recommended (ie, more frequently than biennial and beyond 69 years of age) cannot be explained by general practice data, but reasons may include patient expectations, fragmentation of care, and the persistence of old guideline recommendations. We have reported the most comprehensive snapshot of PSA testing in Australia based on electronic general practice data since the release of the current guidelines for PSA testing of asymptomatic men. Our study also showed that such data can be used to establish benchmarks for designing quality improvement activities and to promote evidence‐based decision‐making in general practice. Box 1 – Prostate‐specific antigen (PSA) testing for 180 Victorian general practices, October 2016 – September 2018, by age group* * Proportion of male patients in age group who were tested. It is recommended that men aged 50–69 years be tested once every two years. Numbers of patients in each age group are provided in the online Supporting Information. Box 2 – Number of prostate‐specific antigen (PSA) tests and median PSA test result levels, by age group table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Age group (years) Number of tests PSA level (ng/mL) Median (IQR) 95th percentile 40–44 2685 (3.4%) 0.7 (0.5–0.9) 1.7 45–49 5894 (7.5%) 0.7 (0.5–1.0) 2.1 50–54 9544 (12.1%) 0.8 (0.5–1.2) 2.6 55–59 12 359 (15.7%) 0.9 (0.6–1.5) 3.7 60–64 12 944 (16.4%) 1.1 (0.6–2.0) 4.7 65–69 12 551 (15.9%) 1.3 (0.7–2.4) 5.5 70–74 10 999 (14.0%) 1.5 (0.8–2.8) 6.4 75–79 6440 (8.2%) 1.6 (0.8–3.3) 8.0 80–84 3327 (4.2%) 1.8 (0.8–3.6) 9.2 ≥ 85 2075 (2.6%) 1.9 (0.8–4.5) 11.7 All ages groups 78 818 1.0 (0.6–2.0) 5.4 IQR = interquartile range.

Guilherme S Franco · Rae‐Anne Hardie · Ling Li · Chisato Imai · Gorkem Sezgin · Julie Li · Adam McLeod · Christopher Pearce · Andrew Georgiou

Mja2 51147
Pharmacology Research letter 28 June 2021 Free

Opioid medication prescribing in Queensland, 1997‒2018: a population study

The need to treat chronic pain and the increasing number of patients requiring opioid therapy are among the factors that have led to prescription opioid‐related harm. Several professional society guidelines aim to reduce the frequency of opioid‐related problems by modifying prescriber behaviour.1,2 We analysed Monitoring of Drugs of Dependence System (MODDS) data for adult Queensland residents (18 years or older) for whom opioids were dispensed during 1 January 1997 ‒ 31 December 2018. Our aim was to determine the most frequently prescribed doses of opioids, and to examine associations between the mean number of prescribers per patient and the opioid doses dispensed. The database included data for 228 861 opioid prescribers during the study period and 18 798 942 dispensed opioid prescriptions. We undertook multivariate mixed effects Poisson regression, with random intercept by patient identification to account for within‐patient correlations and between‐patient characteristics. We adjusted for socio‐economic status of patient residence (by postcode),3 as an association between lower socio‐economic status and greater opioid prescribing has been reported.4 We also adjusted our analysis for duration of opioid use, dose in oral morphine milligram equivalents per day (MME/day), and opioid formulation, as in our previous studies.5,6 The study was approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee (HREC/17/QRBW/669), the University of Queensland Human Research Ethics Committee (2018000623/HREC/QRBW/669), and by the Department of Health under the Public Health Act 2005 (Qld) (RD007970). The number of patients for whom opioids were dispensed increased from 28 299 in 1997 to 322 307 in 2018; the number of Queensland medical practitioners who prescribed opioids increased from 4537 to 20 226 (online Supporting Information, table). The proportion of opioid prescribers who prescribed opioids at doses of 50 to less than 100 MME/day peaked in 2003 (813 of 5530, 14.7%), as did the proportion prescribing 100 MME/day or more (1077, 19.5%), before declining in 2018 to 1294 (6.4%) and 1064 of 22 941 (5.3%) respectively (Box 1, A; Supporting Information, figure). During 1997‒2018, 1 916 842 people (67.8% of people dispensed opioids) were dispensed doses of less than 20 MME/day, 624 114 were dispensed 20 to less than 50 MME/day (22.1%), 159 448 were dispensed 50 to less than 100 MME/day (5.6%), and 127 323 were dispensed 100 MME/day or more (4.5%) (Box 1, B). For modified release opioids, the largest proportions of prescribers and patients were for the 20 to less than 50 MME/day dose category (Box 1, C, D). The mean number of prescribers per patient per year increased with the dose of opioids dispensed (v < 20 MME/day: 20 to < 50 MME/day, incidence rate ratio [IRR],1.04; 95% confidence interval [CI], 1.03‒1.04; 50 to < 100 MME/day, IRR, 1.09; 95% CI, 1.08‒1.09; ≥ 100 MME/day, IRR, 1.22; 95% CI, 1.21‒1.22) (Box 2). However, the mean number of prescribers per patient per year increased as the duration of opioid dispensing decreased (patients dispensed opioids for one month v for 7‒12 months: IRR, 1.36; 95% CI, 1.35‒1.36). This finding is consistent with a report that people using opioids for shorter periods more frequently visit multiple prescribers.4,5 Our findings indicate that most Queensland medical practitioners prescribe lower opioid doses, and that the proportion prescribing lower doses has increased since 2004. The proportion of people dispensed doses of opioids associated with increased risk of accidental overdose (from 50 MME/day) was small and has declined over time. Box 1 – Proportions of patients prescribed opioid medications and of prescribers, by opioid dose prescribed* * Opioids included were morphine, oxycodone, hydromorphone, tapentadol, fentanyl, buprenorphine, and codeine; methadone was excluded because we could not distinguish between prescribing for pain management and opioid replacement therapy. All formulations except lozenges, suppositories and parenteral formulations were included, apart from tablet and sublingual buprenorphine formulations (used to treat gastrointestinal problems and opiate dependence) and fentanyl (approved for palliative care). For complete inclusion and exclusion criteria, see Supplementary Material 3 in reference 6. Box 2 – Mean numbers of prescribers per patient per year, by daily opioid dose, duration of dispensing, and socio‐economic status table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Mean prescribers per patient per year (95% CI) Incidence rate ratio (95% CI) Unadjusted Adjusted* Prescribed dose (MME/day) < 20 1.62 (1.61–1.62) 1 1 20 to < 50 1.76 (1.75–1.76) 1.08 (1.08–1.09) 1.04 (1.03–1.04) 50 to < 100 2.05 (2.04–2.05) 1.26 (1.26–1.27) 1.09 (1.08–1.09) ≥ 100 2.90 (2.89–2.92) 1.79 (1.79–1.80) 1.22 (1.21–1.22) Duration of use (months) ≤ 1 1.81 (1.81–1.82) 1.41 (1.41–1.42) 1.36 (1.35–1.36) 2‒3 1.50 (1.49–1.50) 1.17 (1.17–1.18) 1.16 (1.16–1.17) 4‒6 1.40 (1.39–1.40) 1.09 (1.09–1.10) 1.09 (1.09–1.10) 7‒12 1.28 (1.27–1.28) 1 1 Socio‐economic status (quintile)† 1 (lowest) 1.92 (1.92–1.93) 1.11 (1.11–1.12) 1.07 (1.07–1.08) 2 1.93 (1.92–1.93) 1.11 (1.11–1.12) 1.05 (1.05–1.06) 3 1.80 (1.79–1.80) 1.04 (1.04–1.05) 1.03 (1.02–1.03) 4 1.78 (1.78–1.79) 1.03 (1.03–1.04) 1.01 (1.01–1.02) 5 (highest) 1.72 (1.71–1.72) 1 1 Formulation Immediate release 1.66 (1.65–1.66) 1 1 Modified release 1.97 (1.97–1.98) 1.19 (1.18–1.19) 0.98 (0.99–1.00) MME = morphine milligram equivalent; CI = confidence interval. * Multivariate mixed effects Poisson regression adjusted for socio‐economic status, duration of opioid dispensing, opioid dose, and opioid formulation. † Socio‐Economic Indexes for Areas (SEIFA Index of Relative Socio‐Economic Advantage and Disadvantage (IRSAD).3

Adeleke D Adewumi · Joemer C. Maravilla · Rosa Alati · Samantha A Hollingworth · Xuelei Hu · Bill Loveday · Jason Connor

Mja2 51115

Subscribe to MJA email alerts

No spam, you can unsubscribe anytime you want.

By providing your information, you agree to our Terms of Use and our Privacy Policy.

Thanks for Subscribing! Tell us more

Your email updates will use your name.

Good one! Your updates are coming

Thank you for subscribing to the MJA email alerts. Receive the latest content in your inbox.