Environmental health

To the Editor: The impetigo burden for Australian Aboriginal children living in remote areas is the highest in the world, affecting 45% at any one time.1 This unacceptable public health crisis contributes to ongoing high rates of rheumatic fever and glomerulonephritis, both sequelae of Streptococcus pyogenes or group A streptococcus (GAS) infection.2 GAS infection is the key immediate driver of impetigo.3 Colonisation, social determinants and inadequate housing are overarching drivers.4 To reduce the skin infection burden, the See, Treat, Prevent (SToP) Trial (registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618000520235) was funded as a stepped wedge, cluster randomised trial in partnership with Aboriginal service providers and communities to see, treat and prevent skin infections.1 Before commencing, a situational analysis5 was performed in 2017 to describe trends, driving forces and conditions related to skin infections. The situational analysis5 identified the complex, courageous yet under‐resourced environmental health and health promotion activities in the Kimberley that could be included as prevention aspects in the SToP Trial1 and found: • a well established program of health advocacy and collaboration integrating public and environmental health which prioritises prevention; • remote Aboriginal populations remain relatively stable with predictable mobility between communities, in contrast to the high turnover of the predominantly non‐Aboriginal health workforce; and • access to household maintenance throughout Kimberley communities, necessary to prevent skin infections, remains limited and frequently under‐resourced. Despite this need, the resourcing required for this sector to deliver on these services has not occurred.6 Before the SToP Trial, prior skin infection studies focused on biomedical treatments as short term solutions to improve skin health.1 Integration of diagnosis, treatment and prevention activities in a single trial to inform skin disease control is novel and needful. Aboriginal communities and health care organisations highlighted the urgent need to incorporate prevention to reduce the inequitable burden of skin infections. The key findings of the situational analysis are as follows:5 • services are working together to combat the high burden of skin infections in the Kimberley; • the immediate environment continues to contribute to poor skin health and is an area for intervention; • addressing the social determinants of health is critical to reducing skin infections; • partnerships are required to appropriately achieve the healthy living practices; and • the Kimberley has led the way with the development of the environmental health referral form. The SToP Trial includes clinic and school staff training modules for the identification and treatment of skin infections. These include online options to overcome the logistic challenges limiting face‐to‐face professional development in isolated locations and to support continuous training of new staff. The stability of the community is a strength and community requests have led to the incorporation of family training packages. Partnerships between primary health care and environmental health service providers are allowing for the better integration of prevention measures within communities. Capitalising on the advocacy and collaboration demonstrated by Aboriginal leaders across the region has aided SToP Trial initiatives, with results expected in 2023.

Frieda McLoughlin · Vicki O’Donnell · Asha C Bowen

To the Editor: Wu and colleagues1 describe a case of congenital syphilis where the mother had no apparent risk factors and a single negative syphilis serology collected in early pregnancy. The father had an identifiable risk factor. In metropolitan Perth, Western Australia, infectious syphilis among women of reproductive age is rising, with an over 18‐fold increase from 2015 to 2021 (Box). During this period, most cases (229, 74.1%) were non‐Indigenous women. This growth has been accompanied by cases in pregnancy and, concerningly, neonates with congenital syphilis. The authors1 observed that identifying risk factors during pregnancy is challenging. They may be absent, difficult to ascertain, subject to change during the pregnancy, and are dependent on the pregnant woman and her sexual partners, whose risks she may not know. Identification relies on health care providers checking the risk throughout pregnancy and on whether the woman recognises, discloses or feels safe to discuss a risk factor. In Perth, syphilis diagnoses among pregnant women are occurring across cultural backgrounds. While some women have additional risks such as insecure housing or illicit drug use, this is not the norm. Consequently, and because we have likewise observed neonates with congenital syphilis born to women who screened negative early in pregnancy, routine syphilis serology at initial visit and at 28 and 36weeks (or delivery, if earlier) is now recommended for all pregnant women in metropolitan Perth as per the WA sexual health guidelines2 and local obstetric guidelines.3 This was achieved through the collaboration of clinical and public health staff under the Antenatal and Postnatal Working Group of the WA Syphilis Outbreak Response Group, where a decision was made that monitoring risk factors throughout pregnancy has limitations. Three‐test syphilis screening for all pregnant women minimises the risk of congenital syphilis occurring because of an unrecognised risk factor, ensures emerging risk factors are not missed, helps normalise testing and reduce stigma, and recognises that women remain sexually active while pregnant. Notably, screening is not a replacement for good history taking and clinical examination, but syphilis can present in subtle and unusual ways that can be overlooked. Routine syphilis testing at the first antenatal visit is advised by the Australian sexually transmissible infections guidelines.4 A test early in the third trimester is recommended depending on local guidelines.4 As syphilis rates grow in many parts of Australia,5 other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women. Box – Infectious syphilis cases among women of reproductive age, 2015–2021 Data sources: The number of cases were obtained from the Western Australian Notifiable Infectious Diseases Database, Department of Health Western Australia (Jan 2022); and the rate of cases were obtained from the Australian Bureau of Statistics census‐derived population data from the Epidemiology Branch, Public and Aboriginal Health Division, Western Australia Department of Health (Dec 2021).

Hannah MacKenzie · Suzanne McEvoy · Michelle Porter

Timely and equitable access to cataract surgery can prevent fall-related injuries and support healthy ageing

Lisa Keay · Kam Chun Ho · Kris Rogers · Peter McCluskey · Andrew JR White · Nigel Morlet · Jonathon Q Ng · Ecosse Lamoureux · Konrad Pesudovs · Fiona J Stapleton · Soufiane Boufous · Jessie Huang‐Lung · Anna Palagyi

Health practitioners have the opportunity to contribute their expertise to help reduce the health consequences of climate disasters across the prevention, preparedness, response and recovery phases of disaster management

Sotiris Vardoulakis · Veronica Matthews · Ross S Bailie · Wenbiao Hu · Luis Salvador‐Carulla · Alexandra L Barratt · Cordia Chu

Fit test results and performance evaluation by health care workers should be incorporated into respirator procurement decision making

Irene Ng · Benjamin Kave · Fiona Begg · Charles R Bodas · Reny Segal · Daryl Williams

Life expectancy increased more rapidly for Indigenous than non-Indigenous people but the gap remains considerable

Yuejen Zhao · Shu Qin Li · Tom Wilson · C Paul Burgess

Very high influenza vaccination rates among health and aged care staff will be crucial if influenza activity increases this winter

Lyn‐li Lim · Noleen J Bennett · Sheena G Sullivan · Ann L Bull · Leon J Worth

Australia owes a debt to its IMGs; we need to improve how we manage the transition of an immigrant doctor to Australian practice

Neville D Yeomans · Ayaz Chowdhury · Alan Roberts

An81-year-old man presented to his GP with a shallow, red ulcer on the dorsum of his left index finger over the distal interphalangeal joint, progressive over the previous 3 weeks

Rachel W Xu · Timothy P Stinear · Paul DR Johnson · Daniel P O’Brien

Australia needs better data on health inequities to support building back fairer from the pandemic

Joanne Flavel · Martin McKee · Toby Freeman · Connie Musolino · Helen Eyk · Fisaha H Tesfay · Fran Baum

To the Editor: Larcombe and colleagues1 report a range of potentially harmful chemicals in locally purchased e‐liquids, highlighting the need for rigorous Australian standards and regulation of vaping liquids. However, the biological and clinical significance of these findings is unclear. Simply detecting the presence of a chemical with a potential risk has little meaning. The risk to human health depends on the level of exposure, under a fundamental principle of toxicology that “the dose makes the poison”.2 Apart from flavouring chemicals, most of the chemicals in the e‐liquids were at low or very low levels. Low doses of chemicals are ubiquitous in the environment, including arsenic in tap water and acrylamide in coffee.3 These cause little harm. To properly assess risk, the dose should be referenced to some standard, such as an established occupational or environmental exposure standard. No such comparison was made; therefore, no conclusions should be drawn. Nicotine was found at trace levels in six out of 65 samples. The authors imply that this has “implications for health and addiction”. However, nicotine was detected at a dose of 0.29 mg/L, which is around 1000 times lower than the lowest concentration of nicotine (3 mg/mL) in commercial e‐liquids and is not of any biological or clinical significance. Furthermore, as the authors note, predicting the risk to health should be based on the analysis of vapour rather than e‐liquid. This is a far more useful guide to the exposure of chemicals to the user. Most importantly, any risk should be compared with the risk from smoking. As frequent vaping is largely confined to smokers, minor harm from vaping is justified if it allows switching from the far more harmful behaviour of smoking.4 A Public Health England review found that most toxins responsible for health damage from smoking are absent in vapour and those that are present are at much lower levels (below 5% and mostly below 1%) than in tobacco smoke.5 It is disappointing that the authors declare no relevant disclosures when three of the four funding organisations have established antivaping positions (the Minderoo Foundation, Lung Foundation Australia, Cancer Council Western Australia). This should have been declared in the competing interests statement.

Colin P Mendelsohn · Alex D Wodak

To the Editor: We recently reviewed the first studies of the real‐world effectiveness of coronavirus disease 2019 (COVID‐19) vaccines.1 We found evidence of protection against serious illness and death but noted the difficulties in performing such studies in Australia. This was because of the (then) low national case numbers and lack of ready access to the necessary linked health data. Since then, the literature on vaccine effectiveness has expanded dramatically. By February 2022 the Johns Hopkins Bloomberg School of Public Health and partners had generated a database of 181 studies conducted in 26 countries.2 The most studied vaccines were Pfizer (117 studies), Moderna (47), AstraZeneca (43), Janssen (17) and Sinovac (8). Twenty‐three studies investigated booster doses, and seven studies mentioned analysis of the Omicron variant. Study outcomes included infections (117 studies), hospitalisations (69), deaths (30), and viral transmission (5). Study designs varied, with 32 mentioning cohort analysis and 16 mentioning test negative analysis in their titles. Most studies were performed in the United States (56 studies), followed by Israel (32), the United Kingdom (29), Qatar (9), Canada (8), Brazil (6) and Denmark (4). Not one of the listed studies was conducted in Australia. We should be asking why. Australia no longer lacks the case numbers to make estimates of vaccine effectiveness. We collect good data on vaccination status, infections (including viral variants), hospitalisations and deaths, plus the information needed to adjust for confounding of the associations between vaccine exposure and outcomes. However, authorities have not linked these datasets at individual level and made them available for detailed analysis. This situation should not continue. There are well established principles for protecting the privacy of individuals who are included in routinely collected data.3 The Commonwealth and state governments and relevant agencies seem unable or unwilling to link and properly analyse these data. Consequently, they should ensure that regularly updated comprehensively linked de‐identified datasets can be accessed by qualified researchers. Stephen Duckett has recently called for an Australian review of lessons from the COVID‐19 pandemic using a systems rather than a punitive lens.4 We agree. Better linkage, access and analysis of our health system data should be high on the list.

David A Henry · Mark A Jones · Paulina Stehlik · Paul P Glasziou

The NORDR is designed to protect workers and prevent occupational respiratory disease but will require widespread stakeholder engagement and interaction to succeed

Ryan F Hoy · Fraser J Brims

Information from trusted influential messengers that is clear and consistent might be successful in addressing patients’ beliefs in health-related conspiracy theories

Mathew D Marques · Karen M Douglas · Daniel Jolley

Supporting people with COVID-19 should look beyond medical management and take into account their social and economic situation

Joanne Flavel · Fran Baum

Proactively offering Quitline counselling and nicotine replacement therapy can reduce the prevalence of smoking

Sally Plever · Coral E Gartner

To the Editor: In their recent article, Larcombe and colleagues1 describe the analysis of 65 electronic cigarette fluid samples. The gas chromatography mass spectrometry method, as described in the Supporting Information, used “the ratio between the peak area corresponding to the fragment with the highest signal‐to‐noise ratio … and the peak area of the internal standard” for quantification.1 Direct comparison of the peaks for the analyte of interest and the internal standard does not take into account differences in response factor and/or ionisation efficiency for the different molecules. For accurate quantification, individual calibration curves should be prepared for all molecules of interest. If the authors prepared calibration curves but did not include this information, then the methods section should be modified to reflect this, and additional validation should be provided for all analytes, including limits of detection, limits of quantification, and coefficients of determination for all curves. In addition, all samples should be analysed in triplicate and a standard deviation should be provided to further validate the analysis. Larcombe et al1 note in their article that the determined concentrations of benzaldehyde, menthol, 2‐chlorophenol and benzyl alcohol exceed inhalational LC50 (the median lethal concentrations that kill 50% of a test animal population) values for these compounds. This assertion, as written, is incorrect and should have been reworded to a less confident statement. As the authors themselves acknowledge, the e‐liquid concentration and the inhalational LC50 values are not comparable. Furthermore, the authors did not provide the LC50 values they were using nor a citation to their source for these values. For a more accurate comparison, the volume of e‐liquid vaporised per litre of inhaled vapour would need to be calculated. Assuming the consumption of 9.47 mg of e‐liquid per puff and a puff volume of 55 mL,2 the maximum concentration observed for both benzaldehyde (2.58 mg/m3) and menthol (30.5 mg/m3) would fall below their respective derived no‐effect level (DNEL) values of 9.8 mg/m3 and 132 mg/m3.3,4 We were unable to locate an inhalational DNEL or LC50 value for 2‐chlorophenol. The maximum concentration for benzyl alcohol (251 mg/m3) would exceed its DNEL value of 110 mg/m3 for acute exposure.5 This, along with the high prevalence of benzyl alcohol in e‐liquid samples, requires further investigation.

Jody Morgan · Alison Jones · Celine Kelso

To the Editor: Chan and colleagues1 recently reported a case of putative e‐cigarette or vaping product use‐associated lung injury (EVALI) in a 15 year‐old girl who was a low level user of vaporised nicotine (without adulterants). We believe that, rather than EVALI, her presentation is better explained by urosepsis‐related acute lung injury. Current guidance from the United States Centers for Disease Control and Prevention (CDC)2 emphasises the role of adulterants, especially vitamin E acetate, in EVALI. In a US study completed before the widespread adoption of e‐cigarettes, the incidence of acute lung injury in 15–19‐year‐olds was 16 per 100 000 patient‐years, with many cases stemming from non‐pulmonary sepsis.3 In February 2020, only 2807 cases of vaping lung injury had been reported in the US, representing an incidence of well under one case per 100 000 patient‐years.1 Given these rates, as well as the patient’s prominent dysuria, polyuria, back pain and worsening pyrexia, we think urosepsis triggered the acute lung injury in this case. The authors say that sepsis was ruled out due to negative blood and urine cultures. However, if samples were collected after the initiation of antibiotics, false negative cultures are common in sepsis. The patient met the accepted criteria for sepsis, with suspected infection, a systemic inflammatory response syndrome and acute end‐organ failure,4 and was treated for this condition with antibiotics and corticosteroids for the acute lung injury. The CDC criteria for EVALI emphasise that the diagnosis should only be made where there is “no evidence in [the] medical record of alternative plausible diagnoses”.5 Dysuria, polyuria and back pain are not known symptoms of EVALI, and the authors have not explained how EVALI could account for this aspect of her presentation nor why these symptoms preceded the respiratory symptoms. In conclusion, the evidence to support a diagnosis of EVALI is insufficient in this case, and an alternative explanation is far more likely. Therefore, this case report should not be regarded as evidence for a case of EVALI occurring in Australia.

Cameron RL McKenzie · Joshua Davis · Adrian J Dunlop

Australia to take a world-first step towards offering preventive DNA screening through the public health care system

For the DNA Screen Investigator Group†

Systematically offering cessation support is a low cost means for encouraging elective surgery patients to quit

Ashley R Webb · Lisa Coward · Darshana Meanger · Samuel Leong · Sarah L White · Ron Borland

About 80% of participants could be adequately supported by primary care and community organisations

Seok Ming Lim · Nicole L Allard · Janelle Devereux · Benjamin C Cowie · Michelle Tydeman · Alistair Miller · Khanh Ho · Brigitte Cleveland · Liz Singleton · Karen Aarons · Paul Eleftheriou · Thomas Chan · George Braitberg · Andrea Maier

To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18). The first 100 consecutive patients were all born overseas (Box). Melbourne’s only public sexual health clinic referred 65 patients. Almost all patients were male, all patients had sex with men and reported a median of three sexual partners in 3 months at baseline; 76 patients inconsistently used condoms for anal sex. Fifty‐eight patients reported previous sexually transmissible infections (STIs); STIs were diagnosed in 12/100 patients at baseline, a rate similar to that found in Medicare‐eligible PrEP users.2 Thirty‐four patients had previously accessed HIV post‐exposure prophylaxis (PEP), and 49 patients had previously unsuccessfully attempted to obtain PrEP. The reported barriers to access mainly included costs of medical appointments and pathology, and difficulties navigating Australia’s health care system. All patients received a non‐PBS PrEP prescription. At 3‐month follow‐up, 87 patients had commenced PrEP. Local pharmacies supplied PrEP at cost price (A$40–55 per month) or free to patients with financial hardship; other patients purchased PrEP online (US$20–30 per month) or obtained free PrEP online using assistance coupons (www.pan.org.au; Box). Most patients who ordered PrEP online experienced delivery delays of 4–6 weeks, leaving them at risk of HIV infection. We report that Medicare‐ineligible gay and bisexual men and transgender women were at high risk of HIV infection, yet faced significant financial barriers to accessing PrEP. PrEP uptake has been associated with significant population‐level declines in incident HIV infection in Australia.3 Australia’s Eighth National HIV Strategy aims for virtual elimination of HIV transmissions by 2022,4 and to achieve this goal, Australia must provide universally subsidised PrEP medication and clinical services, irrespective of Medicare status.5 Medicare‐ineligible gay and bisexual men often already attend publicly funded sexual health clinics for free HIV/STI testing and treatment, as reported here. In a high income country like Australia, the additional cost of providing universally subsidised PrEP care would likely be lower than treating preventable new HIV infections, with an estimated lifetime cost of more than US$350 000 per HIV infection diagnosis.6 Box – Demographic characteristics, immunodeficiency virus (HIV) acquisition risk, and prior efforts to obtain pre‐exposure prophylaxis (PrEP) in the first 100 consecutive patients to attend the PrEPMe HIV prevention clinic at the Alfred Hospital in Melbourne, Australia* Values Total number of patients 100 Demographic characteristics Region of birth Asia 47 Latin America 31 Europe 14 Other 8 Age, years, median (IQR) 28 (26–31) Gender Cisgender male 96 Transgender female 4 Visa status Student visa 62 Working visa 34 Other 4 Referral sources Melbourne Sexual Health Centre 65 Word of mouth 16 Other† 13 Unknown 6 HIV risk at initial clinical assessment Sexual partners (3 months), median (IQR) 3 (1–5) Condom use for anal sex (3 months) Always 24 Mostly or sometimes 60 Never 13 Not applicable 1 Unknown 2 Previous STIs (ever) Yes 58 No 42 Previous STIs (ever, specific STIs) Gonorrhoea 35 Chlamydia 21 Syphilis 21 Other‡ 5 STIs diagnosed at baseline Chlamydia only 6 Other§ 6 Previous attempts at HIV risk reduction Previous use of PEP Yes 34 No 57 Unknown 9 Previous unsuccessful attempts to obtain PrEP Yes 49 No 46 Unknown 5 PrEP commencement by 3‐month follow‐up Commenced PrEP 87 Local pharmacy 65 Online 19 Online order did not arrive, then purchased at pharmacy 3 PrEP not commenced 6 Online order did not arrive 3 Other¶ 3 Lost to follow‐up 7 COVID‐19 = coronavirus disease 2019; IQR = interquartile range; PEP = post‐exposure prophylaxis; STIs = sexually transmissible infections. * Enrolment dates: 1 June 2020 to 26 October 2020. † Includes general practices, internet search, “PrEP Access Now” Facebook page, Alfred Hospital PEP program. ‡ Includes herpes simplex virus, Mycoplasma genitalium, hepatitis B virus. § Includes syphilis, hepatitis B virus, both chlamydia and gonorrhoea. ¶ Includes lost prescription, no sex due to COVID‐19.

Vincent J Cornelisse · Jude Armishaw · Mike Catton · Dean Murphy · Edwina J Wright