Environmental health

Australia has relied, for most of its history, on international medical graduates (IMGs) to supplement its workforce. Since 1978, IMGs applying for general registration to practise in Australia have usually needed to pass the examinations of the Australian Medical Examining Council, or since 1986, its successor, the Australian Medical Council (AMC). The AMC provides several pathways to registration by the Australian Health Practitioner Regulation Agency (AHPRA). The route now termed “the standard pathway” consists of a two‐part assessment including a multiple choice question (MCQ) examination followed by a clinical examination. While most IMGs are required to pass both examinations, since 2007, IMGs who qualified in the so‐called competent authority countries (the United Kingdom, Ireland, the United States and Canada) have usually not been required to sit these examinations.1 The examinations have sometimes provoked controversy and political responses in various forms.2,3,4 Partly in reaction to these, but mainly through an internal process of continuous improvement, their formats have been adapted considerably over the 42‐year period. The MCQ examination assesses “basic and applied medical knowledge across a wide range of topics,” and since 2000, its pass mark has been set using item response theory.5,6 The original clinical examination used short cases and viva voces; in 2004, this was replaced by a 16‐station objective structured clinical examination (OSCE). The standard of both examinations is set at that “of newly qualified graduates of Australian medical schools who are about to commence intern training”.6 The last account of the demographic features of candidates attempting the examinations and their performance was provided in 2010.5 Now, a decade later, there have been striking changes in both these parameters, which we document and evaluate in this article. A further aim was to identify some demographic or candidate factors that might influence examination success. Source of data De‐identified information about candidates who took the MCQ and clinical examinations of the Australian Medical Examining Council and AMC, from their inception in 1978 until October 2019, were provided by the Council. It included the country and year of primary medical qualification, gender, year of birth, years of first attempt and success, and number of attempts for each candidate. From this information, we calculated the numbers of candidates, numbers of attempts, the success rate per attempt, and the proportion eventually achieving success each year. To examine the contributions of individual countries, results were aggregated into decades. Countries of training were also consolidated into regions, according to the United Nations geographical regions report, last updated in 1999 (Supporting information, table 1).7 Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (ID: 1750338.3). Demographic features of candidates Over the 42‐year period, a total of 35 699 candidates from 153 countries sat the MCQ examination, 16 588 (46.7%) of whom were female (Box 1). The median age of all candidates at their first MCQ attempt was 32 years (interquartile range [IQR], 28–37 years; range, 20–73 years). The clinical examination was attempted by 20 494 candidates. Their demographic features were similar to that of the candidates for the MCQ. Box 1 shows the number of candidates for the MCQ and clinical examination for the top ten countries of primary medical qualification at each examination. The data for countries grouped by UN region are provided in the online Supporting information, table 1, and data for candidates from all individual countries (except those with very few candidates) are provided in the online Supporting information, table 2. South Asia was the region contributing most candidates, with just under half the total — predominantly graduates from India, Pakistan and Sri Lanka. Next in order were those from South‐East Asia and North Africa. Candidate performance From a low base until about the year 2000, there was a marked increase in candidates attempting each examination, reaching a peak in 2009 for the MCQ and 4 years later for the clinical examination (Box 2 and Box 3). Although the candidate numbers declined slightly after these peaks, they remained almost fourfold higher than in 2000. The pass rate at each attempt in the MCQ examination fluctuated, with most year‐to‐year variations not reaching statistical significance. However, overall pass rates per attempt increased over time, from a low of 28% in 1987 to a high of 66% in 2018. Some candidates showed great persistence: 86 attempted the examination ten or more times. As with the MCQ examination, the pass rate in the clinical examination increased between the 1980s and the 2000s, reaching a peak of 64% in 2007. However, between 2011 and 2012 it fell by more than 10%, followed by a further decline; and for the past 5 years (excepting 2019 when data were incomplete), it has remained just above 30%. Nevertheless, most candidates who persevered managed to pass after one or two further attempts. As with the MCQ, there were a few who found it much more difficult. Five or more attempts were made by 621 candidates (3.0%), 144 of whom have not yet succeeded. Pass rates by individual country are provided in the Supporting information, table 3. In the MCQ, during the past three decades, women had a higher pass rate per attempt and overall, although the magnitude of the difference (about 3%) was small (Box 4). In the clinical examination since 1990, women had both a higher pass rate and fewer attempts. In the most recent decade, the difference in pass rates was substantial (+12%). Box 5 and Box 6 show the pass rates in the MCQ and clinical examinations, respectively, graphed against candidates’ age and the interval (recency) since their medical graduation. There was a marked decline in success with both increasing age and interval since graduation; this was more marked in the clinical examination. While the number of candidates who were 55 years or older was small (245; 1.2% of total), their pass rate was one‐third that of candidates aged 20–29 years, and only 45% of the older group eventually passed. Commentary Before 2000, the number of IMGs attempting AMC examinations annually was usually less than 300 and never exceeded 600. However, between 2000 and 2018, candidate numbers increased more than threefold to an annual mean of 1003 during a period when the number of all Australians born overseas increased only from 4.5 to 7.3 million.8 Some factors likely to have contributed to the increase in candidates were removal in 1998 of the requirement to be an Australian citizen, and offering the computer‐delivered MCQ examination from 2005 in several centres outside Australia. A further increase in candidates for the MCQ examination resulted from the 2006 decision by the Council of Australian Governments that all IMGs with limited or temporary registration with the individual state medical boards should pass that examination. The peak in attempts at the clinical examination in 2013 followed the establishment of the National Registration and Accreditation Scheme in July 2010 and the requirement that limited registrants (non‐specialists) demonstrate progress towards full registration (including passing the AMC clinical examination where applicable). It is important to note that these data are specific to those sitting the AMC examinations. They give only a partial picture of medical immigration over this period. Firstly, they do not include IMGs who were registered as specialists by the various states, and subsequently by AHPRA on advice from specialist colleges. Secondly, until 1992 the Medical Acts in all Australian states allowed graduates from the UK (and usually Ireland) exemption from the need for further examination. For the next 15 years, generalists from those countries usually had to take the AMC examinations, but from 2007 they were again exempted (along with IMGs from Canada and the US) when the AMC introduced the competent authority pathway. The overall success rate in the MCQ examination increased significantly from the 1980s. The AMC made several changes over that time to increase reliability and fairness. One was altering question types to formats less dependent on English language skill; another was publication of annotated question banks to assist candidates in their preparation.5,6,9 From 2000, the pass mark has been set by criterion‐referenced methodology. A further refinement from 2011 was administering the MCQ examination in computer‐adaptive format, where the difficulty of items is adjusted in real time according to a candidate's performance, considered to increase fairness and precision.10 A factor likely to have contributed to the recent lower pass rate in the clinical examination (Box 3) is the removal of nearly all candidates from the competent authority countries. Up till 2009, UK graduates had the highest pass rate in this examination (Supporting information, table 3), and their removal from the pool would inevitably lower the overall rate. However, the decline since 2010 cannot be fully accounted for by this since competent authority candidates comprised less than 10% of the 2000–2009 total. Thus, other factors affecting the most recent cohorts of candidates (eg, the changing mix of parent countries) are likely to have contributed. Many IMGs must often overcome hurdles less likely to be faced by those from competent authority countries. These include adapting to an unfamiliar health system, developing fluency in English, preparing for the examinations while under time pressure from short‐stay visas, and needing to support themselves with sometimes long hours of work outside the health system.11 It is possible, though, that changes in the format or content of the OSCE have also contributed. The differences between the results for women and men in the MCQ should not be overplayed, since the magnitude was small. Others have found little gender effect in postgraduate written examinations in the UK and the US.12,13 However, the outperformance by women in the clinical examination, particularly in the past decade, is more striking. Those findings have been seen elsewhere. Women perform better than men in Step 2 of the United States Medical Licensing Examination.14 Female overseas‐trained doctors were twice as likely as males to pass the UK Federation of Royal Colleges of Physicians’ Practical Assessment of Clinical Examination Skills (PACES) at their first attempt.15 The PACES examination has many similarities to the AMC OSCE, with communication skills important for both. Female superiority in patient–doctor communication has been documented previously,16 and may partly explain the present findings. That performance in the MCQ deteriorated with both age and time since graduation is not entirely surprising: the examination tests knowledge in all domains of medicine, including some of the basic sciences. The longer since these were studied, the more difficult it might be to pass questions based on them, especially for IMGs who had practised as specialists in their original country. More unexpected was the much lower performance in the clinical examination by older candidates. Clinical experience might have been expected to give them an advantage, but this does not appear to have been generally so. We have been unable to find exactly comparable data from medical licensing examinations in other countries. A UK retrospective analysis observed that international graduates aged more than 37 years actually performed better in a postgraduate paediatric examination.17 However, a US analysis noted a negative correlation between age when first certified by the American Board of Internal Medicine and the American Board of Surgery and subsequent success in maintenance of certification examinations.18 Since 1978, these examinations have played an important role in informing the credentialing of generalist IMGs by state medical boards and now the national board. This article has documented substantial changes over the four decades in the demography of candidates, and some factors that were associated with their success in the examinations. The information will be of interest to health planners, but more particularly to those IMGs who have passed through the process and others who are contemplating it. Many rural health services still struggle to meet their workforce needs and rely heavily on doctors who have migrated to practise medicine here.19 Australia continues to owe a debt to its immigrant doctors. Box 1 – Multiple choice question (MCQ) and clinical examinations: numbers of candidates, top ten countries* Country of training 1978–1989 1990–1999 2000–2009 2010–2019 Total MCQ examination India 351 496 2619 2483 5949 Pakistan 32 113 1007 1838 2990 Sri Lanka 159 246 1005 1394 2804 Egypt 179 356 375 1171 2081 Bangladesh 16 99 777 1107 1999 Iran 32 34 664 1197 1927 Philippines 83 182 646 714 1625 China 4 219 641 745 1609 Myanmar 21 66 485 772 1344 Iraq 8 160 420 602 1190 Total all countries 1864 3859 12 722 17 254 35 699 Clinical examination India 190 392 1059 2074 3715 Sri Lanka 101 194 399 960 1654 Pakistan 13 59 342 1168 1582 Bangladesh 7 53 483 831 1374 Iran 8 27 263 688 986 China 0 109 398 475 982 Egypt 78 296 195 375 944 Myanmar 5 45 175 661 886 Philippines 11 104 198 507 820 Iraq 2 85 303 358 748 Total all countries 897 2588 5806 11 203 20 494 * By total number of candidates. Data are listed by the year each candidate first attempted the examination. Many candidates made multiple attempts. International medical graduates trained in the United Kingdom and Ireland were exempted from the Australian Medical Council examinations by most states until 1992. Since 1997, few candidates from the competent authority countries (UK, Ireland, Canada and the United States) were required to take the examinations. Box 2 – Number of candidates and success rate per attempt in the multiple choice question examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 3 – Number of candidates, success rate per attempt and total attempts in the clinical examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 4 – Influence of gender on examination success* Period Gender N Total attempts Total passes Mean (SD) attempts Pass total (%) Pass/attempt (%) MCQ examination 1978–1989 Female 568 1299 412 2.29 ± 1.84 72.5% 31.7% Male 1142 2431 817 2.13 ± 1.68 71.5% 33.6% 1990–1999 Female 1691 3279 1434 1.95 ± 1.57 84.8% 43.7% Male 2164 4275 1729 1.98 ± 1.71 79.9% 40.4% 2000–2009 Female 5438 8666 4813 1.59 ± 1.14 88.5% 55.5% Male 7287 11846 6192 1.63 ± 1.32 85.0% 52.3% 2010–2019 Female 8891 12238 7378 1.38 ± 0.86 83.0% 60.3% Male 8365 12041 6845 1.35 ± 0.85 81.8% 56.8% Clinical examination 1978–1989 Female 257 503 233 1.96 ± 1.58 90.7% 46.3% Male 543 1085 471 2.00 ± 1.47 86.7% 43.4% 1990–1999 Female 1156 2037 1084 1.76 ± 1.07 93.8% 53.2% Male 1432 2917 1243 2.04 ± 1.35 86.8% 42.6% 2000–2009 Female 2636 3662 2428 1.39 ± 0.82 92.1% 66.3% Male 3170 5036 2772 1.59 ± 1.08 87.4% 55.0% 2010–2019 Female 6150 9802 4535 1.59 ± 1.03 73.7% 46.3% Male 5053 9184 3132 1.82 ± 1.30 62.0% 34.1% * MCQ = multiple choice question; SD = standard deviation. * The Australian Medical Examining Council did not list candidates’ gender in a few instances during the first decade. Box 5 – Australian Medical Council multiple choice question (MCQ) examination, 1978–2019: pass rates versus (A) age and (B) recency (interval since graduation) in the year when candidates first attempted the MCQ (all countries combined)* Spearman rank order correlation: (A) r = −0.964, P < 0.001; (B) r = −0.983, P < 0.001. Box 6 – Australian Medical Council clinical examination, 1978–2019: pass rates versus (A) age and (B) recency in year when the examination was first attempted* * Spearman rank order correlation: (A) r = −0.950, P < 0.001; (B) r = −0.950, P < 0.001.

Neville D Yeomans · Jillian R Sewell · Philip Pigou · Stuart Macintyre

As we face a second wave of the pandemic, mobility data may assist government public health action

Lucinda Adams · Robert J Adams · Tarun Bastiampillai

The arrival of social media coincides with the point at which the antivaccination movement became globally coordinated

Helen Petousis‐Harris · Lisbeth Alley

Objectives: To assess catch‐up vaccination of older children and adolescents during the first two years of the “No jab, no pay” policy linking eligibility for federal family assistance payments with childhood vaccination status. Design, setting, participants: Cross‐sectional analysis of Australian Immunisation Register data on catch‐up vaccination of children aged 5 to less than 7 years before (January 2013 – December 2014; baseline) and during the first two years of “No jab, no pay” (December 2015 – December 2017), and of children aged 7 to less than 10 years and young people aged 10 to less than 20 years (“No jab, no pay” period only). Main outcomes: Catch‐up vaccination rates for measles–mumps–rubella vaccine second dose (MMR2), by age group, Indigenous status, and socio‐economic status; catch‐up vaccination of children aged 5 to less than 7 years (third dose of diphtheria–tetanus–pertussis vaccine [DTPa3], MMR1), before and after introduction of “No jab, no pay”. Results: The proportion of incompletely vaccinated children aged 5 to less than 7 years who received catch‐up DTPa3 was higher under “No jab, no pay” than during the baseline period (15.5% v 9.4%). Of 407 332 incompletely vaccinated people aged 10 to less than 20 years, 71 502 (17.6%) received catch‐up MMR2 during the first two years of “No jab, no pay”, increasing overall coverage for this age group from 86.6% to 89.0%. MMR2 catch‐up activity in this age group was greater in the lowest socio‐economic status areas than in the highest status areas (29.1% v 7.6%), and also for Indigenous than for non‐Indigenous Australians (35.8% v 17.1%). MMR2 catch‐up activity in 2016 and 2017 peaked mid‐year. Conclusions: Linking family assistance payments with childhood vaccination status and associated program improvements were followed by substantial catch‐up vaccination activity, particularly in young people from families of lower socio‐economic status.

Brynley P Hull · Frank H Beard · Alexandra J Hendry · Aditi Dey · Kristine Macartney

To the Editor: Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome, is a reversible cardiomyopathy frequently precipitated by a stressful event. Its clinical presentation is indistinguishable from a myocardial infarction,1 with electrocardiogram (ECG) changes and elevation in cardiac enzymes. The syndrome was first described in 1991 in Japan and named in reference to the left ventricle morphological features that resemble a pot used for trapping octopuses. Takotsubo syndrome has recently been reported in association with coronavirus disease 2019 (COVID‐19),2 but we report a case of takotsubo cardiomyopathy brought on by the stress of isolation as a result of social distancing. A 71‐year‐old woman presented to the emergency department complaining of chest pain. On arrival, an ECG demonstrated diffuse ST elevation (Box) and troponin was elevated (7800 ng/L). Coronary angiography was performed immediately which did not demonstrate any obstructive lesion and she was admitted to the intensive care unit (ICU) for ongoing haemodynamic support. Echocardiography performed in the ICU showed a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (Box) suggestive of takotsubo cardiomyopathy. On questioning regarding recent stressors, our patient, who lived alone, reported significant anxiety about not being able to visit family due to social distancing, and was particularly saddened by being unable to see her grandchildren. Public health interventions undertaken by governments around the world in an attempt to reduce the rate of transmission of COVID‐19, or to “flatten the curve”, have included measures such as social distancing.3 While being effective in the aim of lowering infections, these measures may have many unintended consequences. Social isolation is detrimental to mental health, associated with increased stress levels and anxiety, especially in older people, who may be less able to use technology to stay in contact with friends and family.4 In our patient, this stress was enough to trigger takotsubo cardiomyopathy. Box – Electrocardiogram (A) showing diffuse ST elevation. Echocardiogram (B) showing a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (arrows)

Jon Rivers · Joshua F Ihle

Publicly funded reproductive carrier screening programs must weigh up a number of ethical considerations Reproductive genetic carrier screening (RCS) is undertaken by individuals or couples to determine their likelihood of having a child with particular autosomal recessive or X‐linked genetic conditions. It can be undertaken by anyone of reproductive age who wishes to have it, regardless of their family history or ancestry, and either before or during pregnancy.1 Some forms of RCS are currently available in Australia on a user‐pays basis, costing around $400–$500 per person. It is usually accessed via general practitioners but can also be accessed directly from testing companies.2 People who receive an increased chance result are offered genetic counselling to explore their reproductive options, which might include steps to avoid having a child with a genetic condition. Taking the test before pregnancy gives those with an increased chance result a wider range of reproductive options compared with prenatal testing.3 The Australian Reproductive Genetic Carrier Screening Project (Mackenzie's Mission), announced by federal Health Minister Greg Hunt in 2018, is a research project offering RCS to 10 000 Australian couples. Recruitment via participating health professionals commenced in late 2019. Mackenzie's Mission is gathering evidence — including clinical, laboratory, psychosocial, health economic and ethical aspects — to inform how publicly funded screening could be operationalised in Australia within ten years.4 Here, we reflect on the ethical implications of RCS in Australian health care.5 While the issues raised apply to all types of RCS, we focus on aspects relating to large scale, publicly funded initiatives like Mackenzie's Mission. Ethics and the goals of RCS A central ethical issue for large scale RCS initiatives is how their goals are described. Two main foci for articulating the goals of such programs are (i) outcomes for individuals and their families, such as reproductive autonomy; and (ii) outcomes for populations, such as reduced incidence of certain genetic conditions. It has been argued that a goal of seeking to reduce the population incidence of babies who will develop severe genetic conditions is inappropriate for RCS.6 This line of reasoning draws partly on concerns about perceived coercion; when RCS is offered routinely, couples may perceive that participating is the right thing to do, even if testing is optional.7 Additionally, such a goal might be interpreted as implying that couples who receive an increased chance result are then obliged to take action to avoid the birth of an affected child. Any future national program must be delivered as a genuinely optional intervention, respecting couples’ values and preferences. It has also been argued that the goal of reducing the incidence of certain genetic conditions in the population expresses an unfavourable judgement about the value of the lives of people who currently live with such a condition.8 Therefore, in the case of RCS it is considered more ethically acceptable for a program's stated aim to be aligned with the first set of outcomes mentioned above; namely, to support couples’ reproductive autonomy through provision of relevant information to enable choices that are consistent with their values.1 RCS programs are also motivated, at least in part, by the desire to mitigate harms that couples who have parented a baby or child with a severe or fatal genetic condition experience. These harms include the grief of losing a child or witnessing one's child suffering. RCS might enable some parents to avoid such distressing experiences. Emphasising the severity of a condition included in a screening program arguably lessens any implied negative judgement about people living with genetic conditions screened for. However, ethical debate on what constitutes a severe or serious condition remains ongoing.9 Ethical aspects of gene selection A significant component of designing a publicly funded RCS program is determining which genes warrant inclusion for testing.10 Since screening can be stigmatising for people living with the genetic conditions screened for, it is considered most ethically defensible to screen only for genes associated with severe childhood‐onset conditions.1,3 However, because perceptions surrounding seriousness and severity are not purely objective,9 any RCS program must carefully weigh the diverse ways in which a condition can present, as well as the implications of that condition for the person and their family. There are also ethical aspects regarding the classification of gene variants identified during the testing process.11 There can be a degree of uncertainty as to how strongly a particular variant is associated with a genetic condition, an issue compounded in population screening because there is no index case (proband) to facilitate interpretation. This has ethical implications because reporting a variant as disease‐causing when it is not may mean a couple will experience additional uncertainty and perhaps go through unnecessary tests or interventions. On the other hand, not reporting a variant that does turn out to be disease‐causing means a couple may go on to have a child with a serious condition despite receiving a low chance result from RCS. This issue will remain important for some time, especially as variant databases are still developing. Consent for RCS: enabling meaningful choices Whether and how to gain consent can be contentious in many public health screening programs.12 While both consent and pre‐test education are important for RCS,1 determining how best to do this can be complex. It has been argued that when screening is perceived as routine, people will be less likely to reflect critically on whether it is appropriate for them, or to consider whether the results will be relevant to their decision making.7 Support for pre‐test decision making such as educational videos and decision aids can help couples consider the implications of an increased chance result and their options for reproduction. Mackenzie's Mission is one of several large scale population‐based RCS initiatives globally that have curated large panels of genes to test using a couple‐based model.5,10,13 It is important for participants to understand that RCS is designed to provide the couple with information that might help with decisions about reproduction, rather than to convey genetic risk information for their own health. Participants will also be encouraged and supported to reflect on their values and their goals for testing, to help them decide whether this screening will be useful or important for them.14 Reporting results: ethical implications Results of any genetic test can be complex and might be uncertain.15 As such, results from RCS need to be provided in a way that is meaningful and useful. To optimise the utility of their results, participants will require a basic understanding of key concepts such as what it means to carry a recessive genetic condition, and the implications of an increased chance finding. It is also important to ensure that participating in screening is not interpreted as guaranteeing that someone will have a healthy child. Publicly funded population RCS globally is tending towards reporting couple‐based findings. Evidence suggests that participants understand and accept this approach and that it is feasible as a population screening model.5,13,16 Mackenzie's Mission participants will be informed when they both carry the same disease‐causing variant for an autosomal recessive condition, or when the genetic mother is found to carry one of the X‐linked conditions screened for. Reporting only couple‐based findings is justifiable from an implementation perspective, for both programmatic and pragmatic reasons. Programmatically, RCS aims to inform reproductive choices, so it provides couples with information relevant to those choices. Any potential for false reassurance can be carefully addressed during the pre‐ and post‐test education processes. Pragmatically, publicly funded RCS would be prohibitively expensive to offer if it reported individual carrier results, as the majority of individuals screened are likely to be a carrier for something.16 Each of these people would then need individual follow‐up, despite their future offspring having a very low chance of actually having that autosomal recessive condition, even if they were to re‐partner.17 Moreover, this information has no clinical utility for the individual's own health. It also has the potential to provoke anxiety. As such, it is premature and potentially inequitable to provide individuals with information relating to their individual carrier status without providing further support. Further research will inform considerations of the ethical and psychosocial aspects of using an RCS framework to report individual results, including the possibility of offering individual results for a limited number of the more prevalent conditions on the panel. Public funding How RCS is funded is also ethically relevant, not least due to the perceived endorsement of screening by the state when a program is publicly funded. A formal, publicly funded, screening program may have advantages,18 but public funding might also carry tacit value implications. Experience with antenatal screening suggests that blame and guilt can be associated with declining an offer of screening.19 Funding models can also reinforce routinisation, where a screening offer might be perceived as encouraging or even coercing couples to terminate a pregnancy if a genetic condition is identified in the fetus.7 Within public funding structures, ethical issues also arise from the mode of offer of RCS, either in the context of a formal population screening program (likely to be delivered by centralised, publicly funded entities) or via a Medicare item number. Provision via Medicare will allow any provider who can meet the item number requirements to offer the test, and as such is likely to attract a greater commercial presence in RCS. The resulting fragmentation might constitute a lost opportunity for uniform evaluation of program effectiveness and might also give rise to inconsistencies in aspects of test provision, such as counselling. On the other hand, provision through Medicare may also enable RCS to be rolled out more quickly than establishing a formal population screening program. Cost‐effectiveness of population‐wide RCS has not yet been established conclusively by the existing evidence;11 however, one of the aims of Mackenzie's Mission is to generate such evidence for the Australian health care system. RCS and community values Underlying these ethical considerations is the question of how RCS reflects societal values. While most people are likely to agree on core principles such as respecting couples’ choices about whether to participate in screening, there will also be variations in preferences between communities, families and individuals.20 Future delivery of a national RCS program in Australia will need to recognise and respond to this diversity, while also upholding the values that motivate the program. The central values for RCS in Australia are good health outcomes for families and communities, alongside respect for all Australians, equity in program design and delivery, and reproductive autonomy.

Lisa Dive · Ainsley J Newson

The coronavirus disease 2019 (COVID‑19) pandemic has forced many countries to take extraordinary measures to prevent spread of disease. In New South Wales, public health orders introduced during 18–26 March 2020 required the closure of major industries and prohibited non‐essential gatherings of more than 100 people or allowing less than 4 m2 space per person. On 29 March, further public health orders prohibited people leaving home other than for work, study, shopping, medical care, or exercise.1,2 Changes in patterns of presentations to emergency departments (EDs) have been reported during COVID‐19 lockdowns overseas, including reduced numbers of patients with certain high acuity conditions, such as acute coronary syndrome (ACS) and stroke.3,4,5 Understanding the situation in Australia is important for public health policy during this and future pandemics. The Western Sydney Local Health District is a metropolitan health network in NSW of four hospitals (each with EDs) with a total capacity of 1925 beds, serving a catchment of 950 000 people. We analysed triage, International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) coding, and separations data for ED presentations during 29 March – 31 May in each of 2019 and 2020. Differences in mean daily presentation numbers for each triage category and selected presentation types were assessed in non‐paired Student t test with Bonferroni correction. All data analysis was performed in Excel (Microsoft). As a quality assurance project, the study was exempted from formal ethics approval. The number of ED presentations during 29 March – 31 May was almost 25% lower in 2020 than in 2019 (26 617 v 35 268). Presentation numbers in all triage categories were lower in 2020 (P < 0.001), except for category 1 (resuscitation) (506 v 445, 14% increase; P = 0.40). The proportion of patients discharged from the ED was greater in 2020 (60% v 53%) and that of patients who did not wait for treatment smaller (1% v 5%). The number of patients admitted to hospital was lower in 2020 than 2019 (8047 v 11 838), as were the proportions admitted to hospital (30% v 34%) (Box 1). ED presentations with fourteen selected diagnoses were further examined: common infectious diseases (infectious enteric disease, pneumonia), conditions frequently seen in EDs (wrist or hand fractures, femur fractures, appendicitis, renal calculi), conditions for which fewer ED presentations have been reported during COVID‐19 restrictions overseas (stroke or cerebral haemorrhage, ACS, chest pain, transient ischaemic attacks), and conditions that may be exacerbated or for which follow‐up in routine medical services may be reduced by COVID‐19 and its associated restrictions (mental health problems, substance misuse, malignancy). The numbers of presentations with infectious enteric disease, pneumonia, wrist or hand fractures, stroke or intracerebral haemorrhage, and chest pain not resulting in another diagnosis were lower in 2020 than in 2019. The numbers of presentations with ACS were similar. The number of presentations with mental health problems was higher in 2020 (daily mean, 8.4; standard deviation [SD], 3.1) than in 2019 (daily mean, 6.9; SD, 2.6; difference, +1.5 presentations per day; 95% confidence interval, +0.1–2.9) (Box 2; online Supporting Information). Social distancing may have reduced the spread of infectious enteric diseases and community‐acquired pneumonia, and home isolation may have led to fewer fractures. However, lower numbers of presentations with chest pain or stroke (also reported overseas4) may reflect factors other than lower incidence, such as suspension of outpatient clinics and elective procedures, social distancing measures, and public anxiety. COVID‐19 has profoundly affected health care delivery. We found concerning reductions in ED presentation numbers that may indicate delayed seeking of appropriate medical attention. Public health messages should encourage timely presentation of people with time‐sensitive, potentially life‐threatening conditions, even during pandemics. Equally concerning is the higher number mental health‐related presentations, which may reflect anxiety about COVID‐19, loss of job security, or prolonged isolation. Studies of patients presenting to health care services as they re‐open are required to fully appreciate the health implications of the COVID‐19 epidemic. Box 1 – Emergency department presentations to Western Sydney Local Health District hospitals during corresponding two‐month periods in 2019 and 2020 Triage category Resuscitation Emergency Urgent Semi‐urgent Non‐urgent Total 29 March – 31 May 2019 Total number of presentations 445 8910 12 464 10 726 2723 35 268 Daily presentations, mean (standard deviation) 7.0 (3.2) 139 (15.9) 195 (19.3) 168 (22.3) 42.5 (10.7) 551 (41.8) Admitted to hospital 350 (79%) 4550 (51%) 4524 (36%) 2156 (20%) 258 (9%) 11 838 (34%) Discharged: treatment complete 38 (9%) 3350 (38%) 6155 (49%) 7093 (66%) 2039 (75%) 18 675 (53%) Transferred to another hospital or service 26 (6%) 521 (6%) 577 (5%) 299 (3%) 68 (2%) 1491 (4%) Did not wait 0 65 (1%) 560 (4%) 735 (7%) 239 (9%) 1599 (5%) Discharged against medical advice 7 (2%) 413 (5%) 646 (5%) 442 (4%) 81 (3%) 1589 (5%) Died in emergency department/dead on arrival 24 (5%) 11 (< 1%) 2 (< 1%) 1 (< 1%) 38 (1%) 76 (< 1%) 29 March – 31 May 2020 Total number of presentations 506 7609 9095 7346 2061 26 617 Daily presentations, mean (standard deviation) 7.9 (2.6) 119 (18.4) 142 (17.5) 115 (17.9) 32.2 (8.4) 416 (40.6) Admitted to hospital 370 (73%) 3112 (41%) 3072 (34%) 1279 (17%) 214 (10%) 8047 (30%) Discharged: treatment complete 62 (12%) 3836 (50%) 5146 (57%) 5324 (72%) 1525 (74%) 15 893 (60%) Transferred to another hospital or service 26 (5%) 424 (6%) 461 (5%) 304 (4%) 136 (7%) 1351 (5%) Did not wait 0 22 (< 1%) 84 (1%) 170 (2%) 107 (5%) 383 (1%) Discharged against medical advice 9 (2%) 210 (3%) 328 (4%) 267 (4%) 64 (3%) 878 (3%) Died in emergency department/dead on arrival 39 (8%) 5 (< 1%) 3 (< 1%) 0 15 (1%) 62 (< 1%) Change in presentation numbers, 2020 v 2019 +14% –15% –17% –32% –25% –25% table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Mean changes (with 95% confidence intervals) for numbers of emergency department presentations with selected diagnoses (ICD‐10‐AM codes), 29 March – 31 May 2020 v 29 March – 31 May 2019 ICD-10-AM = International Classification of Diseases, tenth revision, Australian modification. * Not resulting in another diagnosis. † Excluding cases without mention of obstruction.

Andrew W Kam · Sarah G Chaudhry · Nathan Gunasekaran · Andrew JR White · Matthew Vukasovic · Adrian T Fung

We need to burn, but it is not a cure-all and the side effects can be serious

Fay H Johnston

Guidelines need to reflect the mounting evidence for airborne transmission of SARS-CoV-2

C Raina MacIntyre · Michelle Ananda‐Rajah · Mark Nicholls · Ashley L Quigley

Air pollution poses global health, equity, and environmental problems with short and long term consequences

Julie M Marchant · Anne B Chang

To the Editor: The incidence of bushfires, forest fires and wildfires, is increasing globally. Epidemiology shows that individuals with chronic respiratory diseases are most affected with increased hospitalisations. However, the impacts or safe exposure levels of bushfire smoke are not well known.1 We were recently awarded the Medical Research Future Fund's Bushfire Impact Research grant 2020 and in this project we will address the following questions: How does bushfire smoke exposure affect respiratory health? How does it exacerbate chronic respiratory diseases and affect different age groups? What are the impacts on cells, tissues and molecular pathways? How can we target the effects therapeutically? Bushfire smoke is a complex mix of inspirable particles, volatile organics, aldehydes, carbon monoxide, and particulate matter (PM).2 Although extensive research evaluating the effects of bushfire smoke has not been carried out, studies utilising cigarette smoke or vehicular PM10−2.5 show that exposure to these insults induces lung inflammation and oxidative stress, and promotes the progression of chronic respiratory diseases.3,4,5 Further, in vitro studies with healthy human fibroblasts and bronchoepithelial cells show that bushfire smoke affects pathways including oxidative stress, barrier function, innate defence, and autophagy.6 Accordingly, we plan to expose mice to the different PM particles from bushfire smoke and will elucidate the acute and prolonged effects on lung inflammation, airway remodelling and lung function. In addition, by using our mouse model of chronic respiratory diseases (chronic obstructive pulmonary disease, asthma) and mice at different ages (pregnant, infant, aged), we will assess the impact of bushfire smoke on predisposition, pathogenesis and progression of chronic respiratory diseases. We will use advanced molecular and multi‐omics (single cell/tissue sequencing, proteomics, epigenetics) technology to elucidate cell and tissue responses. Furthermore, we will define therapeutic avenues for prevention and treatment (antioxidants, metabolic modulators) (Box). The outcomes of this project will inform the development of safe exposure guidelines and define preventive/treatment measures. Moreover, we will address evidence gaps related to harmful health effects of hazardous bushfire smoke exposure which we hope will aid government and health agencies to design appropriate policies, prevention measures, and treatment strategies to deal with future bushfire smoke events. Box – Methodology for evaluating the impact of bushfire smoke COPD = chronic obstructive pulmonary disease; PM = particulate matter.

Vivek Dharwal · Keshav R Paudel · Philip M Hansbro

To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1 A higher proportion of Australians who are socially disadvantaged have dental caries. In the 2012–2014 National Child Oral Health Survey, the mean number of deciduous teeth with dental caries in Indigenous children aged 5–10 years was 6.3 (95% CI, 5.2–7.4) compared with 2.9 (95% CI, 2.7–3.1) among non‐Indigenous children.3 In the 2004–2006 National Survey of Adult Oral Health, almost 60% of Indigenous adults had untreated dental caries compared with 25% of non‐Indigenous Australians.4 In the interests of equity, it is desirable for water fluoridation to provide a greater benefit to groups carrying the highest burden of disease. In Australia, this is the Indigenous population. Community water fluoridation is one of the most effective public health interventions of the 20th century. Its success has been attributed to wide population coverage with no concurrent behaviour change required. Evidence in Australia demonstrates that community water fluoridation has decreased both the prevalence (proportion of population) and severity (amount per person) of tooth decay by 44% in children and 27% in adults.5 However, nearly 3 million Australians (11% of the population) cannot access a fluoridated water supply.5 Access to fluoridated water in Australia varies. In Queensland before 2008, access was limited to 5% of the population.5 At that time, there were higher rates of untreated dental caries in non‐fluoridated than in fluoridated communities. In 2008, the Queensland Government mandated water fluoridation for all community water supplies that serviced communities of more than 1000 people; 134 water supplies were identified. Within 4 years, 90% of Queenslanders had access to fluoridated water and rates of dental caries declined.6 After the 2012 Queensland election, the new government overturned mandatory water fluoridation, with the decision to fluoridate community water reverting to water supply authorities. The subsequent deactivation of water fluoridation plants in 18 local government areas reduced the population coverage to around 76%. This had a disproportionate impact on Indigenous Australians, who are more likely to reside in areas where water fluoridation ceased after 2012 or in areas where it was never implemented. The consequence is that only 50% of the Indigenous population in Queensland have access to fluoridated water compared with 76% of non‐Indigenous Queenslanders.7 The denial of access to fluoridated drinking water for Indigenous Australians is of great concern. We urge the Commonwealth government, through current negotiations for funding agreements for public dental care, to mandate that all states and territories maintain a minimum standard of 90% population access to fluoridated water. Water fluoridation would then be an effective as well as socially equitable public health intervention to reduce the oral health inequalities between Indigenous and non‐Indigenous Australians.

Andrew McAuliffe · Chris Bourke · Lisa M Jamieson

To the Editor: In Australia, gestational diabetes mellitus is diagnosed by 75 g oral glucose tolerance test (OGTT). The diagnostic criteria are fasting plasma glucose (FPG) ≥ 5.1 mmol/L, one‐hour glucose level ≥ 10.0 mmol/L, and/or 2‐hour glucose level ≥ 8.5 mmol/L.1,2 International consensus favours OGTT over single measures of glucose because, in the pivotal Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, hyperglycaemia at each time point was independently associated with adverse outcomes, individual measures were not well correlated with one another, and no single measure was clearly superior in predicting adverse outcomes, such as birthweight above the 90th percentile, shoulder dystocia and pre‐eclampsia.2,3 To reduce contact time at pathology collection centres during the coronavirus disease 2019 (COVID‐19) pandemic, measurement of FPG alone has been advocated.4,5 One guideline advised that a result below 4.7 mmol/L may not merit a follow‐up OGTT.4 Another advised diagnosing gestational diabetes mellitus by stand‐alone FPG greater than 5.1 mmol/L.5 To determine the proportion and characteristics of gestational diabetes mellitus cases that would be missed by using alternative criteria, we extracted the results of all obstetrician‐referred OGTTs performed by our private community‐based laboratory between January 2017 and April 2020. The analysis, including determination of Wilson score confidence intervals (CIs), was performed with SAS 9.4 (SAS Institute). Of 16 169 patients, 1790 (11.1%) were diagnosed with gestational diabetes mellitus by OGTT. A rule‐out threshold of FPG below 5.1 mmol/L would have resulted in 1202 cases (67%; 95% CI, 65–69%) being missed, and a threshold below 4.7 mmol/L would have resulted in 831 cases (46%; 95% CI, 44–49%) being missed (Box). Women with gestational diabetes mellitus and normal fasting glucose did not have significantly lower one‐ or 2‐hour concentrations than those with increased fasting glucose (data not shown). Missing the diagnosis of gestational diabetes mellitus exposes women and their newborns to significant risks, including birth weight above the 90th percentile, primary caesarean delivery, neonatal hypoglycaemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinaemia and pre‐eclampsia. Use of fasting glucose to screen for gestational diabetes mellitus would miss a large proportion of cases, with the potential for significant harm to mothers and their offspring. Clinicians must recognise the substantial limitations of stand‐alone FPG so that pregnant women can be adequately counselled and, if opting out of OGTT, considered for careful monitoring for consequences of undiagnosed gestational diabetes mellitus, such as accelerated growth or polyhydramnios. In regions without significant community spread of COVID‐19, modifying sample collection procedures to ensure strict physical distancing and having dedicated collection centres for vulnerable populations may be better than using deficient diagnostic criteria. Box – Distribution of fasting glucose results at 24–28 weeks’ gestation in patients with (n = 1790) and without (n = 14 379) gestational diabetes mellitus* (GDM) The vertical grey lines denote thresholds below which new guidelines propose that oral glucose tolerance testing is not required during the coronavirus disease 2019 (COVID‐19) pandemic. * Diagnosed using oral glucose tolerance test.

Ranita Siru · Johan H Conradie · Melissa J Gillett · Emily Gianatti · Michael M Page

Current regulations address product safety, but they do not adequately ensure accuracy of formula preparation and provision Breastmilk is the optimum source of nutrition for most infants born at full term. When breastmilk is unavailable or unsuitable, the only safe and nutritious substitutes are commercial infant formulas.1 Infant formula — predominantly powdered infant formula — makes a major contribution to infant nutrition in Australia, with the 2010 Australian National Infant Feeding Survey reporting that 34% of infants had been introduced formula in their first month of life, 45% by 2 months and 69% by 6 months of age.2 In Australia, infant formula products are regulated under Standard 2.9.1 — Infant Formula Products in the Australia New Zealand Food Standards Code (Std2.9.1IFPANZC).3 All commercially produced infant formula products available in Australia and New Zealand must comply with the composition and safety requirements outlined in the Code. Std2.9.1IFPANZC specifies the mandatory nutrient content for infant formula and follow‐on formula to ensure that nutrition requirements are met. The standard includes labelling requirements, specifically prohibiting various claims, images and symbols. While these regulations address product safety, they do not adequately ensure accuracy of formula preparation and provision. In particular, potential for error remains around formula powder reconstitution, given multiple differing brands with variable scoop to water ratios, and volume of feed for differing ages and body weights. In this article, we discuss the infant formula range available in Australia, the infant formula powder reconstitution variability and the potential impacts, and the variability of manufacturer feeding guides compared with recognised recommendations and potential implications. Formula brands and types In Australia, there are more than ten brands of infant formula from which to choose. Within each brand there are often minor variations, from standard formulas meeting basic Food Standards Australia New Zealand (FSANZ) formula composition guidelines through to manufacturer‐specified gold formulas and condition‐specific formulas (Supporting information, table 1). FSANZ guidelines describe the purpose of infant formula labelling as providing information to caregivers to make informed choices, as well as information about appropriate preparation and safe use of infant formula products. Under FSANZ guidelines, all infant formulas must meet essential nutrient requirements. Specific nutrient content and health claims are prohibited in Clause 3 of Standard 1.2.7.4 Despite regulation, there are often misleading names or ingredient claims on infant formulas which construe a health claim or benefit and create doubt or sway opinion in consumers. For example, “[trade name] constipation”, as a name of a formula may be assumed by a consumer to be a superior formula for babies with constipation. Similarly, a statement of “fish oil to help support brain and eye development” could potentially be interpreted by a consumer as a health claim. There is currently no unbiased, freely available source of information to help parents choose a formula and this is often the first point of confusion. The authors frequently encounter parents swapping formulas in response to their infant's behaviour, believing that another formula may offer benefit. Typical examples in clinical practice are changing from a standard term formula to a colic, antireflux, or casein‐predominant formula when there is irritability or spilling. Powdered formula reconstitution While infant formulas are made in liquid ready‐to‐feed and in powdered forms, the latter is predominantly used in the home. Under Std2.9.1IFPANZC, the labelling of a powdered formula product must include the powder to water reconstitution ratio to achieve the specified nutritional composition, and the weight of powder in one scoop. However, the Standard does not dictate scoop size and, consequently, the scoop to water reconstitution ratio is determined by the manufacturer, although the powder weight to water ratio is relatively constant between manufacturers. In Australia, there is significant variation in reconstitution ratios across brands. Australian infant formula dilution reconstitution ratios are most commonly either one scoop per 30 mL water, per 50 mL water or per 60 mL water. The choice between a smaller or larger ratio is manufacturer‐specific. Explanations company representatives have provided for choosing a smaller scoop to water ratio include being able to make up smaller quantities of formula, greater accuracy, and a reconstitution method that yields rounded number volumes of 100 mL. In contrast, companies with larger scoop to water ratios propose reduced risk of error in sleep‐deprived parents who might lose count of scoops. However, none of these justifications are evidenced‐based. While there is a general expectation that parents use the formula label instructions or community advice, brand changes enhance potential for parental miscalculation of formula concentration. Under Std2.9.1IFPANZC, all powdered infant formula products must carry a warning stating, “Warning — follow instructions exactly. Prepare bottles and teats as directed. Do not change proportions of powder except on medical advice. Incorrect preparation can make your baby very ill”.3 This warning is often not obvious, and in practice, we have observed parents swapping between formulas and either assuming that the scoop to water reconstitution ratio is the same, confusing the ratios between brands, or using the incorrect scoop with a different manufacturer's powder, resulting in incorrect formula concentration. A systematic review of five studies supports this observation, finding that significant errors may be made when reconstituting formulas.5 Incorrect dilution ratio results in a formula strength that is either too dilute, increasing risks of nutrient deficiencies and faltering growth, or too concentrated, risking hypernatraemic dehydration or excessive weight gain. A review of reconstitution recipes of the major brands of standard infant formulas reveals a formula powder to water ratio of 0.142–0.15 g/mL (Supporting information, table 2) and a narrow caloric strength range of 4.8–5.2 Kcal/g. Clearly, a standardised reconstitution recipe is possible. We propose that standardisation of reconstitution ratio of powdered infant formula to water would minimise error and risk while providing clarity for parents and health professionals. Formula feeding guides Infant feeding guidelines for health workers1 state that as a formula is designed to remain at a constant strength, it is the amount of formula that should increase as the infant grows. The guidelines outline approximate formula requirements for infants (Supporting information, table 3), which correlate appropriately with the estimated energy requirements of infants as outlined in the National Health and Medical Research Council (NHMRC) Nutrient reference values for Australia and New Zealand.6 The infant feeding guidelines also note that feeding guidelines on formula packaging recommending certain amounts for various ages are guides only and do not necessarily suit every infant.1 Manufacturers of commercial infant formulas usually include a feeding guideline on the formula packaging that outlines the number and volume of feeds recommended for the corresponding ages. This is not a requirement under the Food Standards Code. There is substantial inconsistency in the feeding guidelines for volume and frequency of feed by age printed on the containers (Box), both from one manufacturer to another and also compared with the NHMRC‐recommended volumes by age and weight. The lack of weight standardisation means that the caregivers of a small infant may overfeed, while a genetically larger infant might be underfed. Greater consistency or standardisation of manufacturer feeding guides that correlate appropriately with the NHMRC feeding guidelines may help reduce both over‐ and underfeeding as well as alleviate parental confusion and anxiety around feeding volumes. While both under‐ and overfeeding may have negative clinical consequences, there are no published data to support adverse outcomes as a common consequence of parental misunderstanding. The absence of published evidence, however, should be considered in the light of anecdotal experience of health professionals within our health service, who report spilling and irritability from overfeeding and parental anxiety when their baby does not achieve volumes stated on the formula tin. Expert opinion concurs with our own clinical experience, as shown by the 2018 guideline on gastroesophageal reflux issued jointly by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPAGHAN), where the first step in management of an infant presenting with excess vomiting is to ensure that overfeeding is avoided.7 However, there is clearly a need for further study in the area of parental interpretation and use of the feeding guides provided on formula tins to determine the impact of variation in product labelling on health outcomes. Conclusion Infant formula is commonly used with a choice of brands and types of formula. There is limited access to unbiased advice on formula selection for parents, caregivers and health professionals who encounter feeding‐related problems in daily practice. In addition, there is a wide variation in reconstitution ratios of powdered infant formula due to differences in scoop sizes between manufacturers, which may contribute to error in formula concentration. Standardisation of reconstitution ratios is an opportunity to minimise error. Lastly, formula feeding guides provided on formula tins vary between companies and, by not accounting for weight, differ from NHMRC recommendations, which may lead to over‐ or underfeeding. Standardisation of formula feeding guides in line with NHMRC feeding guidelines, with clearer warning statements, may help reduce these risks. The absence of evidence as to the effectiveness and risks of current food and nutrition policy with respect to infant formula feeding is a significant gap in ensuring the safe care of infants both in our community and worldwide. We propose that this area becomes a future focus of public health research and advocacy for child health. Box – Standard infant formulas — manufacturer-suggested feeding volume(mL) and number of feeds per day juxtaposed as mL/kg/day for a 3rd centile female infant, 50th centile female infant and 97th centile male infant (World Health Organization growth data)

Shelley Farrent · Brian Coppin · Scott Morris

Compared with the mitigation and suppression approaches of most Western countries, elimination can minimise direct health effects and offer an early return to social and economic activity

Michael G Baker · Amanda Kvalsvig · Ayesha J Verrall

To the Editor: In their recent article, Ioannidis and Boyack focused on the misuse of author‐ and journal‐based metrics.1 The “predatory and other easy journals” they allude to are becoming increasingly difficult to distinguish2 in a widening continuum of journal quality that is seeing some overlap between predatory journals and indexed (eg, in Web of Science, Scopus or PubMed) journals that are traditionally perceived to be of peer‐review quality and whose scholarly content has been editorially authenticated.3 This increasing overlap between predatory and indexed journals is accentuated by an increasing lack of reproducibility, often revealed through post‐publication peer review of indexed journals.4 Predatory journals may also seek scholarly validation by allowing citation of their papers to infiltrate supposedly reputable databases.5 However, the continued inability to identify such journals invalidates calls to ban such entities or to not cite papers from currently blacklisted predatory journals, as was recently suggested by the International Committee of Medical Journal Editors.6 Increasing retractions in the biomedical literature as a result of post‐publication peer review — which identifies errors and misuses such as the manipulation of citations discussed by Ioannidis and Boyack, including inflated and coercive self‐citation— affect author‐based metrics and journal‐based metrics differently. It is incumbent upon authors, editors and publishers to correct inflated, skewed or distorted author‐ and journal‐based metrics. To achieve this, retractions need to be destigmatised. Moreover, inflated author‐ and journal‐based metrics (eg, H‐index, Journal Impact Factor [Web of Science Group], CiteScore [Elsevier]) need to be adjusted with corrective, but not punitive, measures, to correct for imbalances and unfair rewards that may be associated with the attribution of citations of retracted (and thus potentially invalid) literature.7 Self‐citations that support stated claims are valid, independent of their number, and involve no ethical breaches. However, the misuse of self‐citations to manipulate author‐ and journal‐based metrics, such as citation cartels,8 raises ethical red flags. Independent of the possible ethical parameters of inflated or coercive self‐citation, such metrics can also be adjusted downwards to reflect the more balanced perspective of an author‐ or journal‐based metric.9 If the identity of predatory journals can be clearly determined and unanimously agreed upon, then the journal‐based metrics of valid, indexed scholarly journals that cite such journals should be adjusted accordingly.

Jaime A Teixeira da Silva

To the Editor: A recent article highlighted a case where self‐collection enabled detection of an early cervical adenocarcinoma and curative treatment in a previously underscreened woman.1 This case underlines the important benefits from self‐collection making cervical screening more accessible and acceptable to women who have previously declined or delayed screening. Unfortunately, self‐collection is currently very underutilised in Australia. Although it is currently restricted to women aged 30 years and over who are 2 or more years overdue for cervical screening, potentially around a million women are eligible.2 In contrast, data from Medicare, VCS Pathology, and the National Cancer Screening Register suggest that fewer than 6000 self‐collected tests were processed over 2018 and 2019, indicating that less than 1% of eligible women have had a self‐collected test. What drives this discrepancy? Self‐collection is highly acceptable to underscreened Australian women, and very high uptake can be achieved with appropriate clinical support.3 A recent survey reported that many practitioners, especially outside Victoria, do not yet feel comfortable discussing or recommending self‐collection, and lack confidence that self‐collection is a reliable test.4 Potentially, this is due to an initial delay in self‐collection being available, confusion about eligibility, and current restrictions giving the false impression that self‐collection is less sensitive. Self‐collection is now available to eligible women nationally (provided samples are sent to one of two accredited laboratories, which accept samples from anywhere in Australia), and updated evidence demonstrates that polymerase chain reaction‐based human papillomavirus (HPV) testing is equally sensitive for detecting pre‐cancer in self‐collected and clinician‐collected samples.5 Another barrier may be difficulties for providers in checking whether women are eligible. The rollout of the provider portal into the National Cancer Screening Register, allowing providers to view a woman's screening history at the point of care, will be important in addressing this issue. Many screening‐eligible women who have not had their first HPV test are now overdue and could be eligible for self‐collection. Self‐collection is a reliable test now available nationally to eligible women, which can have a transformative effect in the lives of underscreened women, as shown in the recent case study.

Megan Smith · Marion Saville · Karen Canfell

To the Editor: In Australia, 2020 began with raging bushfires, and we now confront the coronavirus disease 2019 (COVID‐19) pandemic. While health protection is currently at the top of the public policy agenda, can we rise from these huge ruptures and “build back better”? The full health costs of the bushfires, including the mental health toll, are yet to be quantified. No sooner had the bushfires abated than the battle against the COVID‐19 pandemic began. The immediate public health response has been well managed in Australia.1 Although Victoria is currently grappling with a second wave of infections, by international comparisons the number of cases and deaths around the country has remained low.2 Government leaders have listened to health experts and acted on evidence, including the need for strict physical distancing in the absence of a vaccine, supplemented by universal masking in Victoria. As governments move to revitalise the economy with financial stimulus, what guidance can health experts provide to inform this stimulus? One clear priority is that stimulus accelerates the decarbonisation of the Australian economy. Climate change is a recognised health issue. Published as the bushfires erupted, the 2019 MJA–Lancet Countdown on health and climate change report3 found that Australia is extremely vulnerable to the impacts of climate change on health. There are also health co‐benefits from action on climate change. The clearest example is the transition to renewable energy generation. Globally, in 2015 alone, more than 460 000 preventable deaths were attributable to coal burning.4 An urgent transition to renewable energy would be an evidence‐based public policy response to these deaths and assist a global green recovery from the pandemic which is called for by the World Health Organization.5 Australia is well placed to lead such a recovery as indicated in a recent report by ClimateWorks Australia,6 which provides a blueprint to achieve net zero emissions by 2050 through accelerated uptake of mature zero emission technologies and the rapid development and commercialisation of emerging zero emission technologies in harder to abate sectors (Box). Beyond stimulus for decarbonisation, investments in affordable housing, mass transit infrastructure, safe routes for walking and cycling, regeneration of degraded ecosystems and infrastructure to support working from home would also benefit health through reduced homelessness, improved levels of physical activity, and improved urban air quality. Australia has, thus far, avoided the high COVID‐19 case numbers and death rates seen in some other countries because of evidence‐based decision making. It is essential that decisions about the stimulus for economic recovery are similarly grounded in evidence. The health and wellbeing of current and future generations of Australians depend on it. Box – Summary table of key emissions‐reduction solutions by sector CCS = carbon capture and storage.

Selina N Lo · Anna Skarbek · Anthony Capon

Objective: To evaluate associations between exposure during early life to mine fire smoke and parent‐reported indicators of respiratory and atopic illness 2–4 years later. Design, setting: The Hazelwood coalmine fire exposed a regional Australian community to markedly increased air pollution during February – March 2014. During June 2016 – October 2018 we conducted a prospective cohort study of children from the Latrobe Valley. Participants: Seventy‐nine children exposed to smoke in utero, 81 exposed during early childhood (0–2 years of age), and 129 children conceived after the fire (ie, unexposed). Exposure: Individualised mean daily and peak 24‐hour fire‐attributable fine particulate matter (PM2.5) exposure during the fire period, based on modelled air quality and time‐activity data. Main outcome measures: Parent‐reported symptoms, medications use, and contacts with medical professionals, collected in monthly online diaries for 29 months, 2–4 years after the fire. Results: In the in utero exposure analysis (2678 monthly diaries for 160 children exposed in utero or unexposed), each 10 μg/m3 increase in mean daily PM2.5 exposure was associated with increased reports of runny nose/cough (relative risk [RR], 1.09; 95% CI, 1.02–1.17), wheeze (RR, 1.56; 95% CI, 1.18–2.07), seeking health professional advice (RR, 1.17; 95% CI 1.06–1.29), and doctor diagnoses of upper respiratory tract infections, cold or flu (RR, 1.35; 95% CI, 1.14–1.60). Associations with peak 24‐hour PM2.5 exposure were similar. In the early childhood exposure analysis (3290 diaries for 210 children exposed during early childhood, or unexposed), each 100 μg/m3 increase in peak 24‐hour PM2.5 exposure was associated with increased use of asthma inhalers (RR, 1.26; 95% CI, 1.01–1.58). Conclusions: Exposure to mine fire smoke in utero was associated with increased reports by parents of respiratory infections and wheeze in their children 2–4 years later.

Gabriela A Willis · Kate Chappell · Stephanie Williams · Shannon M Melody · Amanda Wheeler · Marita Dalton · Shyamali C Dharmage · Graeme R Zosky · Fay H Johnston

Engaging First Nations peoples in public health emergencies is critical to reducing health inequities

Kristy Crooks · Dawn Casey · James S Ward

Understanding the multiple identity groups of Aboriginal and Torres Strait Islander LGBTQ+ young people can assist in meeting their health care needs Where does a young, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other non‐heteronormative or non‐binary sexual and gender identities, including asexual) Aboriginal and Torres Strait Islander person go for health care in Australia? Do they attend an Aboriginal community controlled health organisation in search of culturally sensitive care? Or do they visit an LGBTQ+‐friendly health service to access staff trained in sexual and gender diversity? Is there a space for them, and other LGBTQ+ Aboriginal and Torres Strait Islander young people, in the Australian health care landscape? These questions are being posed by Indigenous LGBTQ+ health advocates.1 Recent national policy documents outline the need for comprehensive health care for Aboriginal and Torres Strait Islander LGBTQ+ young people.2,3 Despite this identification in policy, limited information is available to health practitioners on working with Aboriginal and Torres Strait Islander LGBTQ+ young people (Box 1). Practitioners are limited by the absence of an integrated framework as well as a dearth of research into these young peoples’ health needs and service preferences. Intersectionality theory highlights that individuals can face multiple structural inequalities within each of the social groups that they occupy, which also affect their access to health, social and economic resources.4 We suggest intersectionality theory as a guiding principle for research and practice with Aboriginal and Torres Strait Islander LGBTQ+ young people. An intersectional approach means recognising that patients belong to multiple identity groups, such as sexual orientation and cultural groups, which are socially constructed and which affect their social positioning and subsequent treatment, such as discrimination, within health care systems.4 The health and wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Aboriginal and Torres Strait Islander LGBTQ+ young people occupy three intersecting identities, which, when considered separately, are each linked to risks for poor health. The risks for poor physical health and social emotional wellbeing among Aboriginal and Torres Strait Islander peoples are well documented.5 Within Australia, LGBTQ+ individuals experience heightened suicidality, serious assault, homelessness and psychological distress6,7 compared with their heterosexual, cisgender peers. These increased health risks do not indicate inherent vulnerability but rather are outcomes of discrimination, marginalisation, racism, transphobia and homophobia.15 Young people not only experience health risks associated with their development phase — for example, heightened risk of psychopathology, physical injury and emotional dysregulation9,10 — but are also often unaware of health services available to them or have fears around confidentiality.11 LGBTQ+ young people, in particular, report feeling isolated from health services.6 Health practitioners may therefore see Aboriginal and Torres Strait Islander LGBTQ+ young people in a variety of settings, including in suicidal crisis, seeking care after a serious assault or injury, or counselling for prolonged psychological distress. Although health care workers may be aware of the health risks associated with being Aboriginal and Torres Strait Islander, LGBTQ+ or young, the health outcomes for someone with these intersecting identities remain largely unknown. Emerging literature has begun to identify the health concerns of people who are both Aboriginal and Torres Strait Islander and LGBTQ+, although this work is thus far limited to adults.12,13,14 Consistent with research into these groups separately, findings suggest that suicidality, substance misuse and homelessness are primary health concerns for Aboriginal and Torres Strait Islander LGBTQ+ people. However, the evidence in adults also points to a set of health‐related concerns which are unique to being Aboriginal and Torres Islander and LGBTQ+. For example, some individuals move off Country in search of more accepting communities or to access gender‐affirming care.13,14 However, moving off Country can lead to feelings of dislocation due to loss of connection to Country, which can then precipitate illness. Arguably, Aboriginal and Torres Strait Islander LGBTQ+ young people find it harder to move off Country because of reduced financial and personal resources. Support and service in remote areas are also scarce.14 An inability to express gender or sexual identity is another health‐related concern for Aboriginal and Torres Strait Islander LGBTQ+ people. Some people report feeling pressure to suppress their sexual or gender identity when they are in Indigenous communities.12 Exclusion of gender diverse individuals from men's or women's business can negatively affect social and emotional wellbeing.13 Contemporary culture‐based wellbeing programs often continue this practice of providing support along binary gender lines. Some of the authors’ own experiences reiterate this unintentional bias; Indigenous health care providers use terms such as “sis”, “brother” or “sistergirl” when answering the phone, which can mean that people are misgendered. Although we acknowledge that these terms carry meaning to the Indigenous community, they can be problematical for trans and non‐gender‐conforming young people. There is therefore scope to develop a culturally sensitive way to bypass the use of these gendered terms until a young person's pronouns have been established. Intersectionality theory as a guiding framework International models8,15 provide a useful footing on which to consider intersectionality in the Australian health context. These models demonstrate how societal oppressions of racism and heterosexism within health care systems influence internal (eg, an individuals’ self‐concept) and external (eg, lack of LGBTQ+‐specific services, stigma toward multiple minority groups) risk factors. Importantly, the impact of these risk factors resulting from societal oppressions is not simply a multiplicative effect. Rather, individuals living within multiple minority groups face health disadvantage because of their unique social positioning. Common across these models is an emphasis on the social context of health outcomes because membership in multiple minority status groups can be associated with increased stresses and barriers impeding an individual's coping efforts. Further, when practitioners do not consider how a patient's gender, social class, ethnicity and sexual orientation influences their care needs, patients who experience multiple oppressions can become invisible by being left out of health research or ignored in policy and health promotion efforts, leading to delays in seeking care. Such invisibility in health care is a reported concern among Aboriginal and Torres Strait Islander LGBTQ+ people.12 Health care at the intersection: implications for health research and practice Adopting an intersectional approach to health care requires practitioners to consider the relationship between multiple structural inequalities faced by Aboriginal and Torres Strait Islander LGBTQ+ young people, and downstream consequences for this group's wellbeing. Doing so will likely require additional training and professional development. As Box 1 outlines, although not health providers per se, services and supports led by Aboriginal and Torres Strait Islander LGBTQ+ people have emerged in response to the multiple barriers presented by existing health services. These services provide a space for Aboriginal and Torres Strait Islander LGBTQ+ people to discuss intersecting identities. For example, the Gar'ban'djee'lum Network offers a space in which to celebrate sexual and cultural identity, and Black Rainbow partners with an online newspaper to publish content by Aboriginal and Torres Strait Islander LGBTQ+ authors, providing a platform for voices from people living at this intersection. Service providers can increase their awareness of the contemporary issues faced by Aboriginal and Torres Strait Islander LGBTQ+ young people by accessing online information from these organisations. Moreover, concrete steps which practitioners can follow can be guided by an awareness of intersecting categories, diversity of knowledges, power and multilevel analysis, reflexivity, time and space, and equity and social justice.8 Actions that practitioners can take which are consistent with these domains are outlined in Box 2. The increased focus on Aboriginal and Torres Strait Islander LGBTQ+ young people, led by and advocated for by Aboriginal and Torres Strait Islander LGBTQ+ community members and researchers, is a welcome step towards ensuring safe and effective health care for all Australians. However, there has been little guidance for practitioners on how best to work with this patient group. Health services wanting to support Aboriginal and Torres Strait Islander LGBTQ+ young people can: include an LGBTQ+ status question on intake forms; services can also use an open‐ended question format for young people to describe their gender, rather than tick‐boxes of “male”, “female” or “other”; provide visual displays of support in waiting rooms, such as displaying a rainbow pride flag and other pride flags alongside Aboriginal and Torres Strait Islander flags; and establish mechanisms for Aboriginal and Torres Strait Islander LGBTQ+ young people to provide service feedback (eg, asking patients from this group how the service can best meet their needs). Further, although there are increasing calls to apply an intersectional approach in health care — none more powerful than those of Aboriginal and Torres Strait Islander LGBTQ+ young people themselves — research has yet to systematically evaluate treatment outcomes for patients when such an approach is applied. Future research should measure treatment outcomes in services where staff apply an intersectional lens. The omission of young people from previous research into the health and wellbeing of Aboriginal Torres Strait Islander and LGBTIQ+ people also remains a pressing concern. Further research with young people is needed if practitioners and services working with young people are to effectively and appropriately work within an intersectional framework. Box 1 – Current services available for Aboriginal and Torres Strait Islander LGBTQ+ people* Organisation name Description Website Black Rainbow Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ suicide prevention Support for homelessness, domestic violence, and people involved in the justice system http://www.blackrainbow.org.au/ Tekwabi Giz Provides support to the National LGBTI Health Alliance for Aboriginal and Torres Strait Islander LGBTQ+ people, specialised knowledge, advocacy https://lgbtihealth.org.au/tekwabigiz/ IndigiLez Women's Leadership and Support Group Special focus on Indigenous lesbians and same sex‐attracted women Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ people, cultural retreats, safe sex workshops, family days, workshops, social activities, self‐defence workshops https://www.facebook.com/IndigiLez/ Sisters and Brothers NT Social change, advocacy, support, consultation, resource creation, and research, and awareness for sistergirls, brotherboys, and Aboriginal and Torres Strait Islander LGBTQ+ people https://www.facebook.com/SistersBrothersNTCelebratingDiversity/ First Nations Rainbow Acceptance, celebration, raising community awareness, improving wellbeing, and reducing stigma and discrimination https://www.firstnationsrainbow.org.au/ Yarns Heal Suicide prevention among Indigenous peoples, including sistergirls, brotherboys and LGBTQ+ individuals https://www.yarnsheal.com.au/ Gar'ban'djee'lum Network Support, advocacy, information on healthy lifestyles, social events, fundraising, and celebration of sexual and cultural identity https://www.afao.org.au/article/us-mob-garbandjeelum-network/ Blaq Aboriginal Corporation Celebration, representation and increased visibility of Aboriginal and Torres Strait Islander LGBTQ+ community members https://www.blaq.org.au/about-about * This list of organisations in not exhaustive but provides a starting point for practitioners wanting to learn more about Aboriginal and Torres Strait Islander LGBTQ+ health. Information in the table is taken from the organisations’ websites. None of the organisations listed are young people‐specific, although some make note of the importance of young people. Box 2 – Next steps in health care provision for Aboriginal and Torres Strait Islander LGBTQ+ young people Domain8 Next steps for research and practice Intersecting categories: health professionals should consider that patients likely occupy multiple social positions, not just the identity which appears most dominant Develop LGBTQ+ health information guides that are culturally sensitive to Aboriginal and Torres Strait Islander patients and easily accessible to young people Display the Aboriginal and Torres Strait Islander flags alongside the pride flags at health services Including LGBTQ+ status options on patient intake forms Because experiences of discrimination based on sexual and gender diversity among Aboriginal and Torres Strait Islander people can occur within the context of pre‐existing trauma,12 consider applying trauma‐informed care models when working with this patient group Specific health promotion efforts and programs targeted at Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into the social emotional wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into experiences and preferences of Aboriginal and Torres Strait Islander LGBTQ+ young people in the health system Diversity of knowledges: consider Indigenous and queer ways of knowing and being Seek Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ perspectives on their health issues Assess whether Aboriginal and Torres Strait Islander LGBTQ+ young people have a culturally specific understanding of their health and wellbeing, which may differ from dominant, medicalised explanations Primary research into how Aboriginal and Torres Strait Islander LGBTQ+ young people conceptualise health and wellbeing Power and multilevel analysis: health professionals hold greater power than Aboriginal and Torres Strait Islander LGBTQ+ young people due to their positions in society; health issues for this patient group occur across multiple levels of society Reducing power differentials in the healing relationship by using less medicalised language with patients and asking them how to best cater to their specific needs Ensuring young people understand limits of confidentiality so that they can trust practitioners with disclosing their LGBTQ+ status Practitioners attend professional development opportunities that promote appropriate ways of working with Aboriginal and Torres Strait Islander LGBTQ+ young people (such training is currently provided by some organisations listed in Box 1). Primary research into the impact of various societal oppressions on Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ wellbeing Primary research into enablers of effective service delivery in this patient group Reflexivity: consistent reflection on practice decisions and how they relate to patients’ social positioning Practitioners regularly reflect on assumptions they may hold about Aboriginal and Torres Strait Islander LGBTQ+ young people and the root cause of their health problems Discussions with LGBTQ+, Indigenous and mainstream health care providers around attitudes toward Aboriginal and Torres Strait Islander LGBTQ+ young people Time and space: patient needs and preferences are not static, and vary with social positioning Practitioners remain up to date on social trends which may affect this patient group (eg, recent legalisation of same sex marriage, release of the Uluru Statement from the Heart) Practitioners ask individual patients about their experience of living at this intersection, and not assume a universal experience Primary research into health care needs and preferences across the life course in this patient group Equity and social justice: advocating for increased inclusion of Aboriginal and Torres Strait Islander LGBTQ+ young people Health professionals can use their positions of social power to advocate for the needs of Aboriginal and Torres Strait Islander LGBTQ+ young people within their collegiate relations, workplaces and the broader health sector

Bep Uink · Shakara Liddelow‐Hunt · Kate Daglas · Dharma Ducasse

“Now we say Black Lives Matter but … the fact of the matter is, we just Black matter to them”1

If Black lives matter we need to be prepared to examine and address racial violence within the Australian health system My name is Kevin Yow Yeh and today I march for every Black death in custody but I especially march for my grandfather Kevin Yow Yeh Sr. At the age of 34 this man apparently had a heart attack at a Mackay watch house … This last month we've seen plenty of stats, 430 plus Black deaths in custody … and that's only since the Royal Commission, but what about all those deaths that led to that. My grandfather was one of them. Let's humanise these stories. When this man had a heart attack, he left his wife and he left five young children. My grandmother was still having his children when she had to put this man in the ground. That's why we march! Of course we stand in solidarity with our brothers in America. And, of course we stand in solidarity with our sisters in West Papua … but today we stand for our lives here, on stolen land.2 The statistical story of Indigenous health and death, despite how stark, fails to do justice to the violence of racialised health inequities that Aboriginal and Torres Strait Islander peoples continue to experience. This story has been reported on unremarkably in federal parliament for over a decade, as an annual account‐keeping exercise of policy failure and statistical targets not met.3 This story of failure and failing health has been told countless times in health and medical journal publications, and despite growing more frequent in number, these contributions to new knowledge never seem to translate to improved health outcomes. This story of failure does not do justice to the trauma and loss that Aboriginal and Torres Strait Islander communities experience. This story of failure does not do justice to the pain of never meeting the grandfather that you are named after. Tragically, despite the parlous state of Indigenous health, we have not been met here with the kind of urgency that the global Black Lives Matter movement has spurred elsewhere. What we have been presented with, aside from the Health Minister admonishing Black Lives Matter protestors for putting the health of the public at risk,4 has been the triumphal announcement of “research projects”,5 the release of a “landmark report”,6 and a drafting of “refreshed” and “historic targets”.7 All of these supposedly fresh responses were on track before the Black Lives Matter movement hit our shore. Rather than the “new normal” which the threat of coronavirus disease 2019 (COVID‐19) inspired, the Australian health system's Black Lives Matter moment is best characterised as indifferent; a “business as usual” approach that we know from experience betokens failure. When the threat of COVID‐19 loomed, action was swift and the Aboriginal and Torres Strait Islander leadership within and outside of the health system was even swifter in establishing taskforces, lobbying for additional resources for the community controlled sector, instituting special border control measures for remote Indigenous communities, and the development of emergency response plans to protect their communities.8,9 The effective response to the COVID‐19 pandemic sits in sharp contrast to the ongoing pandemic of racism that Indigenous peoples have been fighting since 1788 and which has taken far more Black lives in Australia. Sweet points out: “To date, there is very little sign that senior health policy makers, from the Chief Medical Officer to Health Minister Greg Hunt, will use their authority to name and address the system racism that contributes to poorer healthcare, as it does to overincarceration”.10 While broad attention is often focused on Black deaths in custody, the premature deaths of Indigenous peoples from supposed natural causes inside and outside of custody tell a consistent story of failure and violence that marks the Australian health system and society more broadly. Against the quietude of the Australian health system on racism are the powerful voices of Aboriginal and Torres Strait Islander peoples, on television screens, on public streets and in our spreadsheets, speaking the truth about how little Black lives seem to matter. Both Indigenous clients and clinicians have stories to tell of the violence of racism in the health system, of being cast in the category of less capable, less compliant, less deserving of care and less worthy of the category of human. This then brings us to the coronial inquiry, the endgame of not caring; of neglect. Here, never let us forget the mothers, the children, the cousins and the spouses weeping outside coroner's courts, bearing photos of their loved ones in their hands and on their clothing, simultaneously appealing for care and for justice.11 Moreover, let us not for a second dismiss the anguish of having to fight for the release of recorded footage of your loved one's final moments, to be replayed over and over, in which they too plead vainly, “I can't breathe”.12 So many grieving Indigenous families continue to appeal to the state for care and for justice via coronial inquiries in the hope that their tragedy will not befall another. But the awful truth is that the recommendations of coronial inquiries are not enforceable because the inquest is meant to discover what happened rather than determine responsibility. So again, regardless of the findings, the resulting outcome is business as usual. The coronial inquiry represents a theatre of power where, in the presence of an avoidable Indigenous death, the state declares its benevolence; duly recording the steps taken and policies and procedures adhered to or those requiring review, and the best efforts of police, medical officers or first responders, to deem the death another “unavoidable” tragedy. Gomeroi scholar Whittaker11 notes how the discourse of “natural causes” in coronial inquiries works to render Indigenous peoples as “fated to die” and beyond care because they were “already dead”. The coronial inquiry represents a moment of confluence of the health and legal systems and the state that seek to erase Indigenous existence and affirm the settler trope of a dying race. It represents the theatre of Indigenous health policy writ large. The story of Indigenous health failure, of persisting and alarming health statistics that are routinely attributed to a complex web of social, cultural and economic factors, sustains the notion of the inevitability of Indigenous ill health, of a race destined to die out, despite the best of efforts and intentions. How do we explain an unwavering commitment to a failed Indigenous health policy framework amid a global movement centred around the importance of Black lives, and a National Aboriginal and Torres Strait Islander Health Plan vision of a health system “free of racism” with no strategy for addressing systemic racism?13 How do we further explain the focus on the individual health behaviours or “choices” of Aboriginal and Torres Strait Islander peoples when we know “incessant racial health inequities across nearly every major health index reveal less about what patients have failed to feel and more about what systems have failed to do”.14 As Boyd and colleagues point out, “The solution to racial health inequities is to address racism and its attendant harms and erect a new health care infrastructure that no longer profits from the persistence of inequitable disease”.14 Earlier this year, the National Registration and Accreditation Scheme demonstrated the type of Black Lives Matter moment that the Closing the Gap refresh missed, by launching the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020‐2025.15 The strategy sets clear directions for the Australian Health Practitioner Regulation Agency, the national boards and accreditation authorities, which regulate Australia's 740 000 registered health practitioners to ensure that patient safety for Aboriginal and Torres Strait Islander peoples is the norm. The landmark strategy embodies ambition and partnership to address racism and culturally safe care; shifting the blame of failure for good health from Black bodies and instead demanding structural and individual health reform of health practitioners and the systems that regulate them. It is this shift of focus that has been central to the calls from Aboriginal and Torres Strait Islander peoples. Black wounds have been laid bare, to reveal the violence of health and legal systems upon Aboriginal and Torres Strait Islander peoples in a desperate appeal for those same systems to care. At 34 years of age my grandfather died, where's his justice? … what about all the other families, what about all the other fathers, brothers, sisters, nephews and nieces …? What about all the other mob? Where's their justice? My name's Kevin Yow Yeh, f*** the system, if you're not with us you're against us! What is needed is an Australian health system that has a steadfast commitment to Black lives: not as in need of saving, but as deserving of care; one that matches the staunchness of grieving Black families marching the streets of our capital cities in the midst of a pandemic. Such a commitment demands that we abandon the failed Indigenous health policy of Closing the Gap16 in favour of a health justice framework,17 which would include, but not be limited to: A foregrounding of Indigenous sovereignty rendering visible the strength, capability and humanity of Aboriginal and Torres Strait Islander peoples, services and communities in all processes of health policy formation and implementation, not as partners but as architects. State and federal government commitment to the recommendations of the coronial inquiries into the deaths of Aboriginal and Torres Strait Islander peoples who have died of preventable or avoidable conditions in the health system, and the establishment of an Indigenous taskforce to oversee implementation. An explicit financial commitment from the National Health and Medical Research Council and the South Australian Health and Medical Research Institute (via the Indigenous Medical Research Future Fund) and the Australian Research Council for research that attends to the nature and function of race in producing the conditions that allow racialised health inequalities to persist, from birth to death, including the embodied consequences of racism. The establishment of awareness‐raising campaigns that make clear the various ways in which Aboriginal and Torres Strait Islander peoples may seek justice when experiencing discrimination within the health system, and commeasurable resourcing of legal services to support Indigenous peoples to take action. Introduction of publication guidelines for health and medical journals requiring research relating to racialised health disparities to foreground institutional racism in its analysis, rather than socio‐economic disadvantage and other social and cultural factors. Development of an interdisciplinary Indigenous health workforce agenda that centres the care of Indigenous people beyond capacity building to include attending to racial violence within workplaces across the Australian health system. We offer these strategies not as a solution, but as some small steps towards a radical reimagining of the Black body within the Australian health system; one which demonstrates a more genuine commitment to the cries of “Black Lives Matter” from Blackfullas in this place right now.

Chelsea J Bond · Lisa J Whop · David Singh · Helena Kajlich

To the Editor: The issue of cancer overdiagnosis highlighted by Glasziou and colleagues1 is not new. The problem lies in how clinicians translate caution into the care of individual patients. In August 2019, non‐clinician epidemiologists, via the media, alarmed and confused many post‐menopausal women by reminding us that menopausal hormone therapy (MHT) mildly increases breast cancer risk.2 This was already known; breast cancer is common in post‐menopausal women, with or without a history of MHT use. Women taking MHT understandably comply with government‐recommended and funded screening mammography.3 Thyroid cancer overdiagnosis has been recognised for many years and is addressed in international evidence‐based management guidelines.4,5 The Royal Australasian College of Physicians has the EVOLVE program, endorsed by the Endocrine Society of Australia, to guide clinicians to order fewer thyroid ultrasounds.6 The adoption of thyroid ultrasound reporting systems such as TIRADS has already reduced the number of thyroid fine needle biopsies.7 Furthermore, active surveillance, rather than surgical intervention, is now advocated and supported by evidence for the management of small low risk thyroid cancers.5 Data from overseas show that older patients may accept surveillance over surgery, but younger patients demand intervention due to uncertainty about tumour behaviour. Active surveillance becomes expensive with time.8 Clinicians face anxious patients seeking guidance over mixed messages from the popular press. Genomics and better personalised medicine may eventually allow prognostication. For now, addressing clinical and family histories, physical examination, and appropriate investigations are done on a case‐by‐case basis. Thyroid cancer guidelines have already been adjusted and expanded to outline an individualised approach.

Diana L Learoyd

While mumps outbreaks involving professional rugby league, rugby union, and ice hockey teams have been reported in the media,1,2,3,4,5 there have been few scientific reports. On 30 January 2018, a general practitioner notified the local Public Health Unit of a mumps outbreak in a National Rugby League team, prompting investigation according to the NSW Public Health Act 2010. Four players and two coaching staff had developed fever and parotitis during 21–24 January (Box). Mumps virus was detected by polymerase chain reaction (PCR) in the buccal or throat swabs of two patients; each had detectable mumps IgG but not IgM (Liaison Mumps IgG and IgM, DiaSorin). In the other four patients, who had fever and parotid swelling, mumps was diagnosed clinically. The patients were isolated and their travel restricted; the Public Health Unit recommended measles–mumps–rubella (MMR) vaccination of all asymptomatic players and support staff. A further six cases were diagnosed during 1–10 February, in five players and an intimate contact of one of the earlier PCR‐positive patients; the contact developed symptoms 18 days after symptom onset in the source patient. Mumps virus was detected by PCR in four of the six new patients; two were diagnosed clinically. In one PCR‐positive case, mumps IgG, but not IgM, was detected. In all six PCR‐positive patients, genotype G mumps virus was identified. The offer of vaccination was extended to the partners of players and staff, and to players from four elite clubs who shared facilities with the team; by 19 February, 178 players and support staff and their partners had been vaccinated. No new cases were diagnosed after 10 February, and the outbreak was declared ended on 31 March. None of the 12 patients (median age, 25 years; range, 18–39 years) suffered complications. The nine players were from a pool of 42 elite and junior players, an estimated attack rate of 21%. Significantly, mumps‐specific IgG had been detected in nine patients (all players) at the time of their joining the club; the other three patients (all non‐players) had not previously been tested. Documentation of past vaccination was unavailable. No players or staff who received MMR vaccine during the outbreak developed mumps. The intimate contact who developed mumps was vaccinated at least 10 days after first exposure, at which point they were probably in the incubation phase of infection. This was the first mumps outbreak in NSW for many years, and nine of the twelve patients had pre‐existing mumps IgG, which does not appear to be a reliable marker of protective immunity.6 Patients who underwent both serology and PCR testing had detectable IgG but not detectable IgM. This pattern, generally understood to reflect waning immunity following vaccination — that is, pre‐existing mumps‐specific IgG does not prevent infection but its concentration rapidly increases after infection — was also reported for a community outbreak in Western Australia.7 PCR testing is consequently preferable for detecting infection in vaccinated populations, and outbreak control should include vaccination of contacts, even if they have previously received two doses of mumps vaccine.8 Apart from hockey, mumps outbreaks in elite team sports other than the rugby codes have not been reported. Intensive exposure to saliva may result in greater force of infection; tackling and scrums facilitate frequent contact with saliva from fellow players’ faces and on jerseys contaminated by the wiping of mouthguards. Ensuring at registration that players have received two documented lifetime doses of mumps vaccine may be a more effective preventive measure than relying on IgG screening. Ethics approval All patients and their rugby league club provided written consent for the publication of this report. Box – Timeline of the mumps outbreak in a New South Wales National Rugby League team, 21 January – 10 February 2018 PCR = polymerase chain reaction testing.

Karen Chee · Cassy Workman · Susan Irvine · Mark J Ferson