Environmental health

To the Editor: We read with interest the article by Kault,1 who carried out an analysis on superspreaders, asymptomatic cases, and coronavirus disease 2019 (COVID‐19) elimination. Although all efforts made for preventing or containing the COVID‐19 pandemic are certainly welcome, we raise doubts on some basic aspects used for constructing the prediction model and which do not seem to be evidence‐based. In the risk model of COVID‐19 re‐emergence after release of restrictive measures (eg, lockdowns), Kault made some erroneous assumptions, including the fact that asymptomatic subjects may be as infectious as symptomatic patients with COVID‐19.1 This hypothesis seems to be contradicted by several lines of evidence. First, a meta‐analysis published in 2020 concluded that the rate of asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is 35% lower compared with COVID‐19 patients with symptomatic illness.2 This has also been clearly explained in a seminal study showing that the viral load is the highest in concomitance with symptoms onset, so that the infectiousness of pre‐symptomatic or asymptomatic individuals is probably low.3 Notably, the impact of pre‐symptomatic SARS‐CoV‐2 transmission seems also rather limited, whereby the secondary attack rate was found to account for only 15% of all secondary COVID‐19 cases.4 A second aspect that needs to be highlighted is that presuming that 50% of SARS‐CoV‐2‐positive patients are asymptomatic may also be formally incorrect. Beside the fact that the asymptomatic SARS‐CoV‐2‐positive rate varies greatly depending on many genetic, demographic (ie, age, sex and ethnic origin) and even clinical (eg, time course of disease, comorbidities) variables, an analysis in the official database of the Italian National Institute of Health reveals, for example, that the rate of asymptomatic subjects with SARS‐CoV‐2 infection approximates 70%.5 Combined with lower infectiousness, the high prevalence of asymptomatic subjects bearing SARS‐CoV‐2 infection after release of restrictive practices (eg, lifting of lockdowns) would persuade us to conclude that the possible impact of asymptomatic superspreaders on SARS‐CoV‐2 transmission would be low and perhaps insufficient to influence or guide future policies aimed at restricting individual freedom.

Camilla Mattiuzzi · Giuseppe Lippi

To the Editor: Victoria introduced voluntary assisted dying in June 2019, historic legislation which aimed to enable terminally ill people in limited circumstances to end their life with autonomy, compassion and support. The Voluntary Assisted Dying Act 20171 is considered the most conservative and safe legislation in the world, with 68 safeguards. We compared recent Victorian reporting data2,3 with a 12‐month period of data on Oregon’s Death with Dignity Act (1997),4 as the jurisdictions have similar population sizes and there is no comparable jurisdiction currently operating in Australia. To access voluntary assisted dying in Victoria a person must: have an incurable and advanced disease, illness or medical condition that is expected to cause death within 6 months (or within 12 months for a neurodegenerative condition); be experiencing suffering, which the person considers intolerable; have decision‐making capacity in relation to voluntary assisted dying; be an adult, aged 18 years or older; and be an Australian citizen or permanent resident who has lived in Victoria for at least the past 12 months. Eligibility requirements for Oregonians are comparable; however, there is no requirement to demonstrate intolerable suffering. Based on a total number of 46 581 deaths in Victoria during the 2019–2020 period, 0.3% of deaths can be attributed to voluntary assisted dying.5 In both Victoria and Oregon, the most frequently reported reasons for requesting voluntary assisted dying and dying with dignity were loss of autonomy and losing control of body functions; additionally, loss of dignity and being unable to engage in activities that make life enjoyable were also cited. Data show that: Victorian applicants were aged between 32 and 100 years, with an average age of 71 years.2,3 In comparison, the average age in Oregon was 74 years, with a range of applicants from 18 to over 85 years.4 In Victoria, 44% of applicants were female, 55% were male and 1% selected “self‐described” as their gender,2,3 comparable to Oregon (41% female and 59% male).4 Between 19 June 2019 and 30 June 2020, 231 permits were issued. Of these, 104 (45%) self‐administered the medication, while another 20 (9%) had the medication administered by a medical practitioner (Box).2,3 Oregon data from 2019 (population, 4.2 million) revealed that 290 applicants were prescribed medication, with 150 (59%) self‐administering;4 in Victoria (population, 6.3 million), 54% self‐administered, while another 61 (21%) did not take the medication and died of other causes. In addition to the first 12 months of Victorian data, we also included the cumulative totals to February 2021 (Box). The Victorian Act requires three requests be made to a registered medical practitioner for an individual to access voluntary assisted dying. Medical practitioners can apply for either a self‐administration or practitioner administration permit at any one time. Time from first to last request occurred within 11 days for 25% of applicants and 19 days for 50% of applicants.2 Voluntary assisted dying and dying with dignity represent an option for individuals to choose the manner and timing of their death during the terminal phase of illness. Continued community awareness and conversations about end of life options are essential to ensuring that voluntary assisted dying is available to eligible Victorians who seek access. Box – Victorian voluntary assisted dying data snapshot4,5 Total Stage Status 19 June 2019–30 June 2020 To February 2021 Eligibility First assessment by coordinating medical practitioner Eligible 341 562 Ineligible 7 19 Second assessment by consulting medical practitioner Eligible 297 483 Ineligible 4 8 Permit applications Self‐administration permit Issued 201 350 Not issued 32 44 Practitioner administration permit Issued 30 55 Not issued 9 16 Withdrawn: case withdrawn from portal by medical practitioner or upon notification of death of the applicant 134 239 Medications dispensed For self‐administration 154 281 Confirmed deaths Medication administered Self‐administered 104 184 Administered by practitioner 20 40

Kate Furness · Donna Markham · Tamica Sturgess · Margaret O’Connor

The Olympic Games raise many infection control, health security and ethical challenges

Craig B Dalton · Joanne Taylor

Developing a pathway to prioritise clinical research and prepare for future pandemics remains an urgent need

Asha C Bowen · Steven YC Tong · Joshua S Davis

In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

Lucy Gracen · Elizabeth E Powell

To the Editor: The toll of group A Streptococcus is dramatically unappreciated, despite increasing evidence of its burden.1 In Australia and New Zealand, we recently demonstrated that group A streptococcal throat and skin infections cause a sizable burden at the population level — cellulitis is the main contributor to the total burden of all group A streptococcal diseases and acute rheumatic fever and rheumatic heart disease contribute disproportionately relative to their frequency of occurrence.2,3 At a global level, the burden of group A Streptococcus is not abating. Global Burden of Disease data suggest that incident cases and deaths due to rheumatic heart disease alone have surpassed those of meningitis (Box). In 2019, more than 85% of rheumatic heart disease cases occurred among people aged under 35 years.4 No other group A streptococcal‐specific endpoints are available from the Global Burden of Disease data, yet all‐cause cellulitis was ranked the 24th most frequently occurring condition in high income countries in 2019.4 Group A Streptococcus causes outbreaks of poststreptococcal glomerulonephritis, contributing to the burden of chronic renal disease, and it is estimated to be the fifth most lethal pathogen on the planet, behind the human immunodeficiency virus (HIV), Mycobacterium tuberculosis, Plasmodium falciparum and S. pneumoniae, yet expenditure on vaccine development is only 0.17% of that spent on vaccines for HIV infection, malaria and tuberculosis.5 The divergence in numbers of cases and deaths due to group A Streptococcus compared with meningitis partially demonstrates the value of vaccination. Another major benefit of vaccination is a substantial reduction in antibiotic consumption. Indeed, pharyngitis is a major driver of antibiotic consumption globally, and an estimated 17% of antibiotic prescriptions for pharyngitis among children in the United States could be prevented by a group A Streptococcus vaccine.6 Two major initiatives aim to progress vaccine development. The Australian Strep A Vaccine Initiative (ASAVI) and the Strep A Vaccine Global Consortium (SAVAC) are addressing technical and investment barriers and leading at least one of the current vaccine candidates to an efficacy trial for pharyngitis prevention by 2024.5 An effective vaccine may prevent health and economic burdens due to the full range of group A streptococcal diseases and associated antibiotic consumption. Box – Estimated number of new cases (left) and deaths (right) due to meningitis and rheumatic heart disease globally* * Data obtained from the Global Burden of Disease study 2019.4

Jeffrey W Cannon · Julie Bennett · Michael G Baker · Jonathan R Carapetis

A shared language will promote climate change and health research and underpin a sustainable future Climate change requires collective action across many government, non‐government and private sectors.1 The development of a shared terminology to conduct, share and use research will be critical to the effective communication and collaboration needed to achieve this collective action.2 At the same time, climate change mitigation and adaptation is an exponentially growing field of multidisciplinary research and practice, augmenting the scale of the challenge.3,4 It will be vital that this cross‐disciplinary research effort is supported, but currently, there is poor alignment in the use of relevant terms across different research and policy fields, with little standardisation of terminology in the national and international literature. This article builds on other international efforts to address the need for shared terminology. A 2018 article provides definitions for the fields linking human health to ecosystems and environments and highlights planetary health.5 Another publication defines key terms that focus on vulnerability assessments and health equity implications.6 Leading international organisations, including the Intergovernmental Panel on Climate Change (IPCC)7 and the World Health Organization,8 have developed glossaries relevant to climate change and health. However, many terms require refinement for the Australian context. In an Australian collaborative endeavour, we developed an Australia-specific glossary of 55 terms that we believe are key to enhancing local intersectoral communication and collaboration on climate change and health.9 The methods included a systematic search and review of existing glossaries relevant to climate change and health, plus three rounds of stakeholder engagement including an online survey, a workshop and further discussion via a shared online document (Supporting Information). The glossary’s target audiences are researchers from various disciplines needing to collaborate to address health and climate change, and partners who need to understand and use that research to drive change (eg, government, policy, private sector, and otherdecision makers). We acknowledge that the language and priority issues in health and climate change will continue to evolve, and welcome contributions from other stakeholders to further develop and refine the terminology in the glossary. The need for multidisciplinary collaboration on health and climate change issues in Australia is reflected in the recent National Health and Medical Research Council’s Special Initiative in Human Health and Environmental Change.10 This initiative will support a multidisciplinary, collaborative network of researchers across Australia. It is hoped that this glossary could assist multisectoral collaborations. Key terms This section outlines and discusses some of the essential principles, considerations and challenges identified in developing the glossary and illustrates these with some of the most debated key terms. Notably, several definitions integrated Aboriginal and Torres Strait Islander perspectives. We included the term “Indigenous knowledges” for its Australian relevance and its importance in sustaining and caring for the land on which we live. Furthermore, we applied an eco‐social interpretation of health and climate change relationships, recognising that human and environmental health are inextricably linked. We amended several pre‐existing definitions to include considerations of other sentient beings and ecosystems. Components of climate change Challenges in defining climate‐related terms are illustrated by the definitions of climate change from the IPCC and the United Nations Framework Convention on Climate Change (UNFCCC).7,11 Despite both being derived for United Nations processes, there are stark differences. Both refer to two components of the changing climate: anthropogenic climate change (human component) and natural variability in the Earth’s climate. While the IPCC distinguishes between these in their climate change definition, the UNFCCC has split them into separate terms: “climate change” (anthropogenic causes) and “climate variability” (natural causes). Our stakeholders recommended distinguishing between the two components and explicitly stating the existential threat of climate change to create a greater sense of urgency, and also chose “health emergency” to urge immediate action as many Australian health and medical professional organisations (eg, the Australian Medical Association12 and the Royal Australasian College of Physicians13) have declared climate change a health emergency. Equity and justice Previous definitions for “climate equity” and “climate justice” appear to be human‐centric. Our proposed definitions for climate justice and climate equity are broader, to capture the links between human health and other species and ecological systems. In Australia, the destruction of biodiversity, wetlands, mangrove swamps, and rainforests is an indiscriminate loss of sensitive ecological systems and a form of injustice. There is an even more expansive notion of climate justice which includes attention to inequity in impacts, to participation and procedural justice, and to the functioning and provision of basic needs of vulnerable communities.14 Related to climate justice is “just transition”. A policy report by the Australian Council of Trade Unions15 notes that a just transition should ensure that communities facing transitions can flourish rather than simply survive. We amended a pre‐existing definition to explicitly state that transition should be towards sustainable economic systems that promote social justice. It is also important to acknowledge Aboriginal and Torres Strait Islander perspectives for just transitions, and that Aboriginal and Torres Strait Islander peoples be at the centre of decision making to ensure that environmental stewardship is promoted.16 Anxiety, grief and solastalgia Climate change is adversely affecting mental health, with visible impacts and increasing trauma from extreme weather events (eg, Australia’s unprecedented 2019–20 bushfire season). Terms that acknowledge and highlight the psychosocial and emotional harms of climate change include “climate anxiety/grief” and “solastalgia”, coined by Australian environmental philosopher Glenn Albrecht.17 This is especially relevant to Aboriginal and Torres Strait Islander peoples.18 Our climate anxiety/grief definition explicitly states the anxiety felt around losses for future generations. We also recognise that different generations may have varying baselines for how they think of climate change. Fires There are many variations in terminology used around fires, particularly international definitions, which may cause misunderstanding and inappropriate use of some terms in the context of climate change. In Australia, the term “bushfire” is very widely used and is therefore the term included in our glossary. The management of fires in Australia involves burning, often referred to as “hazard reduction burning”, which itself carries fire‐related health risks and consequences. In Australia, “cultural burning” describes burning practices developed by Aboriginal and Torres Strait Islander peoples to enhance the health of the land and its people.19 A commonly confused fire‐related term is “fire disasters”, which is often misused when discussing fires in Australia integral to ecosystem functioning and not classified as disasters; for example, annual savanna fires, which are part of the seasonal cycle of those ecosystems involved. A bushfire is classified as a disaster when it is uncontrollable and adversely affects lives, properties or the environment. Heat In Australia, extreme heat events have claimed more lives than all other extreme weather events combined.20 Many ways of defining “heatwave” exist in global and Australian contexts, with variations across sectors and regions. It is generally agreed that heatwaves are prolonged periods of excessive heat, with “prolonged” usually defined as multiple consecutive days and “excessive” being the exceedance of an extreme threshold. Our stakeholders decided to include a detailed definition from the Bureau of Meteorology21 which also considers overnight temperatures. High night‐time temperatures affect health and wellbeing by limiting respite from heat and reducing sleep quality, with relevance for a health‐focused glossary. Responses Actions, strategies and interventions to address the health impacts of climate change fall into either adaptation or mitigation categories.6 Mitigation aims to reduce the human contribution to climate change, and adaptation is a process or strategy to manage the inevitable changes that are already beginning to occur.7 The IPCC definition of maladaptation was selected and adapted for our glossary because it allows for flexible interpretations across sectors. Our version of the IPCC definition recognises that “maladaptation” refers to the situation where an adaptation strategy causes unintended consequences. For example, one proposed strategy for bushfires is to remove bush, but this was based on a flawed argument that less bush equates to fewer bushfires. The resulting loss of biodiversity from this strategy would be an unintended consequence and thus a maladaptation. Resilience Although not commonly used in Australia at present, the term “climate resilience” is widely used internationally and has growing relevance here. Climate resilience in the Australian context involves considering how communities have responded to and recovered from past natural disasters to improve their resilience for future events. Hence, our glossary’s definition builds on the IPCC’s definition to focus on strengthening for future events7 and explicitly mentions political and governance systems’ capacity to cope with future perilous events. Indigenous knowledges The United Nations Educational, Scientific and Cultural Organization (UNESCO) and IPCC definitions of Indigenous knowledges7,22 refer broadly to all First Nations peoples’ knowledge systems. We could not identify an existing definition of Indigenous knowledges for the Australian context, an important topic for further development. When referring to Indigenous knowledges in Australia, it is appropriate to refer to these knowledge systems as Aboriginal and Torres Strait Islander knowledges.23 The international definition also lacks the important spiritual and cultural aspects of Indigenous knowledges and the fact that these knowledge systems have been passed down over many thousands of years and underpin Indigenous peoples’ understandings today. Aboriginal and Torres Strait Islander knowledges include an intricate understanding and connection to Country, developed over thousands of years to care for the environment sustainably. Caring for Country, which embodies set stewardship values for land and sea environments, describes these sustainable land management practices, as well as being a key aspect in the continuation of Aboriginal and Torres Strait Islander cultures.19 Conclusion The glossary is now publicly available. We hope that policymakers, researchers and stakeholders from different sectors will refer to the glossary to facilitate their discussions and help translate research into policies and practices. Given that language is continuously evolving, as are health and climate change issues, we acknowledge the limitations in the perspectives presented in the glossary and invite contributions from various stakeholders to make this glossary a dynamic and useful tool. By doing this, we can build a shared language to underpin a just transition to a sustainable future for our country.

Matilde Breth‐Petersen · Lucie Rychetnik · Alexandra L Barratt · Ying Zhang

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

Overlooking the potential for airborne transmission of SARS-CoV-2 leaves Australia vulnerable to outbreaks

Zoë Hyde · David Berger · Andrew Miller

Understanding the mental shortcuts people make and the values they bring to weighing risks is critical to informing effective risk communication

Julie Leask · Samantha J Carlson · Katie Attwell · Katrina K Clark · Jessica Kaufman · Catherine Hughes · Jane Frawley · Patrick Cashman · Holly Seal · Kerrie Wiley · Katarzyna Bolsewicz · Maryke Steffens · Margie H Danchin

Transferable strategies and actions for increasing health assessments for people with an intellectual disability

Jodie Bailie · Alison Laycock · Veronica Matthews · Ross S Bailie

Clinical record A 44‐year‐old male health care worker presented with fevers, fatigue and head “fogginess” with abdominal discomfort and increased bowel frequency 8 days after receiving his first dose of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) (AstraZeneca). He was previously well, with a past history of depression and was only taking escitalopram. He had no prior thrombosis or exposure to heparin. The low platelet count, 70 × 109/L (reference range, 150–400 × 109/L), and markedly elevated D‐dimer, 114 mg/L (upper limit of normal, 0.5 mg/L), with vague abdominal pains prompted a computed tomography (CT) venogram of the abdomen, which demonstrated thrombosis with complete occlusion of the portal and splenic veins and protrusion of a tongue of thrombus into the superior mesenteric vein (Box 1). CT venogram of the head did not show central venous sinus thrombosis. The rest of the full blood count and the blood film showed no features of microangiopathic haemolytic anaemia. The prothrombin time, activated partial thromboplastin and fibrinogen levels, liver and renal function tests were all normal. Antiphospholipid antibodies were negative and a heterozygous prothrombin G20210A mutation was identified. Antibodies to the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) nucleocapsid protein and the respiratory polymerase chain reaction (PCR) test for coronavirus disease 2019 (COVID‐19) were negative, ruling out active COVID‐19 infection as a potential thrombosis aetiology. Antibodies to the heparin–platelet factor 4 (PF4) complex in the patient’s plasma was strongly positive (optical density, 1.94) by enzyme‐linked immunosorbent assay (ELISA)‐based test (Asserachrom HPIA IgG; Stago). Three functional assays, including serotonin release assay (SRA; Hidex 300 SL, Hydex), multiple electrode aggregometry (MEA; Roche Diagnostics) and flow cytometry (BD Fortessa, ETH Zürich; procoagulant assay) all detected heparin‐independent PF4 antibody complexes that activated donor platelets.1 Immediate anticoagulation was started with the anti‐factor Xa agent fondaparinux 10 mg (weight, 105 kg) subcutaneously every 24 hours and intravenous immunoglobulin (1 g/kg) administered on days 2 and 3, and repeated on days 7 and 8 after admission. Despite achieving the anti‐factor Xa fondaparinux level 6 hours after receiving a dose of 0.94 U/mL (target range, 0.50–1.20 U/mL), the platelets remained between 6 × 109/L and 20 × 109/L for the initial 6 days. The patient subsequently developed an acute abdomen clinically and a repeat CT scan showed extension and occlusive thrombus into the superior mesenteric vein with venous outlet obstruction and bowel ischaemic features. He underwent an immediate laparotomy with resection of 1.8 m of ischaemic bowel. Contemporaneously, given clot extension had occurred on fondaparinux, anticoagulation was changed to thrombin inhibitor bivalirudin, which had a short half‐life (25 minutes) that allowed for titratable perioperative anticoagulation and an intravenous pulse of methylprednisolone 1 g administered to augment PF4 antibody immunosuppression. The patient returned to the theatre 48 hours after the first laparotomy, where further compromised bowel was resected. Methylprednisolone 1 g daily was reinstituted for 4 days, with an immediate platelet peak to 385 × 109/L at completion of this 4‐day pulse. He was discharged after 34 days without further complications. He has transitioned to warfarin and continues to be well while monitored in the haematology outpatient clinic. Box 2 summarises the time course of treatment and response. Discussion In March 2021, Australia began the roll‐out of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) to combat the COVID‐19 pandemic. In Europe, where more than 20 million doses of this vaccine had been administered by mid‐March 2021, there were case reports of thrombosis at unusual sites associated with thrombocytopenia, which occurred at day 4–28 after vaccination and had a mortality rate of up to 25%, at an estimated rate of 1:100 000.2 In Australia, the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) was initially offered to people working in high risk professions without age restrictions. By the end of March 2021, about 350 000 first doses of the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) had been administered Australia‐wide. This is the first reported case of thrombosis at an unusual site with thrombocytopenia following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) in Australia. The temporal association, the detection of anti‐PF4 antibodies with platelet activation in the absence of heparin, which is neutralised at high dose heparin, is consistent with the most recent reports.3 This entity, currently labelled as vaccine‐induced thrombotic thrombocytopenia (VITT) — also known as thrombosis with thrombocytopenia syndrome (TTS) — has pathological similarity to autoimmune heparin‐induced thrombocytopenia but without prior heparin exposure. More evidence is needed to demonstrate if the serum of patients with VITT contains antibodies that can bind to PF4 independent of heparin following vaccination for COVID‐19. Furthermore, the mechanism responsible for profound platelet activation following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]), as evidenced by ELISA high optical densities, remains to be established.3 While the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) is delivered via adenovirus vector, to the best of our knowledge, there are no reported VITT cases associated with mRNA COVID‐19 vaccines. It is doctrine in the management of heparin‐induced thrombocytopenia that, in addition to immediate cessation of all heparins, a non‐heparin anticoagulant is commenced to prevent (further) thrombosis. Given the pathogenic similarities of VITT cases to heparin‐induced thrombocytopenia, we initially used fondaparinux, as our patient was clinically stable with normal renal function at presentation. It is unclear if the clinical deterioration in our patient, despite achieving favourable therapeutic fondaparinux drug level, was resultant of anti‐factor Xa drugs non‐efficacy and/or because of the severity of the venous outflow obstruction with compromised ischaemic small bowel. In principle, the surgical removal of any ischaemic tissue would be associated with clinical improvement. The benefit of intravenous immunoglobulin remains debatable, but in vitro spiking experiments and observation of platelet increment after its administration suggest that there may be a role.3,4 It is possible that intravenous immunoglobulin displaces the binding of anti‐PF4 antibody complex to FcgammaRIIA (an Fc receptor for IgG) receptors on platelets.5 In our patient, it is difficult to ascribe a specific clinical and platelet recovery to intravenous immunoglobulin solely given the simultaneous timing of surgical removal of ischaemic intestine, the commencement of alternate anticoagulation with bivalirudin, and pulsed high dose steroids. It is noted that pulsed methylprednisolone was prescribed in the majority of recently reported cases.3 In line with evolving guidance documents, clinicians assessing patients who present with organ‐specific thrombotic symptoms 4–28 days following vaccination with the COVID‐19 vaccine (ChAdOx1‐S [recombinant]) should look for any combination of thrombocytopenia and elevated D‐dimer, and/or low fibrinogen, with a low threshold for requesting imaging of the appropriate organ — in particular, the brain central venous sinus and abdominal splanchnic venous systems — for thrombosis plus anti‐PF4 ELISA testing in consultation with haematology. Lessons from practice Vaccine‐induced immune thrombotic thrombocytopenia (VITT) is rare but potentially life‐threatening. VITT should be considered when patients present at day 4–28 after vaccination with unusual site thrombosis: splanchnic and/or central venous sinus thrombosis, or thrombocytopenia (or falling platelets) and markedly elevated D‐dimer. Specific testing to detect anti‐platelet factor 4 (PF4) antibody is needed to support VITT. Treat with non‐heparin anticoagulation, intravenous immunoglobulin, and consider pulsed methylprednisolone. Avoid platelet transfusions. Box 1 – Computed tomography venogram at presentation showing (A) a filling defect of portal vein, contrast in superior mesenteric vein and its tributaries (arrow, coronal plane) and (B) a thrombus in the superior mesenteric vein (the arrow shows the contrast, axial plane) Box 2 – Time course and management IV = intravenous; IVIg = intravenous immunoglobulin; SC = subcutaneous.

Jay Hocking · Sanjeev D Chunilal · Vivien M Chen · Tim Brighton · James Nguyen · Jocelyn Tan · Stephen B Ting · Huyen Tran

The social determinants of incidence should be addressed, and other relevant host, pathogen, and health system factors investigated

Cameron M Wright · Rachael Moorin · Glenn Pearson · John R Dyer · Jonathan R Carapetis · Laurens Manning

Objectives: To evaluate the implementation and acceptability of the self‐collection cervical screening pathway since commencement of the renewed National Cervical Screening Program (rNCSP), from the perspectives of screening participants and primary care practitioners. Design, setting, participants: Qualitative study; individual semi‐structured interviews with 45 screening participants and 18 primary care practitioners in Victoria who had engaged with the self‐collection pathway during the first 17 months of the rNCSP (1 December 2017 ‒ 30 April 2019). Results: The self‐collection pathway was highly acceptable as an alternative cervical screening pathway for most participating screening participants and practitioners. Some screening participants indicated that they would not have been screened had the pathway not been available. Acceptability was lower among those who had tested positive for HPV types not 16/18, a result that requires additional testing of a clinician‐collected cervical sample. Use of the self‐collection pathway is driven more by practitioners than their patients. Interpretations of the self‐collection guidelines varied between practices. Barriers to expanding promotion of the pathway by practitioners included difficulties with identifying eligible participants. Conclusions: Increasing the accessibility of the self‐collection pathway to under‐ and never screened women could reduce inequities in cervical cancer outcomes for those not participating in the main screening pathway. Practitioners should be provided resources to integrate self‐collection into routine practice and to efficiently implement the entire self‐collection pathway, in order to maximise its use and to optimise the experience for screening participants.

Nicola S Creagh · Claire Zammit · Julia ML Brotherton · Marion Saville · Tracey McDermott · Claire Nightingale · Margaret Kelaher

Novel PPE, such as 3D printed face shields, must be compliant with regulatory requirements and a clinical evaluation protocol should be developed

Mathilde R Desselle · Marianne Kirrane · Ian T Chao · Jasamine Coles Black · Maria A Woodruff · Jason Chuen · Clair Sullivan

Genomic surveillance enhances detection and response to emerging SARS-CoV-2 variants

Patiyan Andersson · Norelle L Sherry · Benjamin P Howden

The Academy focuses on the nation’s most pressing health challenges and supports Australia’s thriving health and medical research sector

Ingrid E Scheffer · Ian H Frazer

Objectives: To investigate the prevalence of non‐alcoholic fatty liver disease (NAFLD) and its risk factors in regional Victoria. Design: Prospective cross‐sectional observational study (sub‐study to CrossRoads II health study in Shepparton and Mooroopna). Setting: Four towns (populations, 6300‒49 800) in the Goulburn Valley of Victoria. Participants: Randomly selected from households selected from residential address lists provided by local government organisations for participation in the CrossRoads II study. Main outcome measures: Age‐ and sex‐adjusted estimates of NAFLD prevalence, defined by a fatty liver index score of 60 or more in people without excessive alcohol intake or viral hepatitis. Results: A total of 705 invited adults completed all required clinical, laboratory and questionnaire evaluations of alcohol use (participation rate, 37%); 392 were women (56%), and their mean age was 59.1 years (SD, 16.1 years). Of the 705 participants, 274 met the fatty liver index criterion for NAFLD (crude prevalence, 38.9%; age‐ and sex‐standardised prevalence, 35.7%). The mean age of participants with NAFLD (61 years; SD, 15 years) was higher than for those without NAFLD (58 years; SD, 16 years); a larger proportion of people with NAFLD were men (50% v 41%). Metabolic risk factors more frequent among participants with NAFLD included obesity (69% v 15%), hypertension (66% v 48%), diabetes (19% v 8%), and dyslipidaemia (63% v 33%). Mean serum alanine aminotransferase levels were higher (29 U/L; SD, 17 U/L v 24 U/L; SD, 14 U/L) and mean median liver stiffness greater (6.5 kPa; SD, 5.6 kPa v 5.3kPa; SD, 2.0 kPa) in participants with NAFLD. Conclusion: The prevalence of NAFLD among adults in regional Victoria is high. Metabolic risk factors are more common among people with NAFLD, as are elevated markers of liver injury.

Stuart K Roberts · Ammar Majeed · Kristen Glenister · Dianna Magliano · John S Lubel · Lisa Bourke · David Simmons · William W Kemp

Introduction: Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care. Main recommendations: This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial‐based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies. Changes in management as result of this statement: This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with “do‐it‐yourself” technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Anthony J Pease · Sofianos Andrikopoulos · Mary B Abraham · Maria E Craig · Brett Fenton · Jane Overland · Sarah Price · David Simmons · Glynis P Ross

Risk‐based testing is failing a third of people living with chronic hepatitis B in Australia The United States Preventive Services Task Force recently issued new guidance that all adults aged 18–79 years should be offered screening for hepatitis C virus infection,1 expanding on prior risk‐ and age‐based recommendations. The rationale is that hepatitis C virus infection is a common condition (estimated 1% prevalence) that is leading to an increasing burden of disease from cirrhosis and liver cancer, it is easy to test for, there are well tolerated and highly effective treatments available, and treatment costs have dropped substantially in the past 5 years. The guidance acknowledges that risk‐based screening has been insufficient in increasing the number of people diagnosed and able to access treatment, and further change is needed to address the ongoing burden of adverse outcomes. In Australia, an estimated 80% of people living with hepatitis C have been diagnosed,2 and treatment uptake is among the highest in the world; however, progress in diagnosing people living with chronic hepatitis B is much less impressive. We argue that Australian guidelines for hepatitis B screening should be similarly changed and expand from a risk‐based approach to a more universal one. Hepatitis B is a condition that affects more than 225 000 Australians,3 and when untreated, it leads to serious adverse outcomes such as liver cirrhosis and cancer in up to one‐quarter of people affected despite being generally asymptomatic.4 Infant vaccination in Australia since 2000 has reduced local transmission,3 but hepatitis B is most commonly acquired at birth or in early childhood when there has been inadequate access to vaccination, and it disproportionately affects Australians born overseas.2 While a cure is not yet available, highly effective antiviral treatments can be accessed through Medicare which have been shown to reduce liver cancer risk by up to 70% within 5 years.5 Based on this evidence, treatment for hepatitis B is recommended in national and international guidelines when there is either cirrhosis or ongoing liver inflammation to reduce morbidity and mortality associated with hepatitis B virus infection. Australia’s National Strategy for Hepatitis B sets the target of 80% of people diagnosed by 2022, but this proportion has barely improved in recent years, from 63% in 2011 to 69% in 2018.3 Although about 6000 people6 are newly diagnosed with hepatitis B each year, the number of people living with hepatitis B in Australia has continued to increase due to the addition of people who acquired the disease in their country of birth (Box).7 This leaves an estimated 71 000 Australians (plausible range, 32 000–93 000) undiagnosed and at risk of significant adverse outcomes. As this estimate is reliant on underlying model estimates — incorporating data on migration, natural history, immunisation and transmission7 — these data are subject to uncertainty. However, even accounting for this uncertainty, it is estimated that there is only a 4.6% chance that Australia will reach the 2022 target of 80% of cases diagnosed.3 The late diagnosis of hepatitis B in an individual is a missed opportunity for that person to receive appropriate care, including antiviral treatment to prevent liver cancer and cirrhosis.5 In New South Wales in 2011–2012, 29% of people diagnosed with hepatitis B‐related liver cancer were diagnosed late (< 2 years before their cancer diagnosis).8 Failure to diagnose not only affects the individual but is a missed opportunity for family members to be appropriately screened and receive vaccination to prevent transmission of hepatitis B within households. Data indicate only a third of people requiring antivirals to prevent liver cancer or cirrhosis are currently receiving them in Australia.7 Increasing the percentage of people receiving treatment to 20%, as per the National Strategy target, would prevent an estimated 1700 deaths by 2030.7 Improving diagnosis is key to meeting these treatment targets. For over 25 years, the diagnosis of most people affected by hepatitis B in Australia has relied on risk group‐based screening. The National Hepatitis B Testing Policy lists 16 indications and 13 risk groups that should be considered for testing. Universal screening is only recommended during antenatal care, and a substantial proportion of women are first diagnosed with hepatitis B at this time. For clinicians, conducting a guideline‐based ascertainment of risk is complex, requiring knowledge of country of birth; Indigenous status; history of travel, vaccination, incarceration, and medical procedures; occupation; sexual activity; family history; and previous or current injecting drug use. There is limited evidence regarding the acceptability and uptake of these recommendations, but research assessing general practitioner attitudes to hepatitis B has identified discomfort with profiling patients based on cultural background.9 A study of GPs identified that 33% were not aware people from these communities are the main at‐risk population for hepatitis B, and 67% agreed that assistance with identifying patients who should be tested was needed.10 This targeted approach to testing can also contribute to the experience of stigma and discrimination among people affected by or at risk of hepatitis B, particularly given the structural and health care inequalities experienced by many members of these groups. Chronic hepatitis B meets all the World Health Organization criteria for disease screening:11 it is an important health problem for the person and the community; highly accurate diagnostic tests are available; there is typically a long asymptomatic period of infection; treatments are available and they are more effective when started earlier in the course of the disease; and based on cost‐effectiveness studies, the cost of diagnosis and treatment is economically balanced in relation to health care costs as a whole. A further advantage with hepatitis B is that, given the availability of a highly effective vaccine and the generally lifelong nature of infection, screening will usually only need to be done once. Subsequently, one‐time screening will simplify patient engagement in regular follow‐up and monitoring, with most needing annual recall for reimbursed blood tests and liver ultrasounds (for Medicare‐eligible people, the majority of Australians living with hepatitis B). Community engagement strategies including community codesigned and place‐based outreach programs will also be essential. Although some hepatitis B community outreach occurs in Australia, it is profoundly underfunded compared with other community programs such as those for the human immunodeficiency virus (HIV), and increased investment will be central to supporting a more universal testing approach. The prevalence at which hepatitis B screening is cost‐effective has been estimated at 0.3%12 (United States) and 0.41%13 (the Netherlands), well below Australia’s estimated prevalence of 1%.7 Although further study is needed to assess local cost‐effectiveness of screening, the management and treatment of people diagnosed with hepatitis B has been found to be cost‐effective in Australia. A 2009 study found that appropriate treatment was not only cost‐effective but more so than many currently existing population‐based cancer prevention programs.14 More recent research has also suggested that improving the hepatitis B cascade of care in Australia is cost‐effective.15 The current risk‐based screening approach for hepatitis B in Australia has failed to meaningfully increase the proportion of people diagnosed with this disease in the past decade, and we argue that it is time for a radical rethinking of our approach to testing for hepatitis B. Although difficult to quantify due to crossover in populations, given the breadth of the existing screening criteria — including all women who have been pregnant in the screening era (3.5 million Australians), all migrants from countries with more than 2% prevalence (2.1 million), all Aboriginal or Torres Strait Islander people (850 000), all adults at higher risk of infection (1.4 million), and any person with existing liver disease (over 5 million) — it is likely that most of Australian adults meet least one screening criteria, and a universal approach would represent a relatively small expansion in the total number eligible. We believe that guidelines should now recommend that all Australians aged 20–79 years whose hepatitis B status has not been documented should be offered testing. This minimum age coincides with the enactment of universal hepatitis B vaccination in Australia, which led to a substantial reduction in prevalence. However, screening would still be required in cases where a child was born overseas or was born in Australia to a mother living with hepatitis B. The upper age limit for offering testing may not reach cost‐effectiveness thresholds; however, this has not been locally established and there is evidence that older Australians have a considerable burden of hepatitis B6 and liver disease.7 Offering testing should always be conducted within the context of informed consent,16 and given most tests currently take place in primary care settings, GPs should be supported to incorporate hepatitis B screening into standard preventive health care for all adults.2 In line with Australia’s historical approach to blood‐borne virus responses, involvement of community and professional organisations and people with lived experience should be central to implementation. There is a need to change the way we approach testing for hepatitis B in Australia as we fail to meet both interim and longer term targets.7 Innovation and simplification of our testing policy are necessary to reach people unaware of their risk, encourage clinicians to test, and reduce stigma and discrimination associated with questioning people about risk factors. This approach would help integrate routine hepatitis B screening and care into primary care. A fundamental change is needed if Australia is to meet our National Strategy targets for 2022 and the WHO elimination targets for 2030. Importantly, it would allow the more than 70 000 Australians with undiagnosed hepatitis B7 to be informed about their condition and to enable them to access care and potentially life‐saving treatment. To not do so will further entrench the status quo and the ongoing preventable morbidity and mortality associated with late diagnosis of hepatitis B.7,8 Box – Trends in chronic hepatitis B diagnosis in Australia during 2010–2019, incorporating modelled estimates of diagnosed and undiagnosed population (area) and annual surveillance notifications of newly diagnosed cases (line) Modelled data sourced from previously published work.7 Annual number of notified cases sourced from the Australian Government Department of Health National Notifiable Diseases Surveillance System.6

Nicole L Allard · Jennifer H MacLachlan · Lien Tran · Nafisa Yussf · Benjamin C Cowie

Objective: To determine rates of potentially preventable hospitalisation of people with intellectual disability in New South Wales, and compare them with those for the NSW population. Design: Retrospective cohort study. Setting: Potentially preventable hospitalisations in NSW, as defined by the National Healthcare Agreement progress indicator 18, 1 July 2001 ‒ 30 June 2015. Participants: Data collected in a retrospective data linkage study of 92 542 people with intellectual disability in NSW; potentially preventable hospitalisations data for NSW published by HealthStats NSW. Main outcome measures: Age‐adjusted rates of potentially preventable hospitalisation by group (people with intellectual disability, NSW population), medical condition type (acute, chronic, vaccine‐preventable), and medical condition. Results: The annual age‐standardised rate for people with intellectual disability ranged between 5286 and 6301 per 100 000 persons, and for the NSW population between 1278 and 1511 per 100 000 persons; the rate ratio (RR) ranged between 3.5 (95% CI, 3.3–3.7) in 2014–15 and 4.5 (95% CI, 4.2–4.9) in 2002–03. The difference was greatest for admissions with acute (RR range: 5.3 [95% CI, 4.9–5.7] in 2014–15 to 8.1 [95% CI, 7.4–8.8] in 2002–03) and vaccine‐preventable conditions (RR range: 2.1 [95% CI, 1.6–3.0] in 2007–08 to 3.4 [95% CI, 2.2–5.2] in 2004–05). By specific condition, the highest age‐standardised rate was for admissions with convulsions and epilepsy (all years, 2567 per 100 000 population; v NSW population: RR, 22.2; 95% CI, 21.3–23.1). Conclusion: Age‐standardised rates of potentially preventable hospitalisation are higher for people with intellectual disability than for the general population. The reasons for these differences should be investigated, and strategies for averting potentially preventable hospitalisation developed.

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

Onsite “buddies” are not always available to monitor the donning and doffing of personal protective equipment (PPE) in hospitals, especially during a pandemic, potentially leading to poor PPE compliance and increased risk of health care infections.1,2 We therefore compared monitoring of PPE donning/doffing procedures in a standard critical care setting3,4 by remote buddies with monitoring by onsite buddies. We designed 30 procedural scenarios (15 donning, 15 doffing) that included random errors in some procedural steps (online Supporting Information). Four buddies (two onsite, two remote), unaware of the number and type of errors in each scenario, concurrently viewed and assessed each step. The remote buddies viewed the procedures via videoconferencing on their computers. The camera of the transmitting laptop computer was positioned so that the entire body of the person donning or doffing PPE could be seen. Procedures were live‐streamed to the remote buddies via the hospital Wi‐Fi network. The buddies were not permitted to communicate with each other or with the person donning or doffing PPE. The study was approved by the Melbourne Health Human Research Ethics Committee (QA2020104). Sensitivity (correctly identifying correct procedure) was 100% for both onsite and remote buddies; specificity (correctly identifying incorrect procedure) was 98.9% for onsite buddies and 94.5% for remote buddies; overall accuracy was respectively 99.7% and 98.7% (Box). Concordance between assessments by onsite and remote buddies (κ = 0.95), by the two onsite buddies (κ = 0.97), and by the two remote buddies (κ = 0.98) was very good. The most frequent error was remote buddies missing chin exposure below the mask, probably because of the two‐dimensional view provided by the camera. Paying specific attention to the mask position when the donner turns side on in front of the camera might prevent this error. Practical considerations for remote buddies include the need for reliable hospital network and internet connections, or a wired hardware system, to avoid disruption of monitoring. As the remote buddy is unable to physically intervene when they identify an error, clear verbal communication is important. The psychological effect of having an onsite buddy was not characterised, but may influence user acceptability of remote buddies. All buddies were very experienced in providing observation feedback, but we did not assess their proficiency. Their accuracy may also have reflected greater vigilance while being observed (the Hawthorne effect). Finally, we did not weight the donning and doffing steps according to their importance for safety. Having a trained observer monitor PPE compliance is important for health care safety. The high level of accuracy and the agreement between onsite and remote buddies were encouraging. Apart from identifying errors, remote buddies could also provide step‐by‐step instruction in donning and doffing procedures, which could improve compliance and minimise contamination.5 Using remote buddies may help preserve PPE supplies and ensure reliable access to monitoring, even when PPE supply or onsite staff numbers are limited, while also reducing the infection exposure risk for the monitoring observers. Box – Personal protective equipment (PPE) monitoring assessment accuracy by onsite and remote buddies Scenario outcome* Buddy outcome* Pass Fail Onsite buddies (390 tests) Pass 298 1 PPV, 99.7% Fail 0 91 NPV, 100% Sensitivity, 100% Specificity, 98.9% Overall accuracy, 99.7% Remote buddies (383 tests†) Pass 292 5 PPV, 98.3% Fail 0 86 NPV, 100% Sensitivity, 100% Specificity, 94.5% Overall accuracy, 98.7% PPV = positive predictive value; NPV = negative predictive value. * For each step of each PPE donning/doffing procedure: pass = correctly performed; fail = not correctly performed. † Seven assessments were missing because of internet interruptions.

Reny Segal · William PL Bradley · Daryl Williams · Romulo Correa de Araujo Nunes · Irene Ng

People with existing mental health problems or living in difficult circumstances may be at particular risk

Helen Herrman · Christian Kieling

Objectives: To examine associations between community cultural connectedness indicators and suicide mortality rates for young Aboriginal and Torres Strait Islander people. Study design: Retrospective mortality study. Setting, participants: Suicide deaths of people aged 10‒19 years recorded by the Queensland Suicide Register, 2001‒2015. Main outcome measures: Age‐standardised suicide death rates, by Indigenous status, sex, and age group; age‐standardised suicide death rates for young First Nations people by area level remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, and by cultural connectedness indicators (at statistical area level 2): cultural social capital index score, community Indigenous language use, and reported discrimination. Results: The age‐specific suicide rate was 21.1 deaths per 100 000 persons/year for First Nations young people and 5.0 deaths per 100 000 persons/year for non‐Indigenous young people (rate ratio [RR], 4.3; 95% CI, 3.5‒5.1). The rate for Aboriginal and Torres Strait Islander young people was higher in areas with low levels of cultural social capital (greater participation of community members in cultural events, ceremonies, organisations, and community activities) than in areas classified as having high levels (RR, 1.8; 95% CI, 1.2‒2.7), and also in communities with high levels of reported discrimination (RR, 2.7; 95% CI, 1.7‒4.3). Associations with proportions of Indigenous language speakers and area level socio‐economic resource levels were not statistically significant. Conclusion: We found that suicide mortality rates for Aboriginal and Torres Strait Islander young people in Queensland were influenced by community level culturally specific risk and protective factors. Our findings suggest that strategies for increasing community cultural connectedness at the community level and reducing institutional and personal discrimination could reduce suicide rates.

Mandy Gibson · Jaimee Stuart · Stuart Leske · Raelene Ward · Robert Tanton