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Environmental health

Substance‐related disorders Letters 13 December 2021 Free

Screening and brief interventions for harmful alcohol use: where to now?

To the Editor: We read with great interest the article by Holmwood1 which provides a new perspective on alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care settings. Holmwood argues that even though addressing unhealthy alcohol consumption in clinical practice has its place, the effectiveness of SBIRT in reducing alcohol intake is supported by little evidence. The author concludes that emphasis should be placed on strategies with the strongest evidence, such as harm reduction policies. We agree with Holmwood that effective strategies to reduce alcohol consumption should be adopted, and SBIRT itself will not solve the problem entirely. As the author pointed out, the 2018 Cochrane review2 shows that the effect of SBIRT on the reduction of alcohol consumption might be limited. Yet, as stated in the review, we emphasise that while the reduction of alcohol consumption due to brief intervention is relatively small, the benefit on the population level and public health is still likely to be positive.2 With an alcohol intake of 11.9 L per capita (aged 15 years or older), the Czech Republic ranked in the third place in the world in 2019.3 In the Czech Republic, health care professionals are obliged by law to provide SBIRT to their patients.4 However, studies among Czech patients show that less than half of them are asked about their alcohol consumption by their doctor, and only 7.9% of patients are advised to lower their alcohol consumption.5 Studies among Czech doctors report that a quarter do not provide brief intervention to any of their patients.5 It would be interesting to know related information from Australia, but with respect to Czech data, we believe there should be an increased emphasis on the education and training of health care professionals in SBIRT and on supporting general practitioners in providing brief interventions (eg, adequate financial reimbursement of their time) to increase the use of SBIRT in clinical practice. That way, SBIRT can be used to its full potential and complement other strategies to address the high alcohol consumption and related harms.

Jana Malinovská · Jan Brož

Mja2 51348
Environmental health Letters 15 November 2021 Free

The absence of women involved in the criminal justice system from Australia’s national discussion on preventing family and domestic violence

To the Editor: The Standing Committee on Social Policy and Legal Affairs recently completed its inquiry and final report into family, domestic and sexual violence in Australia.1 This comprehensive report made 88 recommendations to inform Australia’s next National Plan to Reduce Violence Against Women and their Children (National Plan). The report explores violence victimisation in diverse communities (eg, Indigenous people, people with a disability). However, consideration of women involved in the criminal justice system is conspicuously absent. Many women involved in the criminal justice system are victim‐survivors of family, domestic and sexual violence. Estimates suggest that between 70% and 90% of women in prison in Australia have been victims of violence.2 In addition, our previous research found that women released from prison are 16 times more likely to die from violence compared with women of the same age in the Australian population.3 However, the only mention of women involved in the criminal justice system as victim‐survivors in the report is in the subsection discussing Indigenous people which acknowledges that Indigenous women experience disproportionate levels of violence victimisation and incarceration. While Indigenous women should be a priority group for violence prevention, and are over‐represented in prisons in Australia, this was a critical missed opportunity to address the over‐representation of victim‐survivors in the criminal justice system. For many Indigenous and non‐Indigenous women, their offending is connected to previous experiences of violence victimisation.2 Victim‐survivors are also being funnelled into the criminal justice system due to inappropriate criminal justice responses to family and domestic violence.4 As noted in the report, the current National Plan (2010–2022)5 has not been successful in reducing violence against women, and as such, this type of violence remains a prominent and all too common issue in Australia. Women involved in the criminal justice system should be among the priority groups for national violence prevention strategies. The next National Plan should address the health and social needs of these women, which are often drivers of both criminal justice involvement and violence victimisation (eg, mental health, housing, financial independence). Trauma‐informed criminal justice responses that recognise the impact of traumatic experiences on health and behaviour, such as pre‐arrest diversion to mental health or family violence services,6 are also needed. Without this, women who are victim‐survivors of violence will continue to be criminalised due to a misunderstanding of the impacts of family, domestic and sexual violence on their health, lives and behaviour.

Melissa Willoughby · Stuart A Kinner

Environmental health Letters 1 November 2021 Open Access

Screening for hydroxychloroquine retinopathy in Australia

To the Editor: We read with interest the perspective by Sonido and colleagues.1 We wish to highlight that Australian and New Zealand guidelines on screening for hydroxychloroquine retinopathy have been published by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO),2 written by a panel of retinal specialists in consultation with relevant medical disciplines. Key recommendations in the RANZCO guidelines include: baseline examination within the first year of hydroxychloroquine use; annual screening after 5 years of use for patients with no risk factors; and consideration of earlier review for patients at increased risk, such as those who receive hydroxychloroquine doses > 5 mg/kg/day; have renal impairment; use concurrent tamoxifen; have concomitant retinal or macular disease; or receive chloroquine.2 The guidelines recommend baseline examination within 1 year of beginning treatment to exclude concomitant retinal and macular disease, which may confound findings or add to the effects of hydroxychloroquine maculopathy.2 This contrasts with the recently updated United Kingdom guidelines, which do not recommend any form of screening in the first 5 years of treatment.3 The RANZCO minimum requirements for screening include dilated fundus examination, automated visual field testing, and spectral domain optical coherence tomography of the macula. Although automated macular visual field testing is appropriate in Caucasian patients, additional wider field testing is recommended in Asian patients to detect pericentral changes. Fundus autofluorescence and multifocal electroretinography are additional useful investigations and require interpretation by ophthalmologists trained in their interpretation. Patients who are found to have signs of retinopathy at screening or who have equivocal findings should be promptly referred for specialist ophthalmologist retinal assessment. Using the 2016 American Academy of Ophthalmology guidelines (comparable to the RANZCO guidelines), the cost‐utility of screening for hydroxychloroquine retinopathy was found to range from US$33 155 to $344 172 per quality‐adjusted life year.4 By reducing unnecessary screening in the first 5 years of dosing, we anticipate costs in the lower range per quality‐adjusted life year for screening using the RANZCO guidelines. Education of prescribers is necessary. United States studies show that 27% of patients are prescribed dosages exceeding current retinal guidelines,5 with significant non‐adherence to screening recommendations by both prescribers and patients. We encourage all prescribers of hydroxychloroquine to educate patients regarding screening, monitor for all complications, and report to the Therapeutic Goods Administration to obtain a comprehensive Australian dataset of all complications.

Adrian T Fung · Vicky Lu · Heather G Mack

Eyeball
Environmental health Perspectives 21 October 2021 Free

The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb

The fourth annual assessment of Australia’s exposure, vulnerability and response to climate change finds us continuing to lag behind the rest of the world

Paul J Beggs · Ying Zhang · Alice McGushin · Stefan Trueck · Martina K Linnenluecke · Hilary Bambrick · Helen L Berry · Ollie Jay · Lucie Rychetnik · Ivan C Hanigan · Geoffrey G Morgan · Yuming Guo · Arunima Malik · Mark Stevenson · Donna Green · Fay H Johnston · Celia McMichael · Ian Hamilton · Anthony G Capon

Climate20change202021
Women's health Letters 18 October 2021 Free

Non‐invasive prenatal testing: clinical utility and ethical concerns about recent advances

To the Editor: Thomas and colleagues1 describe the ethical complexities that can arise in the use of non‐invasive prenatal testing (NIPT) based on the detection of cell‐free fetal DNA in the maternal circulation to screen for chromosomal and other genetic fetal conditions, especially if the clinical utility and implications of the testing are not well understood and explained. They indicate that “the current NIPT tests available are for specific chromosomal aneuploidy, extended panels of targeted conditions and low resolution whole genome sequencing”. We support that all tests (for screening or diagnosis, and not just genetic tests) should be explained. However, we remind readers that there are specific tests using NIPT of cell‐free fetal DNA that have strong potential to benefit women and their fetuses and are at very low risk of the ethical hazards that concern Thomas and colleagues. A lead example is testing in women who are RhD (antigen) negative to predict whether the fetus is RHD (genotype) positive. Such testing can establish with a high level of certainty whether the fetus is RHD negative, in which case the woman can be spared the need for antenatal RhD immunoprophylaxis to prevent alloimmunisation. This approach not only spares around a third of women who are RhD‐negative the need for immunoprophylaxis but may also help reduce the burden on a small and altruistic pool of RhD immunoglobulin donors.2,3 In RhD‐negative women with preformed RhD antibodies, similar testing can be used to determine whether or not there is a need for intensive surveillance during the pregnancy for haemolytic disease of the fetus and newborn. To consider all tests that use NIPT based on cell‐free fetal DNA as carrying the same complexity of explanation and ethical risk would resemble a conclusion that all immunochemistry is ethically risky because of the difficulties of explaining and interpreting prostate‐specific antigen tests, or that all fetal ultrasound is unethical because in some countries it is used inappropriately for sex selection. We encourage readers to consider that the underlying reason and specific target for each test, much more than the platform on which it is run, determines the level of ethical complexity.

Helen G Liley · Michael J Peek · James Daly

Women's health Letters 18 October 2021 Free

Non‐invasive prenatal testing: clinical utility and ethical concerns about recent advances

To the Editor: The scope of genetic testing has advanced exponentially in the past 5–10 years and conversations between patients and clinicians are becoming more nuanced. This highlights the value of genetic professionals who are skilled at ensuring patients’ understanding of genetic testing to satisfy the legal requirements for consent.1,2 Other complexities in the setting of prenatal testing include finding of variants of uncertain significance, variable penetrance or expressivity associated with most genetic conditions, and potential future treatments for adult‐onset conditions uncovered by testing. Thomas and colleagues3 referred to power imbalance between a doctor and a patient as a factor that could ethically undermine consent for non‐invasive prenatal screening (NIPS). However, this power imbalance exists across all facets of medicine. Patients today are more medically savvy owing to easy access to information technology, thus reducing the knowledge gap (and the power imbalance). A doctor’s duty of care is to provide accurate and appropriate information that is understood by the patient in order to make a valid consent.2 There is no alternative to a valid consent for NIPS than one that is built upon an “I and thou” doctor–patient relationship.4 This relationship is a dynamic and shared experience, focusing not on the knowledge but on supporting expectant parents in making value‐consistent decisions.5 Uncertainties are not unique to NIPS; perinatal uncertainties are not new to either genetics or medicine, which can arise when a diagnosis is not made as well as when a diagnosis is made. Another ethical concern regarding NIPS is access and equity. As there is no Medicare funding for NIPS, should genetic disorders be screened out by the rich, would genetic conditions become the disease of the poor? This has implications for the society as a whole. Is there a duty to have a healthy child versus should we value diversity and disability? Would there be less social or medical support should society become less tolerant of individuals with disability? Genetics and other areas of medicine are evolving rapidly; nevertheless, the shared ethical considerations, including valid consent, uncertainty, and access equity, have remained to shape the moral principles of our society in this genomics era.

Alison McLean · Kathy Wu

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