Environmental health

COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020. Unemployment alone is associated with a two‐ to threefold increased relative risk of death by suicide compared with being employed,3 and sudden spikes in unemployment are associated with corresponding surges in the population rates of suicide.4 The global financial crisis, which led to the deepest recession since the 1930s and the loss of 30 million jobs worldwide, is estimated to have resulted in at least 10 000 additional economic suicides between 2008 and 2010 in Europe and North America.5 Projections using historical data suggest suicide rates may increase by 3.3–8.4% over the 2020–2021 period in the United States6 and up to 27% in Canada.7 Of course, all this is speculative and although the links between economic recessions and suicide are well documented, what is less clear is how the relationship plays out in the context of larger sociocultural and health events such as COVID‐19. The 1918–1920 influenza pandemic caused around 39 million deaths worldwide and resulted in governments implementing quarantine, public hygiene and social distancing policies, but evidence regarding its impact on world economies and suicide is limited. The severe acute respiratory syndrome (SARS) epidemic of 2003 came at the height of the Asian financial crisis, so disentangling the two is difficult. However, during this period, suicide rates in a number of Asian nations increased in tandem with unemployment, reaching historical peaks in 2003.8 As the situation continues to change daily, an accurate estimate of likely unemployment resulting from the COVID‐19 pandemic is difficult. Even current estimates under‐represent the impact, as individuals who are still employed but at significantly reduced hours are discounted. This is of particular concern when considering the global financial crisis, which saw Australian unemployment take a comparatively minor increase from 4.0% to 5.8% and coincided with an increase in suicide rates of 22% and 12% for unemployed men and women respectively.9 As the present crisis may potentially double the current unemployment rate, one can extrapolate to alarming conclusions, with some (albeit unpublished) modelling reflecting this projection.10 Despite this grim speculative forecast, this is not the whole story. There are marked differences between the present crisis and those that have come before. For instance, the current recession is supply (rather than demand) driven, and the prospect of recovery, although slow, is conceivable and may bolter optimism. Although major industries will be severely affected, there is potential for increased local spending as the borders remain closed. In addition, some hope may be found in the resilience shown by civilians in times of global unrest — for instance, the often cited “Blitz spirit”11 — and the possibility that the shared experience of the pandemic might bring a sense of social cohesion, which may prove life‐preserving. Notwithstanding considerable evidence of the psychosocial impacts of mass unemployment, we argue that the impact of the COVID‐19 pandemic on suicide rates is far from predetermined, and that early and sustained action can prevent many suicides and other adverse mental health outcomes. During prior recessions, Austria, Sweden and Finland have each displayed resilience in the face of substantially increased unemployment.5 In fact, despite sizeable rises in unemployment rates in Sweden and Finland in the early 1990s, the rate of suicide decreased.4 We suggest that, based on the available literature, there are several factors that may moderate the impacts of widespread unemployment. These include both early prevention measures and crisis care: sustained welfare spending; labour market programs and protections; and adequate funding of, and access to, mental health services, including prevention programs and engaging new technologies in the reporting and care response. Firstly, countries with sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job search initiatives for the unemployed.12 Robust social policies to ensure adequate welfare benefits for people with low or sudden loss of income are thought to be central to offsetting the impact of the recession on suicide.13 Where governments expand public welfare spending in the wake of disasters, there is good evidence for a reduction in suicide. The federal government's introduction of the JobKeeper and JobSeeker payment schemes are likely to mitigate suicide risk while simultaneously stimulating the economy and require long term investment. Secondly, countries with active labour market programs, which assist the unemployed to find work or retrain, and those with labour market protections have lower rates of unemployment‐related suicide than countries that do not.12 It has been estimated that, during European recession periods in the past 50 years, each US$100 per capita of investment in active labour market programs reduced the association of unemployment with suicide by 0.4%.4 Thirdly, it is critical that investment is made immediately in mental health, not just in terms of treatment but also in evidence‐based prevention programs. Different approaches are required to reduce attempts, and deaths, involving both public health and clinical services. In terms of direct suicide prevention interventions, there is increasing evidence for multilevel systems approaches — using components ranging from individual‐level (eg, assertive aftercare, psychosocial interventions) to public health interventions (eg, general practitioner and gatekeeper training),14 in addition to indirect interventions (targeting risk factors). Critical to effectiveness is the degree of penetration of these services, based on early population modelling, and the types of factors likely to differentially affect communities, including indigenous communities. Improving quality, availability and access to programs and crisis support services is vital to preventing suicide,14 with the current crisis both creating new challenges and compounding pre‐existing systemic issues. While the mental health sector is rapidly mobilising to improve access and the government has been quick to revise the Medicare rebate in this regard, it is vital that resource allocation and innovation continues beyond the span of the physical distancing measures. While increasing telehealth services is critical, the health professionals available to support them are unlikely to increase to meet need, and blended services that include automatised digital components may be a more efficient solution. The additional $48.1 million in mental health funding announced in May 2020 is a positive step; however, further funding for evidence‐based prevention initiatives is more important than ever to alleviate demand on treatment services. In terms of suicide prevention, digital interventions may hold some utility for both at‐risk and actively suicidal individuals, especially where other health services are lacking.15 Of course, economies undergoing recessions by their very nature have significant financial constraints, and governments will inevitably have to review spending across all services. It is critical that these limited funds are directed toward the most viable and cost‐effective services. Importantly, not all groups are affected equally, and subgroup consideration is vital. In crisis periods, it can be the most disadvantaged groups that are disproportionately affected, and marginalised and at‐risk populations require specific attention. It is also important to consider that many of the adverse consequences of job loss, including house repossession, mounting debt, mental health problems and relationship strain, are delayed and, therefore, long term investment is required.16 Finally, engaging new technologies in the fight against suicide may present a valuable new tool. This includes information technology‐enabled coordinated care and the dynamic reporting of suicide risk using immediate and real‐time data so that developing hotspots can be identified and shut down and local services can be mobilised. Although this field of study is in its infancy, the potential for concepts such as integrated, geospatial mapping, hotspot surveillance, and real‐time reporting could lead to significant advancements in predicting and intervening in suicidal behaviour.17 Ultimately, the economic fallout resulting from the COVID‐19 pandemic represents a threat, requiring urgent mobilisation and planning. There are certain steps required to moderate the mental health impacts of widespread unemployment, including sustained welfare spending; labour market programs; adequate investment in, and access to, mental health treatment and prevention services; and the dynamic reporting of suicide risk to aid regional responses and means restriction. The current economic crisis presents an opportunity to implement policies that would not only mitigate the impact of the recession on suicide but may incidentally reduce the national health and economic burden presented by emotional distress in any economic cycle. In doing so, there may be the ability to emerge from the current crisis stronger and more resilient as a nation.

Mark Deady · Leona Tan · Nathasha Kugenthiran · Daniel Collins · Helen Christensen · Samuel B Harvey

The major impediments to control are lack of commitment, funding and coordination, not lack of knowledge It has been a long time coming, but Australia is starting to understand the tragedy and injustice of rheumatic heart disease (RHD) in Aboriginal and Torres Strait Islander people. No condition is more emblematic of “the gap”: in Australia, the burden of RHD is borne almost exclusively by Indigenous people, with rates among the highest in the world. It is a disease with social determinants, including poverty and overcrowded housing, it starts in childhood but stretches into adulthood, it kills people prematurely, and, most devastatingly, it is preventable. The major impediments to its being controlled or even eliminated are lack of commitment, funding and coordination, not lack of knowledge. Over the past five years, a network of researchers and service providers has come together in the National Health and Medical Research Council‐funded End Rheumatic Heart Disease Centre of Research Excellence. The Centre is about to publish The RHD Endgame Strategy: The blueprint to eliminate rheumatic heart disease in Australia by 2031. It has already modelled what will happen if we fail to alter course in RHD control: more than 10 000 Indigenous Australians will develop RHD over the next 11 years, of whom 563 will die and 1370 will require heart surgery as a direct consequence of RHD. More than $317 million would be needed for their medical care alone.1 Hearteningly, END RHD, a coalition of organisations led by the Aboriginal Community Controlled Health Organisation (ACCHO) sector, has formed to support communities at greatest risk of RHD, to advocate implementation of the Endgame Strategy, and to educate Australians about the role they can play in ending RHD. END RHD is co‐chaired by the chief executive officer of the National Aboriginal Community Controlled Health Organisation, Ms Pat Turner AM, and includes representatives from ACCHO peak bodies in each of the jurisdictions in which RHD is a major problem. END RHD embodies the essential elements of what is needed to rid Australia of this devastating disease: Indigenous leadership, community empowerment, and a primary focus on the social determinants of disease, in addition to strategies targeting streptococcal A skin and throat infections and care for people with established RHD. A study in this issue of the MJA2 highlights RHD care, other elements needed to implement the Endgame Strategy, and some of the challenges in doing so. Francis and colleagues report a cross‐sectional echocardiographic screening survey of children and young people in the remote Northern Territory community of Maningrida. They found an extraordinarily high prevalence of definite RHD (5.2% of screened people aged 5–20 years), of whom 62% had previously been undiagnosed and 25% had severe disease. This project had many admirable elements that could inform activities in other communities. The focus on education and health promotion in local languages, intense community engagement, and local leadership were exemplary, to which the very high participation rate is testament. However, a range of questions remain unanswered. Why, for instance, are the reported results so different from the findings of the gECHO study,3 conducted a decade earlier? In this study, in which almost 4000 Indigenous children aged 5–15 years in remote communities across northern and central Australia were screened, the prevalence of definite RHD was 0.86%; 53% of cases were previously undiagnosed, and only one in 18 new cases was severe. While the prevalence of definite RHD was highest in the Top End of the NT (1.5%), where Maningrida is located, the threefold difference in prevalence between the two studies is remarkable. A single community may not be representative of an entire region, but if the Maningrida findings are to stimulate consideration of more widespread screening, how one identifies communities in which it is warranted is critical. The difference in prevalence found by the two studies is difficult to explain. There is no evidence that socio‐economic determinants of group A streptococcal infections and RHD had dramatically worsened in this region over the past 10 years to a degree that would explain such discordance. However, four years prior to the study by Francis and colleagues, a large cluster of acute rheumatic fever (ARF) cases was identified in Maningrida: more than 1.5% of 5–14‐year‐old children developed ARF over a 6‐month period.4 As most people with RHD in the NT do not have known histories of ARF, and ARF can be very mild or even asymptomatic, it is likely that a substantially greater proportion of Maningrida residents had ARF at this time.5 Such a significant outbreak has rarely, if ever, been reported for an Indigenous community, and the study of Francis and colleagues may have included a number of RHD cases related the ARF outbreak four years earlier. Francis and his co‐authors also point out that auscultation is still used in child health checks in NT Indigenous communities. This approach, however, is less accurate than flipping a coin for diagnosing RHD, and should therefore be abandoned for this purpose.6 We commend the authors for the careful wording of their recommendations. They recognise that echocardiographic screening may have obvious benefits; besides detecting new cases of RHD and facilitating life‐saving treatment and secondary prevention, it is an excellent tool for motivating a community to focus on RHD, which, together with education about prevention and related activities, can enhance engagement. But it is also intensive and costly: hence the need to focus on more practical methods for implementation, as the authors point out, but also to ensure that communities are advised about a threshold for screening in accordance with established criteria. They must also be provided with adequate technical support and advice before embarking on such screening programs. Australia has a rare opportunity to eliminate RHD by implementing the Endgame Strategy. In so doing, we will make an important step towards closing the health gap between Indigenous and non‐Indigenous Australians, not only by reducing the burden of RHD but also the burdens of other diseases that share similar social determinants. But success depends on communities being supported to direct local strategies that comprehensively address streptococcal A infections, ARF and RHD at many levels. Maningrida is a perfect example.

Jonathan R Carapetis · Alex Brown

To the Editor: The great complexity and unmet need in rare diseases is highly challenging for the estimated two million Australians with a rare disease.1 The coronavirus disease 2019 (COVID‐19) pandemic has created enormous health, social and economic burdens, exacerbating the challenges and uncertainty facing people with severe, chronic and often disabling rare disease. Systemic, nuanced, flexible and coordinated responses are required. The vulnerability of rare disease patients is evidenced by the preliminary results of a global survey of over 5000 mostly European rare disease patients,2 which found that nine out of ten patients are experiencing interrupted care because of COVID‐19. Issues include frequent cancellation or postponement of surgeries and transplants, allied health and primary care or specialist appointments, and interrupted psychiatric care. There are reports of losing access to in‐home and hospital therapies and diagnostics, and of closures of hospitals and units that provide ongoing rare disease care. Over half of respondents with access to follow‐up care through hospitals chose not to attend in fear of contracting COVID‐19. Despite a relatively smaller Australian COVID‐19 burden, these sentiments are echoed locally. The Australian National Strategic Action Plan for Rare Diseases1 has three pillars: awareness and education; care and support; and research and data. This policy framework underpins rational, evidence‐based and evolving responses for Australians with a rare disease. The peak body, Rare Voices Australia, drew on the Action Plan to formulate a statement3 outlining measures to ensure the rare disease community is protected and considered in the national COVID‐19 response. Issues addressed in the statement include triage; clinical care guidelines informed by rare disease experts; continuity and coordination of care; stricter isolation and enhanced testing; and increased utilisation of digital health, including virtual clinics and telemedicine. Subsequently, Rare Voices Australia also called for governments to exercise flexibility around school attendance for rare disease families. Positively, the European survey2 revealed increased participation in telemedicine, with a high degree of satisfaction. Australian rare disease specialist clinics have historically provided care over vast distances. Australia's transition to telehealth therefore provides an opportunity to connect with families, particularly those with huge disease burden, within their community. This may enable transition to more person‐centred health care, a foundation principle of the Action Plan.

Gareth S Baynam · Carol Wicking · Kaustuv Bhattacharya · Nicole Millis

To the Editor: The use of Bluetooth‐enabled apps like Australia's COVIDSafe to contact trace people exposed to coronavirus disease 2019 (COVID‐19) raises challenging moral and public health questions. Leins and colleagues1 rightly note that such tracing may endanger human rights. Yet the ethical decisions for governments and citizens are complex. The absence of vaccines and effective treatments, and the significant asymptomatic transmission of SARS‐CoV‐2, compels reliance on traditional tactics of social distancing, quarantine and contact tracing.2,3 Although the added value of digital contact tracing over manual tracing remains uncertain, even marginal improvements may interrupt disease transmission, save lives and improve public health resourcing. This could especially benefit vulnerable and disadvantaged people who suffer disproportionate harms,4 without treating digital contact tracing as a “silver bullet”. Whether, and which, digital contact tracing options are warranted depends on tough cost–benefit judgements. COVIDSafe's centralised storage of data on Amazon's servers facilitates access by governments with extraordinary power to interfere in citizens’ lives. Alternatively, decentralised data storage on smartphones has privacy advantages — but providing individual app users with the discretion to act on notifications of potential exposure to COVID‐19 may compromise disease control efforts. A hard choice exists between allowing personal data to be accessible by democratically elected governments versus powerful technology giants like Apple and Google which support decentralised data storage.5 Even greater invasions of privacy have been proposed, however, with location tracking options such as Norway's Smittestopp app (https://helsenorge.no/coronavirus/smittestopp) promoted as necessary to understand community interactions and the effects of social distancing policies for current (and future) outbreaks. While Leins and colleagues highlight significant ethical drawbacks, a full ethical analysis of digital contact tracing must also weigh its potential benefits. Certainly, citizens should agitate for strong protections to prevent abuse of power and misuse of personal information. However, even when governments offer ethically suboptimal contact tracing options, it may be permissible and even a moral requirement, all things considered, for citizens to support options to help protect the community. For its part, the Australian government should recognise that deploying digital tracing without sufficient transparency and community and expert input leaves citizens with harder moral decisions.

Simon Coghlan · Marc Cheong · Benjamin Coghlan

Tetrahydrocannabinol‐containing (THC) products with vitamin E additives are implicated in the pathogenesis of EVALI Electronic cigarettes, or e‐cigarettes, are battery‐powered devices that heat liquids containing nicotine and other chemicals in order to produce vapour.1 “Vaping” is the act of inhaling the vapour produced by an e‐cigarette.1 First marketed in 2005, e‐cigarette use is viewed by many as less harmful than traditional cigarette smoking, and championed as a strategy for smoking cessation.1,2,3 A detailed discussion of e‐cigarette use in smoking cessation is available in the United States Surgeon General's 2020 report, and is beyond the scope of this article; however, the report states that “there is presently inadequate evidence to conclude that e‐cigarettes, in general, increase smoking cessation”.2 Thus far, no e‐cigarette product for the therapeutic purpose of smoking cessation has been submitted to Australia's Therapeutic Goods Administration for safety evaluation or approval. Vaping in the US was initially associated with nicotine‐containing solutions. However, it is important to note that nicotine or nicotine salts may no longer be the only active ingredient in vaping solutions.1,4,5 In particular, unregulated vaping solutions or “home‐brew” products that contain tetrahydrocannabinol (THC) oil, or cannabinoids, can be obtained in the US.4,6 Vaping solutions come in a wide range of flavours, many designed to appeal to adolescents.1,2 Indeed, e‐cigarette manufacturers have used celebrity endorsements and social media‐based marketing campaigns to target adolescents, and these strategies appear to have been highly successful.1,2 There has been significant uptake of vaping among tobacco‐naive high school students, particularly in the US, where it is estimated that one in four high school students are current e‐cigarette users;7 moreover, in 2019, 14% of year 12 students reported vaping cannabis in the preceding 30 days.8 Between 2011 and 2018, e‐cigarette use increased among US high school students from 1.5% to 20.8%, even when traditional cigarette use declined from 15.8% to 8.1%.9 Consequently, from 2017 to 2018, overall use of tobacco products (traditional and e‐cigarettes combined) increased from 19.6% to 27.1%.9 In contrast, e‐cigarettes use among adults in the US has remained largely stable at 8.1 million e‐cigarette users (3.2%).10 It is possible that for young non‐smokers, e‐cigarettes may normalise smoking and serve as a gateway to nicotine dependency and traditional cigarette smoking, although this is strongly debated.1,9 In 2016, the Australian National Drug Strategy Household Survey reported that e‐cigarette use within the 12–17 and 18–29 years age brackets was about 7.1% and 16% respectively.11,12,13 The 2017 Australian secondary students’ alcohol and drug survey found that 13% of students had used an e‐cigarette at least once.14 Of the 2410 students who used an e‐cigarette, 48% reported that they had never smoked a traditional tobacco cigarette before using an e‐cigarette.14 E‐cigarettes may be perceived by young people as “a cool new gadget” and “safer than smoking”.1 Unfortunately, it has become abundantly clear that the use of illicitly sourced e‐cigarettes can be dangerous.10 In 2019, disturbing reports emerged of an acute and, for some, deadly outcome from vaping.15 Across the US, e‐cigarette users began to be admitted to hospitals with acute respiratory failure. In August 2019, the first fatality was documented in Illinois, while 200 other cases across 22 states were under investigation by the Centers for Disease Control and Prevention (CDC).15 This epidemic has spread very rapidly. There have been over 2800 hospitalised cases reported from every US state and territory and a total of 68 deaths.16 Patients were predominantly male (66%) and under 35 years of age (76%).6 [Correction added on 2 July 2020 after first online publication: Information has been updated on the second last sentence.] The CDC has termed this new disease “e‐cigarette or vaping product use‐associated lung injury” (EVALI)17 and has proposed four obligatory criteria for its diagnosis: use of an e‐cigarette (“vaping”) in the 90 days before symptom onset;18 pulmonary infiltrates or ground glass opacities on x‐ray or computed tomography scan; absence of pulmonary infection (defined by negative respiratory viral panel, negative influenza polymerase chain reaction, negative urinary pneumococcal antigen and sputum culture including Legionella, and bronchoalveolar lavage [BAL] culture); and no evidence of an alternative plausible diagnosis such as a cardiac disease or a neoplastic process.17,18 Patients with EVALI typically present with both respiratory (dyspnoea, cough, fever) and gastrointestinal (nausea, vomiting, diarrhoea, abdominal pain) symptoms.15,19 Usually, there is no prior history of respiratory disease. Diagnosis may be challenging, as EVALI can mimic infective pneumonia and gastrointestinal symptoms may sometimes precede respiratory symptoms.15 Respiratory failure may be severe enough to require invasive ventilation and intensive care support.15,19 Imaging findings include ground glass opacities on chest imaging,20 suggesting diffuse lung injury with bronchiolitis obliterans and cryptogenic organising pneumonia.19 Pathologically, limited lung biopsies have shown acute lung injury, acute fibrinous pneumonitis and diffuse alveolar damage.21 “Foamy” or lipid‐laden macrophages are often seen, suggestive of lipoid pneumonia.15 Aetiology and pathophysiology of EVALI: reasons for its recent emergence Careful epidemiological investigation has revealed two key findings explaining the recent emergence of EVALI after more than a decade of e‐cigarette use. Firstly, 80% of hospitalised patients with EVALI have admitted to using THC vaping products.6 Eighty‐four per cent of the reported THC products were acquired via informal channels and were probably manufactured outside of regulated facilities.15 The CDC identified “Dank Vapes” — a group of largely counterfeit THC‐containing products — as the most commonly reported THC brand across the US and used by 56% of patients with EVALI admitted to hospital.6 In contrast, only 13% of hospitalised patients with EVALI reported exclusive use of nicotine‐containing products; however, traces of THC were found in BAL samples.6,19 There may be unreliable self‐reporting and it is possible that the nicotine e‐cigarettes may have been contaminated by black‐market THC additives. Most patients reported using combination products containing either THC, cannabidiol or nicotine.6 Secondly, there is mounting evidence that a specific additive to vaping solutions — vitamin E acetate — played a major role in the 2019 EVALI outbreak.19,20 It is hypothesised that vaping the vitamin E acetate oil causes direct lung injury and lipoid pneumonia.21 Supporting this, BAL fluid from 51 patients from 16 states diagnosed with EVALI yielded vitamin E acetate in 94% (48/51) of the BAL samples.19 In an analysis of the THC‐containing e‐cigarette products used by 12 patients, vitamin E acetate was found in products from 11 patients.19 It is likely that this substance was added as a diluent or filler, and this practice appears to be a very recent development.19 The same chemical analysis performed on THC e‐cigarette products seized in 2018 did not find vitamin E acetate.19 Current evidence shows that THC‐containing products with vitamin E acetate additives are implicated in the pathogenesis of EVALI.21 Given the outbreak has only manifested in the past 18 months, it is likely that the addition of these substances into e‐cigarette solutions is a very recent occurrence. The CDC outlines three broad tenets for treating suspected EVALI: cover possible infective agents with empiric broad‐spectrum antibiotics; administer systemic steroids (optimal dose unknown); and provide best supportive care with oxygen therapy and close monitoring.15,17,20 In mild to moderate cases, the decision to start steroids can be delayed until culture results exclude or identify potential infectious pathogens.17 In severe cases, systemic corticosteroids should be given early due to the potential life‐threatening nature of EVALI.20 There have been reports of progressive ventilatory failure despite administration of high dose steroids (methylprednisolone 1 mg/kg), with patients requiring extracorporeal membrane oxygenation.20 So far, there are no confirmed reports of EVALI in Australia. Unlike in the US, nicotine‐containing liquids are illegal in Australia and can only be obtained on medical prescription for personal use.11 The sale of e‐cigarettes to people aged under 18 years is also illegal.11 In practice, however, a 2015 survey of Australian e‐cigarette use found that 90% of users purchased e‐cigarettes and liquids from unregulated online stores.11 Even legal nicotine‐free liquids sold in Australia have been found to contain traces of nicotine and other toxic substances, with no regulation of products.22 Most Australian e‐cigarette users are therefore vulnerable to the possibility of potentially dangerous substances being added to solutions, as has occurred in the US. Conclusion Vaping THC oil contaminated with vitamin E acetate is linked with severe lung injury and death. With more than 2800 cases of EVALI reported and 68 deaths, e‐cigarettes are definitely not risk‐free. Australian clinicians should maintain vigilance and ask every patient about e‐cigarette use. Adults using nicotine‐containing e‐cigarettes as an alternative to cigarette smoking should not revert to tobacco smoking.2 A reasonable and precautionary strategy is to advise patients that little is known about the long term effects of e‐cigarettes, and also to inform users that severe lung disease and death have occurred mainly with unregulated solutions. We recommend further research and ongoing field monitoring of e‐cigarette usage patterns in Australia.

Maitri Munsif · Mark Hew · Eli Dabscheck

A rigorous and well supported primary care response to COVID‐19 is essential to protect the most vulnerable people in Australia In late December 2019, a pneumonia caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) was reported to the World Health Organization following identification in Wuhan, China. The outbreak was declared a public health emergency of international concern on 30 January 2020 and a pandemic on 11 March 2020. The respiratory disease complex was officially renamed coronavirus disease 2019 (COVID‐19) on 11 February 2020. On 27 February 2020, the Prime Minister of Australia announced the activation of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID‐19).1 Australia has a strong system of primary care provided by doctors, nurses and other health care workers, including allied health professionals, midwives, community pharmacists, dentists, and Aboriginal health workers. Comprehensive primary care services are available to all members of the community through general practice and Aboriginal community‐controlled health services, provided by general practitioners, primary care nurses, allied health and other health care professionals working at the forefront of the health system. Many of the nation's most vulnerable people also access services through aged care, home care and disability care services. Australia's primary care response to COVID‐19 acknowledges the need to protect vulnerable populations,2 to continue the provision of regular primary care services to the whole community for acute and chronic conditions, preventive care and mental health concerns,3 and the need to support and protect health care workers in community settings4,5 as well as in the nation's hospitals.6 In early March 2020, a targeted action plan was initiated by the Australian Government Department of Health to develop and refine the national COVID‐19 primary care response (Box 1). This action plan acknowledged the essential, first‐contact role of general practice in the nation's pandemic response,7 and was informed by lessons from previous epidemics and pandemics where primary care had limited involvement in both planning and response8,9 and by focused consultation with primary care stakeholder organisations. Consultation included a Primary Care COVID‐19 Preparedness Forum, led by Australia's Chief Medical Officer and held on 6 March 2020 with representatives from general practice and other medical specialties, nursing, allied health, pathology, pharmacy, practice management, rural workforce, Aboriginal and Torres Strait Islander health, the disability sector, Primary Health Networks, and federal, state and territory governments. The Australian Government also established the National Aboriginal and Torres Strait Islander Advisory Group on COVID‐19, co‐chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO). Issues considered in the framing of the primary care response included measures required to protect both the public and the primary care workforce from infection, the management of people presenting to general practice with fever and/or respiratory symptoms, the continued health care management of vulnerable people at increased risk of COVID‐19, concerns about seasonal influenza in winter, arrangements for pathology testing in the community, and the impacts on business continuity for community‐based health services. The primary care response was supported by a funding package of $2.4 billion announced by the Australian Government on 11 March 2020, which included $1.1 billion specifically allocated to support the COVID‐19 response in primary care.10 Key components of the primary care response included: funding of a whole of population model of telehealth (using telephone or video consultations); establishment of call centres to triage people with fever or respiratory symptoms, provide advice and direct them to the most appropriate health services; establishment of a nationwide network of respiratory clinics based in the community to complement state‐ and territory‐run fever clinics; development and delivery of online infection prevention and control training for all care workers; measures to safeguard the health of the members of remote Aboriginal and Torres Strait Islander communities across the continent; and ensuring consistent messaging to members of the nation's primary care workforce. Telehealth New funding provided through Australia's Medicare Benefits Schedule (MBS) enabled a shift to the use of telehealth modalities for all appropriate consultations between patients and their health care providers. Telehealth initiatives were rolled out in a rapid, staged approach: beginning with support for the use of telehealth for members of the nation's most vulnerable populations; followed by items specific to obstetrics and midwifery, nurse practitioner care, and mental health care provision; then measures to enable vulnerable health care providers to continue providing care through telehealth; and then moving to whole of population telehealth consultations for all patients by all health care providers funded under the MBS (Box 2). On 30 March 2020, bulk‐billing incentives for people with concession cards and children aged under 16 years being seen in general practice were doubled to ensure there were no barriers for the population needing to access health care services and advice, and additional payments were introduced to support the ongoing viability of the nation's general practices.11 At the time of writing (2 June 2020), over 11 million telehealth services had been delivered to the people of Australia. National call centre People with fever or respiratory symptoms, or with concerns about possible exposure to COVID‐19, were encouraged to call Healthdirect — the Australian Government‐funded national call centre that provides free health information and advice. Healthdirect activity peaked at around 37 000 calls from members of the public per week in mid‐March 2020. The Healthdirect website also provided an online COVID‐19 symptom checker, which can be downloaded as an application for mobile phones and other devices (www.healthdirect.gov.au). Since 25 March 2020, up to 370 000 people per day have used the symptom checker. General practice‐led respiratory clinics Evidence from prior epidemics has demonstrated that neglect of usual care can be an unintended consequence of prioritising the emergency response, resulting in increased morbidity and mortality related to other causes.3,12 The establishment of a network of more than 120 general practice‐led respiratory clinics has redirected people with fever and/or respiratory presentations away from general practices and emergency departments. Primary Health Networks have had a crucial role in supporting general practices and Aboriginal community‐controlled health services, working with their local hospital networks to identify and help establish respiratory clinics. In addition to protecting other patients and health care staff from potential infection, the respiratory clinics allowed other general practices across the country to continue providing regular essential primary care services to their patients. Online infection prevention and control training A series of online education modules was created to provide consistent, evidence‐based information to health care workers and others working in community settings with vulnerable people. This series included eight modules targeting residential aged care workers and a 30‐minute online course, targeting all care workers, including those working in hospitals, primary care, aged care and disability care.13 It provided education on aspects of infection prevention and control for COVID‐19 and has been completed by over 800 000 health care workers at the time of writing. Protection of remote Aboriginal and Torres Strait Islander communities The primary care response recognised that Aboriginal and Torres Strait Islander people, as well as other people living in remote communities, are at increased risk of COVID‐19, due to pre‐existing health issues, difficulties with service access and high population mobility. Building on the strength of Aboriginal and Torres Strait Islander leadership and on measures initiated by many communities themselves, on 26 March 2020, the Australian Government enacted biosecurity restrictions on entry and travel to remote communities. Grants were provided to support remote communities in self‐determining appropriate planning and preparedness activities, adapting national plans and protocols for local use to enable early retrieval and evacuation of suspected cases, and establishing the mechanisms to support responses to any outbreak, including the deployment of appropriate health care workers. Communication with members of the primary care workforce Regular webinars with primary care doctors, nurses, mental health and allied health professionals were initiated, along with regular teleconferences with the representatives of national primary care professional organisations, with the aim of providing consistent and ongoing two‐way communication with the nation's primary care workforce.14 Since 19 March 2020, there have been over 100 000 live views of online webinars and over 130 000 accesses of online newsletters, along with use of the content by medical media outlets and reproduction by national professional organisations in their own newsletters and emails to their membership. The primary care response was supported by a series of government fact sheets and other COVID‐19‐specific resources developed to assist the primary care workforce in knowing how to protect their patients and themselves from COVID‐19. These have been made publicly available at www.health.gov.au. Primary Health Networks supported these initiatives through the provision of updates about the management of people with suspected or diagnosed COVID‐19. Conclusion Lessons from previous epidemics and pandemics have emphasised the critical importance of engaging early and effectively with primary care4 and the need for a single source of trusted information from health authorities for both clinicians and members of the public.5,15 Australia's primary care response has sought to achieve this, through early collaborative planning and ongoing two‐way communication with the nation's primary care workers. The Australian Government's investment in primary care during the COVID‐19 pandemic is an investment in essential elements of the nation's health system, enabling optimal frontline care while mitigating spread and protecting the ongoing health of the nation's most vulnerable citizens. Box 1 – Aligning Australia's coronavirus disease 2019 (COVID‐19) response with existing knowledge The known: Lessons learnt from previous epidemics and pandemics emphasise the frontline role of primary care and the need for strong, consistent communication with the primary care workforce and the wider community The new: Australia's primary care response to COVID‐19 has seen rapid implementation of initiatives to protect the nation's most vulnerable citizens, preserve existing health system function, support and treat people with COVID‐19, and optimise workforce capacity The implications: Australia's investment in the primary care response to COVID‐19 is enabling effective frontline care while mitigating spread, and protecting the ongoing health of the nation's most vulnerable people Box 2 – Staged introduction of Australia's coronavirus disease 2019 (COVID‐19) telehealth response Stage/date Description Stage 1 (13 March 2020) General practitioner consultations using telehealth for patients aged at least 70 years, Indigenous people aged at least 50 years, pregnant women, parents of children under 12 months of age, and those who are immunocompromised or have a chronic medical condition resulting in increased risk from coronavirus infection Stage 2 (16 March 2020) Supporting telehealth consultations by obstetricians, midwives, nurse practitioners, and some mental health providers Stage 3 (23 March 2020) Enabling vulnerable GPs and other medical specialists (in the same categories as in Stage 1) and providers authorised to use telehealth item numbers to provide care for their patients using telehealth Stage 4 (30 March 2020) Extending existing telehealth items to all Australians. This included a substantial investment in mental health support, with specific commitments to children and young people, older Australians, and health care workers Stage 5 (6–20 April 2020) Supporting expanded telehealth for many specialist medical services and allied health services, including consultant physicians, psychiatrists, geriatricians, public health physicians, neurosurgery, chronic disease management by nurses and Indigenous health workers, and group psychotherapy

Jane Desborough · Sally Hall Dykgraaf · Lucas Toca · Stephanie Davis · Leslee Roberts · Catherine Kelaher · Michael Kidd

Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable. Our subacute sector is presently able to deal with patients requiring rehabilitation. However, rehabilitation needs following COVID‐19 are broad, complex and include cognitive, motor and respiratory sequelae to the infection, acute respiratory distress syndrome, and the thromboembolic response. Planning and anticipatory action has been Australia's strength so far. In the same vein, an active planning approach is now required for the post‐acute and rehabilitation response. This pandemic will inevitably have its waves, and will continue to threaten until a vaccine is rolled out. Not having a plan for possible surges is unconscionable, particularly when the consequences of the relaxation of restrictions are unknown. Currently, Australian numbers are at a trickle; however, the challenge has been front and centre in countries such as Italy,1 Spain, the United Kingdom and North America.2 In Wuhan, China, 36% of those with severe COVID‐19 had neurological complications such as stroke, critical care neuropathy, and the complications of prolonged bed rest (eg, venous thromboembolism, disseminated intravascular coagulation, acute kidney injury, delirium anxiety, post‐traumatic stress disorder).3 In Italy, rehabilitation physicians have been treating post‐extubation dysphagia, impaired mobility, critical care myopathy and neurocognitive losses,1 while the British Society of Rehabilitation Medicine has established a framework of partnership with acute services to improve patient flow, outcomes and access to ventilators.4 In the United States, hospitals have had to rapidly transition acute patients to rehabilitation hospitals. In New Orleans, a 1000 bed post‐acute hospital was dedicated to post‐COVID‐19 disability, with rehabilitation teams treating patients battling persistent hypoxia, stroke and mental illness.5 The majority of patients who are ventilated for more than 7 days suffer complications that require rehabilitation, 60% are unable to walk, and 17% die within a year.7 One‐third suffer neurological complications, many require inpatient rehabilitation for over 3 weeks, and some take over 150 days to regain their capacity to walk independently.8 Others with stroke or cardiac complications of COVID‐19 will require rehabilitation for up to 6 weeks, with some requiring lifelong support. Australia needs to plan now, not just for survivors in the initial post‐acute stage, but also to manage individuals affected in subsequent waves. Such patients may require rehabilitation, along with those, fearful of infection, who present to hospital late with non‐COVID‐19 conditions like stroke, and those with deteriorating chronic diseases who have not had access to hospital based services. That means not only estimating the patient population but also ensuring that subacute health workers have sufficient access to personal protective equipment, staffing and training. In the Australian Government's emergency response plan,9 the recovery phase devolves to the states, but there is no mention of the post‐acute phase. In April, the New South Wales Ministry of Health established a rehabilitation community of practice to advise it. This follows international experience, as the International Society of Physical and Rehabilitation Medicine's disaster committee lead, Australia's Fary Khan states: “early rehabilitation reduces disability and improves clinical outcomes”.10 Currently, many rehabilitation units are not prepared. Inpatient rehabilitation units (public and private) are almost always working to capacity. COVID‐19 patients will be expect to be accommodated in addition to usual patients (eg, strokes, spinal injuries, amputations). The NSW Rehabilitation Community of Practice has developed a staged COVID‐19 escalation plan,11 but the plans turn on one integral point — contagion. When COVID‐19 survivors come to rehabilitation wards will they no longer be infected? While a national statement exists,12 local de‐isolation protocols are yet to be implemented or updated in many hospitals and local health districts. Many people with severe COVID‐19 have positive nasal swabs for up to 37 days13 but are not considered infectious once 10 days have elapsed from after first symptoms. Attention to this timetable is critical should we need to make ICU beds readily available by shifting patients to rehabilitation. In some US rehabilitation hospitals, patients are assumed to always be infectious, which has a significant impact on personal protective equipment usage. To ensure de‐isolation, moderate and severe COVID‐19 patients transferring to rehabilitation must have negative swabs on 2 consecutive days, be symptom‐free for 2–3 days and be at least 10 days from symptom onset. In NSW, these criteria are currently being put in place and such a protocol will require discussion, review of the evidence, and leadership to execute. Once we have a de‐isolation protocol, we can confidently activate a staged escalation plan. While our ICUs are coping with current numbers, our subacute sector has been managing with innovative models of care, such as mobile rehabilitation teams.14 The NSW Rehabilitation Community of Practice's COVID‐19 response principles11 refer to mobile rehabilitation teams, variously called ART (acute care rehabilitation team) or SMART (specialist management with acute rehabilitation treatment) teams. They provide rehabilitation and discharge planning services to patients in the acute hospitals. It is a parallel care model in partnership with acute care that has been successful in decreasing length of stay and facilitating early discharge or transfer to inpatient rehabilitation facilities. These teams have discharged almost 50% of their patients directly home, avoiding inpatient rehabilitation admissions, and have been active in many NSW hospitals since 2009. Once home, tele‐rehabilitation physician consultations, supported by community‐based allied health practitioners, can be delivered, although additional resources are still being sought. Similar models exist or are under development in other jurisdictions as well. In the event that our acute hospitals start to face challenges in accommodating those needing COVID‐19 or ICU beds, the subacute sector will need to escalate to the next stage to create access. Options include decanting non‐COVID‐19 patients to the private sector, increasing resources to acute or mobile rehabilitation teams, scaled up tele‐rehabilitation services, and preparation for public hospital rehabilitation inpatient units to manage COVID‐19 patients. However, in order to decant to the private sector we need completed agreements with private hospitals, as flagged on 31 March by the Minister of Health.15 Many private hospitals have facilities that are well suited for rehabilitation patients. This would require delineating private hospitals as COVID‐19‐free facilities and would be dependent on appropriate triage and testing facilities. Managing the logistics will be a challenge in the subacute sector, particularly if planning is left as an afterthought. The efficient flow of disabled COVID‐19 patients from acute to rehabilitation care will likely produce better patient outcomes and improve safety. Egress from acute hospitals means access to intensive care and ventilation for the community. If Australia and New Zealand's success at flattening the curve continues, our existing subacute sector will manage. If not, mobile rehabilitation teams will need to be expanded, systems for patient flow to the private sector will need to be operational, and enhanced tele‐rehabilitation services will need to be working. This will require the same vision and leadership that made our acute COVID‐19 response world leading, collaborative and publicly supported. In the UK and the US, we see the brutality of this pandemic, with mass burials and the tragic toll on health care workers. Australia and New Zealand have avoided this so far, but it is because we have planned well. We now need to prepare for the recovery phase because surviving may not be the same as living.

Steven G Faux · Kathy Eagar · Ian D Cameron · Christopher J Poulos

To the Editor: There is marked concern among health care workers in Australia regarding the safety of caring for patients with coronavirus disease 2019 (COVID‐19), which partly relates to highly publicised reports of health care workers dying from COVID‐19 overseas. The concern has caused high levels of anxiety in many health care workers, the use of personal protective equipment (PPE) outside of government guidelines, and many seeking exemptions from being involved in the care of patients with COVID‐19. The reports of health care worker deaths overseas generally do not explore whether the infection was contracted caring for patients or through community contact, or whether appropriate PPE was worn. In March 2020, a clinic was established to screen staff from Royal Melbourne Hospital and neighbouring hospitals who had developed a fever or new respiratory symptoms. A targeted history was taken and a swab was performed according to public health department recommendations at the time. In addition to this, a public screening clinic run by the hospital was also available for health care workers practising in the broader community, so those working in non‐hospital settings could be identified and tested. At 6 April 2020, 1160 symptomatic staff had been assessed in the staff clinic and the majority had been swabbed for COVID‐19, while a number of health care workers also attended the public clinic. Across both staff and public screening clinics, 11 health care workers were found to be positive for COVID‐19. Of these, eight had a history of travel or close contact with a COVID‐19 case in the community. The other three had no obvious COVID‐19 contact in the workplace, during a period when fewer than ten patients with COVID‐19 were treated at the hospital. Two of the staff, while identifying as health care workers, did not work in a clinical hospital setting and were judged to be at low risk of contracting infection from an unwell patient in their workplace. The other worked in a hospital ward where no known COVID‐19 infected patients had been managed. Although a dedicated service for screening and supporting staff may not be feasible in all settings, it does provide access to rapid testing which gives valuable reassurance for staff. Importantly, monitoring the data helps to contextualise our local experience. These data indicate that COVID‐19 is very uncommon in health care workers at present, and that the large majority who have contracted COVID‐19 have done so away from work. There is already intensive training in the use of appropriate PPE in the workplace, and we continue to reassure health care workers that this affords high level protection. Victorian census data in 2016 suggest that approximately 12% of adults identify as health care workers,1 which gives some context to the state‐wide data suggesting that 11% of positive cases to date have occurred in health care workers.2 This is not to trivialise the risk that frontline health care workers face, particularly when caring for unrecognised cases without using PPE. Our data show that currently, community acquisition of COVID‐19 is likely to be occurring in health care workers more often than work‐related acquisition. Health care workers should focus on taking measures (eg, social distancing and hand hygiene) to protect themselves from COVID‐19 when away from work. Ongoing monitoring of the epidemiology related to staff clinic presentations may help provide information on local risks.

Stephen Muhi · Louis B Irving · Kirsty L Buising

How to deal with diabetes and COVID‐19 — do we just dial in? The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the subsequent announcement by the World Health Organization of a global pandemic, has altered health care across the public and private sectors. Clearly, coronavirus disease 2019 (COVID‐19) is having a huge impact on general practitioners, emergency physicians, respiratory physicians, intensivists and related staff, and is also impacting the day‐to‐day delivery of chronic health care. Conditions such as type 1 and type 2 diabetes require regular, usually face‐to‐face contact with GPs, endocrinologists, diabetes educators, dieticians and podiatrists to optimise glycaemic control. However, with recommendations regarding social isolation to minimise spread of COVID‐19,1 the delivery of such health care is increasingly being delivered using telehealth. This has been greatly facilitated in Australia with the announcement of temporary Medical Benefits Schedule telehealth (videoconference and telephone) item numbers during the COVID‐19 pandemic.2 The eligibility criteria for bulk‐billing include individuals who are immunosuppressed or with chronic health conditions, which include diabetes mellitus. Significantly, the eligibility criteria also include pregnancy. At a time when individuals are being asked to socially isolate to minimise exposure to SARS‐CoV‐2, many who greatly need ongoing health care are avoiding these appointments out of fear of infection from those also attending the clinic and perhaps from clinicians, who are recognised to be at high risk of infection. It is therefore crucial that telehealth care services are offered (and if not available, fast tracked). This may be via videoconference, or a phone call for those who are less able to use newer technologies or if videoconferencing services are not available. Services traditionally offered in a group setting, such as group education for those with gestational diabetes or type 2 diabetes, may also be delivered via this technology. The use of diabetes management technology can benefit health care and telehealth consultation. Continuous or flash glucose monitoring can be used with both type 1 and 2 diabetes with therapeutic benefit. Many of these devices upload automatically to cloud‐based software. Other devices such as insulin pumps and blood glucose meters can be uploaded by the user before the consultation, which places a greater burden on the individual. Involvement of parents, carers and diabetes educators before the appointment may be of benefit. This may lead to improvements in individual diabetes self‐management. The electronic medical record is vital in updating changes to medications, results and scheduled appointments. Many pathology providers facilitate electronic access to test results, but anecdotally some patients may avoid having pathology tests taken in order to minimise travel and exposure to others. The individuals who are at greatest risk of complications from COVID‐19 are still being determined. It seems clear that those with diabetes and other chronic comorbidities are at increased risk of morbidity. A number of small observational studies have analysed comorbidities in individuals with severe SARS‐CoV‐2 infection from China. Rates of diabetes (type unspecified, but most likely to be type 2 diabetes given the low incidence of type 1 diabetes in China3) are reported between 7.4% in confirmed cases infection,4 and up to 17% in cases with severe pneumonia.5 A recent meta‐analysis of six studies (including 1527 people) analysed the prevalence of comorbidities among individuals with severe and non‐severe COVID‐19.6 Diabetes complicated 11.7% of severe cases compared with 4% of cases of non‐severe COVID‐19. This did not reach statistical significance; however, this is clearly limited by a lack of statistical power and further analyses are required. Retrospective analysis of survivors and non‐survivors of the 2002–2003 SARS coronavirus outbreak suggested that diabetes was a predictor for mortality.7 This association seemed to be driven by glycaemic control, with an independent association with elevated fasting plasma glucose. This further highlights the need to maintain ongoing medical care to optimise glucose control throughout the current COVID‐19 pandemic. All people who currently smoke should be advised to cease smoking. In addition, receiving the recently available influenza vaccine, which is usually recommended for people with diabetes, would be advisable, although patients should be aware that this will not protect against COVID‐19. Individuals with both type 1 and type 2 diabetes need to have clear action and sick day plans in the eventuality that they become unwell, and should be encouraged to seek face‐to‐face care for complications such as myocardial infarction or high risk foot ulcer. This should be emphasised even for individuals with long standing diabetes, whose initial diabetes education may have occurred years ago. Individuals with type 1 diabetes should have ketone monitoring strips available (preferably blood continuous subcutaneous insulin infusion ketone test strips), know when to test for ketones, and be aware of the need for additional insulin doses (via injection or continuous subcutaneous insulin infusion) during an intercurrent illness. Excellent sick day management resources are available on the websites of the Australian Diabetes Educators Association (https://www.adea.com.au) and National Diabetes Services Scheme (https://www.ndss.com.au). Individuals using hybrid closed loop insulin pumps should be educated that during illness the wearer may need to exit automatic mode to enable more rapid correction of hyperglycaemia with manual correction boluses of insulin and a temporary increased basal rate.8 The algorithm within the hybrid closed pump may otherwise not adapt quickly enough to manage hyperglycaemia during acute illness. With the increased use of sodium–glucose cotransporter type 2 (SGLT2) inhibitors in Australia and internationally, all individuals treated with SGLT2 inhibitors should be educated on the need to withhold these drugs during illness to minimise the risk of ketoacidosis.9 This should be reiterated to GPs and emergency physicians to screen for SGLT2 inhibitor use in patients presenting with COVID‐19 or any illness. There have been mixed anecdotal reports as to whether non‐steroidal anti‐inflammatory drugs (NSAIDs) may predispose patients to COVID‐19. There has been suggestion that NSAIDs may upregulate angiotensin‐converting enzyme 2 (ACE2),10 and therefore potentially predispose by a similar mechanism suggested for angiotensin receptor blockers (ARBs). Currently there are no guidelines to avoid the use of NSAIDs. In relation to COVID‐19, there is also increasing interest in the use of ACE inhibitors and ARBs in individuals with type 1 or type 2 diabetes and other chronic care conditions, such as diabetes. SARS‐CoV‐2 binds to ACE2, allowing entrance into the host cells.11 ACE inhibitors and ARBs can result in upregulation of ACE2 in some tissues in both human and animal models.10,12,13 However, not all investigators have found a link between these antihypertensives and upregulation of ACE2.14 It has been proposed that ACE inhibitors and ARBs may theoretically increase susceptibility to COVID‐19 by increasing ACE2 levels. However, there is currently no evidence to link the use of these agents to increased risk or severity of COVID‐19. Indeed, other research groups have hypothesised that the use of ARBs may be a potential therapeutic modality.15 Following SARS‐CoV‐2 binding to ACE2, there is downregulation of ACE2 with subsequent increased angiotensin levels and exacerbation of COVID‐19 related lung injury. It has been proposed that the downregulation of ACE2 by ARBs might protect against such injury.15 Other groups have suggested that ARBs may stabilise the binding of ACE2 to the type 1 angiotensin receptor and may therefore reduce available binding sites for SARS‐Cov‐2.16 Currently, there is no evidence to suggest changing antihypertensive therapy, and multiple national and international bodies including the Australian Diabetes Society, Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and the American College of Cardiology and European Society of Hypertension have recommended that ACE inhibitors and ARBs should not be ceased.17 Trials are currently underway to assess the impact of these agents during COVID‐19 infection (https://clinicaltrials.gov). Patients should be encouraged to continue their ACE inhibitor or ARB drugs, and if not prepared to do so, be offered alternative drugs for blood pressure control. This is a time of great concern to all individuals, and perhaps more so to those who have been informed they are at greater risk of COVID‐19 and its complications. This may necessitate a greater state of preparedness. The current advice is that there will be no shortage of insulin supplies or consumables needed for insulin pump therapy or blood glucose monitoring equipment, yet anecdotally, local pharmacy shortages of insulins, ketone strips and oral hypoglycaemic drugs have been reported and are being addressed by government prescription limits. Should patients be unable to obtain their usual prescriptions, suitable alternatives can be recommended to them by their diabetes care clinicians. It is critical that individuals with diabetes and other chronic conditions do not hoard these medical supplies and inadvertently create a critical supply shortage. Continuation of health care to at‐risk individuals is crucial throughout the pandemic. Telehealth is the key for the delivery of such care. It is important that people with diabetes are educated regarding the management of their condition during acute illness, including medication changes. It is also critical that there is no deterioration in the medical management of glycaemia and other complications of diabetes, which, if neglected, may result in increased morbidity and mortality independent of COVID‐19.

Emma S Scott · Alicia J Jenkins · Gregory R Fulcher

A fresh examination of potentially preventable hospitalisation rates gives new insights and strategic direction Australia lies at a critical juncture for health reform. In August 2019, the Minister for Health, the Honourable Greg Hunt MP, released Australia's Long Term National Health Plan,1 a 24‐page document anticipating the imminent initiation of a 10‐year Primary Health Care Plan. In October 2019, the Minister announced experts to provide independent advice for this purpose.2 With their counsel, this 10‐year Primary Health Care Plan will set a path to guide future primary health care reform. This undertaking behoves laser‐like focus on population‐based system‐level indicators. Potentially preventable hospitalisations (PPHs) comprise a nationally agreed set of 22 specific conditions selected through precise rationale.3 Hospitalisation for any one of those diagnoses is potentially prevented through effective community‐based primary health care.3 Total PPHs reflect a holistic system‐level indicator calculated by combining hospital admissions for all 22 agreed conditions from routinely collected data. As national coding requirements ensure consistency across jurisdictions, age‐standardised PPH rates per 100 000 people permit comparisons over time and place. While it is tempting to focus on one or several individual conditions, it is the total age‐standardised PPH rate that best reflects the integrated functioning of primary health care in that location.4 We accessed 2017–2018 age‐standardised total PPH rates for all 331 Statistical Areas Level 3 (SA3).5 As geographical footprints, SA3s provide a regional breakdown of Australia. Each SA3 has a population between 30 000 and 130 000 people and often closely aligns with the local government area.6 Total PPH rates are inequitably distributed in Australia, with the highest rates clearly visible in SA3s in remote and very remote regions (Box 1). We note the national median PPH rate is 2742 per 100 000, but PPH rates by SA3 are highly skewed (Box 2). The ten SA3s demonstrating the worst PPH rates each feature rates more than double the national median. Indeed, the highest PPH rate (26 661 per 100 000 population in Barkly, Northern Territory) is more than 16 times the lowest (1662 per 100 000 population in Stonnington East, Victoria). We then ranked PPH rates by deciles, noting the first decile comprises the 10% of SA3s across Australia with the best (lowest) PPH rates, while the tenth decile comprises the 10% with the worst (highest) rates. This distribution is also inequitable, exhibiting marked variation between states and territories (Box 3). Median PPH values for Queensland and the NT fall in the eighth and tenth worst deciles respectively (Box 3). Given that 75% of the SA3s in the Australian Capital Territory rank in the best two deciles for SA3s nationally, bureaucrats residing in the nation's capital may have limited awareness of the daily reality of system‐level health inequity elsewhere. Unabated continuation of inequities in the performance of primary health care compromises the health and wellbeing of Australians living every day in these locations. High total PPH rates also place relentless pressure on hospitals already showing strain. In response, recapitalisation of comprehensive primary health care as the foundation of the Australian health care system requires serious, proportionate and long term resource reallocation within health budgets across Commonwealth, state and territory governments. A fair and functional frontline primary health care system was assumed as a viable platform for the nation's coronavirus disease 2019 (COVID‐19) response.7 PPH rates provide much‐needed insight into geographic health inequity and emphasise the importance of strategic focus. A meaningful national mandate to reduce the size of the gap in age‐standardised total PPH rates between the lowest and highest SA3 deciles should be implemented through the 10‐year Primary Health Care Plan. It is also important to identify mechanisms to shift skew and median values by jurisdiction towards the best attainable rate. In addition, an explicit goal could be set in every SA3 to deliver a specific time‐based trajectory for total PPH rates. These strategic imperatives are the Minister's to set. Health care reform requires political leadership. In the Plan, there should be arrangements for continuous public monitoring of significant quantitative improvement in total PPH rates. At the very least, substantial new funding for local rejuvenation of primary health care in all SA3s in the worst decile should be prioritised. If not, we fail Australians living in these locations yet again. Box 1 – Distribution of potentially preventable hospitalisation (PPH) rates by Statistical Area Level 3 (SA3) in Australia Box 2 – National distribution of age‐standardised potentially preventable hospitalisation (PPH) rates per 100 000 population by Statistical Area Level 3 (SA3) Box 3 – Distribution by decile of age‐standardised total potentially preventable hospitalisation rates at Statistical Area Level 3 (SA3) by state and territory Decile (%) Total SA3s Jurisdiction 1 2 3 4 5 6 7 8 9 10 ACT 3 (38%) 3* (38%) 1 (12%) 1 (12%) 0 0 0 0 0 0 8 (100%) NSW 15 (17%) 15 (17%) 10 (11%) 10* (11%) 6 (7%) 8 (9%) 12 (13%) 5 (5%) 7 (9%) 1 (1%) 89 (100%) WA 4 (12%) 4 (12%) 5 (15%) 6* (18%) 4 (12%) 4 (12%) 2 (5%) 0 2 (5%) 3 (9%) 34 (100%) Tas 3 (20%) 1 (7%) 0 4* (27%) 4 (27%) 1 (7%) 0 2 (5%) 0 0 15 (100%) SA 2 (7%) 3 (11%) 5 (18%) 2 (7%) 7* (25%) 1 (3%) 4 (15%) 1 (3%) 0 3 (11%) 28 (100%) Vic 4 (6%) 6 (9%) 8 (12%) 6 (9%) 8 (12%) 13* (20%) 10 (15%) 7 (11%) 3 (4%) 1 (2%) 66 (100%) Qld 2 (3%) 1 (1%) 3 (4%) 4 (5%) 5 (6%) 6 (7%) 5 (6%) 18* (22%) 20 (24%) 18 (22%) 82 (100%) NT 0 0 1 (11%) 0 0 0 0 0 1 (11%) 7* (78%) 9 (100%) Total number of SA3s in each decile 33 33 33 33 34 33 33 33 33 33 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; Qld = Queensland; SA = South Australia; Tas = Tasmania; Vic = Victoria; WA = Western Australia. * Indicates the decile in which the jurisdiction's median potentially preventable hospitalisation rate lies.

Gemma C Ma · Jeanette E Ward

OECD data indicate that Australia is a comparatively high user of residential aged care The Royal Commission into Aged Care Quality and Safety interim report highlighted many concerns about aged care in Australia.1 These include that “the system designed to care for older Australians is woefully inadequate”, and that “aged care services … have simply not been seen as a priority by successive Australian Governments”. To inform the Royal Commission, we undertook a review of international approaches to the provision of aged care.2 As a component of our review, we examined data reported to the Organisation for Economic Co‐operation and Development from 13 countries.3 The list of countries included in the review was developed in consultation with experts and with input from representatives from the Royal Commission. Countries were selected based on the availability of information, applicability to the Australian aged care system, and to ensure a diverse range of countries were represented. Long term care is the provision of services for medical needs, personal care and assistance in living independently for people with long term dependencies due to their health care needs. Long term care can be provided in institutions (eg, nursing homes or residential aged care facilities) or by providing services to assist people to remain living in their own homes, including community services such as respite care. The OECD defines long term care institutions as specifically designed nursing and residential care facilities that provide accommodation and care as a package, with the predominant service being care. Institutional long term care recipients are those receiving formal long term care in institutions other than hospitals. We compared numbers of older long term care recipients in institutional care (12 countries) and estimates of long term care expenditure for older people (12 countries) (Box). Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations (Box). The relative use of institutional care, as opposed to home or community care, was also highest for Australia, with 52.5% of long term care recipients aged ≥ 65 years and 58.6% of long term care recipients aged ≥ 80 years in institutional care. This is in comparison to a range of 21.6% in Japan to 34.6% in the Netherlands for recipients aged ≥ 65 years, and 23.1% in Japan to 41.8% in Canada for those aged ≥ 80 years (Poland is an exception, with institutional care provided for 94.1% of long term care recipients aged ≥ 65 years, and 100% aged ≥ 80 years, based on 2006 data; however, long term care is highly limited, with only 1.6% of the population aged ≥ 80 years receiving care). Our estimates of gross domestic product (GDP) expenditure on long term care for older people comprise the health component of government/compulsory long term care expenditure (not age‐specific) plus social expenditure on old age benefits in kind, as reported to the OECD. This approach best captures Australia's long term care expenditure on older people. Benefits in kind are services such as the home care packages program. However, this estimate does not capture cash benefits such as the carer allowance in Australia or direct cash payments that are a component of aged care benefits in some other nations (eg, Germany, England, Poland). In the OECD database, these payments cannot be separated from non‐care related cash provisions for older people, such as the age pension. The expenditure estimates indicate that many other nations spend a much greater proportion of their GDP on long term care for older people (Box). Different approaches to funding are used in other countries, including the provision of universal social care insurance, some of which includes compulsory contribution schemes such as in Japan and Germany.5 Limitations in these international comparisons include possible differences between nations in reporting or definitions of institutions, lack of data on the dependency levels of care recipients, and comparisons being limited to OECD nations reporting institutional care use. Nevertheless, the data indicate that in Australia a comparatively high proportion of older people live in institutions, with a relatively low financial investment in the whole aged care sector. While many countries have wait lists for home care services, the wait times of over 12 months for home care packages at the approved level (for level 2 and above; ie, beyond basic care needs, providing low to high level care) may lead to premature admission to institutional care for some people.6,7,8 In November 2019, the Australian government announced funding of an additional 10 000 home care packages at a cost of $496 million.9 However, in September 2019, there were about 63 000 people waiting for an approved home care package, and an additional 49 000 people were offered, while waiting, a package at a level lower than that approved.6 Some countries focus on keeping older people at home, with greater emphasis on preventive and rehabilitation approaches.10,11 In Denmark, for example, legislation obliges local municipalities to assess all older people applying for home care for their suitability for reablement: short term home‐based training programs aiming to increase people's independence.11 To reduce the number and proportion of older Australians living in residential aged care, there needs to be an increase in investment across the sector, particularly in home‐ and community‐based care. Box – Estimates derived from OECD data2 on proportion of older population receiving long term care (LTC) in institutions (A), and LTC estimates for expenditure on older people as a proportion of gross domestic product (GDP) (B) Notes: Data refer to 2015 or nearest year. A: Data not available for UK; it is unclear whether or not older people living in skilled nursing facilities are counted in US data. B: Data not available for New Zealand. Old age benefits in kind were not reported for Canada or Poland; Germany reports zero expenditure as benefits in kind. US expenditure may only include institutional care.4 Data extracted on 6 May 2019 (A) and 15 September 2019 (B) from https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.3

Suzanne M Dyer · Madeline Valeri · Nimita Arora · Dominic Tilden · Maria Crotty

The current reduced capacity of post‐release services may compound offender vulnerabilities, increasing their risk of harm to themselves and others The coronavirus disease 2019 (COVID‐19) pandemic has affected many countries internationally and has been implicated in more than 445 000 deaths worldwide.1 The speed at which this infectious disease is transmitted has led to calls to immediately release prisoners from custody in some countries, including Australia, and has already led to the release of some prisoners in others. The reasons for these calls to action are intuitively rational. Custodial environments are susceptible to a COVID‐19 outbreak given the confined conditions and potential for overcrowding.2 Moreover, prison populations are often vulnerable, having poorer physical and mental health and other social challenges (eg, substance misuse, homelessness) compared with the general population.3 At the time of writing, Australian governments have yet to immediately release select prisoners into the community as part of efforts to mitigate the spread of COVID‐19, despite recent advocacy to do so. Experts across a number of sectors have recommended the early release of prisoners from vulnerable groups if possible, including Indigenous Australians, women, children, older prisoners, victims of domestic violence, and those with chronic health issues.4 However, the proposed early release strategy requires a nuanced assessment of its potential societal consequences and, most importantly, its immediate impact on the health and wellbeing of candidate prisoners for release. Victoria and New South Wales — Australia's most populous states — provide a useful case in point. Stage 3 restrictions — home confinement except for restricted essential activities5 — have been in effect for approximately 2 months. Some restrictions were eased in late May, although limits on public and private gatherings remain in place. Prisons in both Victoria and NSW have yet to record a single case of COVID‐19 within the inmate population. In Victoria, a number of safety mechanisms have been introduced by correctional centres to help manage the potential transmission of the virus.6 These include: temperature testing of all staff before entry to the facility; sending staff home who present with high temperatures and other flu‐like symptoms, and requiring them to undertake a COVID‐19 test before returning; isolating all new prison admissions for up to 14 days; isolating prisoners who display cold or flu‐like symptoms; adjusting programs to abide by physical distancing; and enabling prisoners to connect with family members via video calls on tablet devices (“video visits”) as an alternative to in‐prison visitation. Moreover, conventional medical, psychological and cultural support services continue to be available to prisoners. Similar precautions have been implemented in NSW correctional centres,7 which hold the largest proportion of prisoners in Australia. With no confirmed cases in both Victorian and NSW correctional centres and ongoing efforts to restrict the materialisation of COVID‐19 in custodial settings, the potential costs of releasing vulnerable prisoners into the community necessitates scrutiny. Any prisoners released under anti‐COVID‐19 preventive measures will return to a general community enduring social restrictions and society‐wide economic contraction. The post‐release community support services ordinarily available to released offenders are currently compromised or are experiencing significant delays.8,9,10,11 Moreover, government social security services (ie, Centrelink), which are heavily relied upon by individuals after release, are currently overwhelmed as they service thousands of newly unemployed clients.12 Mental health and crisis support services are also strained as they adjust to remote service delivery and contend with an elevated spike in community‐wide help seeking.13 The reduced capacity for intensive case management, monitoring and re‐entry assistance for released prisoners is a serious concern given their higher levels of complex mental and physical health needs, as well as histories of unemployment, addiction, social disadvantage and homelessness.3 Australian research points to high rates of mortality and self‐harm shortly after release from custody.14 Key predictors of post‐release mortality include mental disorder, suicide and substance misuse — concerns that transitional support programs and other post‐release interventions will be unable to optimally manage during the national lockdown. This scenario poses an increased health risk for released prisoners, compounding their vulnerability and increasing the likelihood of problem behaviour and recidivism. Without readily available coping strategies and assistance with pro‐social functioning, released prisoners with histories of violence, aggression, impulsivity and serious mental illness may put themselves and others (particularly cohabitants) at risk. Calls to release prisoners who are survivors of domestic violence must also consider the heightened risk of revictimisation after release. The social isolation, economic stress and reduced options for support during stage 3 restrictions may exacerbate unhealthy relationship dynamics, especially among those with complex needs. Moreover, physical distancing may not be adhered to by those whose behavioural and psychological needs are untreated. Proposals to immediately release vulnerable prisoners to avert the ostensible threat of COVID‐19 in Australian custodial environments warrant consideration. The potential for a COVID‐19 outbreak in custody is a genuine concern, notwithstanding proactive measures employed in Victorian and NSW correctional centres. However, this advocacy must consider the broader social context. A focus on early release cannot be uncoupled from the current compromised community environment prisoners will face after detainment. Community support services are increasingly strained at a time when released prisoners will have a greater need for them. As such, it is important to balance the relative health and safety trade‐offs of remaining in custody — in Victorian and NSW prisons, there are no confirmed cases of COVID‐19 and health supports remain available — with early release into a resource‐depleted community. The real prospect of harmful outcomes for immediately released vulnerable prisoners must be weighed heavily during this challenging period.

Stephane Shepherd · Benjamin L Spivak

A false impression of technological panacea may see much needed interventions overlooked and may introduce unintended consequences and risks In the face of coronavirus disease 2019 (COVID‐19) limiting free movement, experts are scrambling to mitigate the profound impact that the disease is having on our lives. For many countries, this approach involves increased testing, isolation, and education about hygiene practices until a vaccine is found. To varying degrees, without much evidence as to their efficacy, countries are turning to technology to solve some of the current challenges.1 Increasingly, smartphone applications (apps) are being contemplated for tracking proximity of people to determine possible sources of transmission, with elements of technological solutionism. Such technical solutions require trust, and without honest and clear information about the possibilities and limitations of technologies, an app's benefits may be undermined by low adoption, or conversely a false impression of a technological panacea may see much needed interventions overlooked. For example, the Australian Government's target of a 40% uptake of the COVIDSafe app may or may not be effective in helping to control the disease, while 60% uptake is supported by independent modelling from the United Kingdom.2 Furthermore, such summary statistics do not clarify to the public the wide range of other factors and assumptions that must be considered in predicting the app's efficacy. Much is being written about the different technological models and whether they trace, track and comply with privacy and human rights frameworks, including whether this information can, in fact, ever be anonymised.3 Fully effective anonymisation is unlikely when collecting data as granular as regular interaction with others in addition to age, gender and postcode demographics, as has been demonstrated by previous attempts to de‐anonymise data.4 If these data are accidentally or deliberately linked with other datasets, such as births in hospitals or the public Myki public transport dataset,5 anonymity is virtually impossible to guarantee. Successful uptake of new technologies requires trust. When adoption is insufficient, collective benefits are not guaranteed. Civil society in the United Kingdom called for clear and comprehensive primary legislation to regulate data processing in symptom tracking and digital contact tracing applications, including with a strict purpose, access and time limitations.6 Such regulation may improve trust. Technology embeds values Even when people are told of the limitations of technology, they may have magical thinking about its capabilities.7,8 In early May 2020, the Australian Government furthered this magical thinking by direct messaging Australians that downloading the COVIDSafe app would help to keep people safe and ease restrictions, linking the two directly and potentially conflating the capability of COVIDSafe. Contact tracing apps may assist in manual tracing, in turn slowing the virus’ spread, but usage of an app does not render the individual protected from infection nor does it guarantee successful tracking without intensive manual efforts. Yet statements by those in authority have made strained assertions about COVIDSafe, likening the use of the app to the use of sunscreen9 or a digital vaccine: “You could think about contact tracing as a digital vaccine with our contact data being the virtual antibodies”.10 Such statements are incorrect representations of the app's capabilities.11 Even the technical details of the app are not immune from false messaging. For example, the app records all Bluetooth contacts, not just those that last 15 minutes or that are within 1.5 m. The filtering occurs after contacts are uploaded. Furthermore, there are some inaccurate statements on the official COVIDSafe website; for example, the frequently asked questions section states that “all information that is stored on the phone is digitally encrypted;” however, metadata, such as the device make and model for each contact, are stored unencrypted.12 Communication must be fact‐based, transparent and consultative, any short term gains in support from the use of emotive and persuasive messaging may be undone when they are ultimately demonstrated to be false. Centralised versus decentralised data collection The fundamental difference between centralised versus decentralised tracking is in who learns what. In the centralised approach, the central authority learns who an infected person has interacted with, whereas this does not occur in the decentralised system. Decentralised systems are no more challenging to implement but they better protect privacy. In a centralised approach (Box 1), such as TraceTogether (Singapore) or COVIDSafe (Australia): encrypted identifiers are issued by the central authority to each device; devices broadcast the encrypted identifiers via Bluetooth, and nearby devices listen for such broadcasts and record any that they receive; if a person tests positive, they report to the central authority all the identifiers they have received within a predetermined timeframe; and the central authority decrypts the identifiers and maps them to the individuals they were issued to and duly notifies them if they are deemed to be at risk. The above is a very high level description and there are many technical challenges in implementing such a system securely.13 In a decentralised approach (Box 2), as proposed by decentralised privacy‐preserving proximity tracing (DP‐3T), Covid Watch, Apple and Google: devices generate random identifiers that are not linked to an individual; identifiers are broadcast via Bluetooth and recorded by nearby devices; a person who tests positive publishes a list of the identifiers they have broadcast; and all apps on user devices download such lists and check if they received positive identifiers so as to identify likely contacts. While there are variations in the details, in the decentralised approach, the central authority does not map identifiers to individuals. Although the distinction between centralised versus decentralised tracking may seem small, from a privacy perspective, there is a significant difference. In the case of COVIDSafe, the identifiers are generated and provided to the phone individually rather than as a daily batch: the central authority can monitor whether the app is being used in at least 2‐hourly increments, and possibly as frequently as every 9 minutes, due to regular checks for new identifiers. Models reflect differing societal priorities. In Germany, where there are legal protections for both individual and group privacy, the decentralised app has been chosen. In fact, it has been suggested that a decentralised smartphone contact tracing system — as contemplated by DP‐3T, Apple, Google, and governments across Europe — would be likely to comply with human rights and data protection laws. In contrast, a centralised smartphone system would pose a greater risk to fundamental rights and would require significantly greater justification to be lawful.6 Even when consent for central data collection has been sought, it is unclear what users are consenting to in the absence of fully open code that includes server‐side code, a clear regulatory framework, and with omissions, such as the COVIDSafe's Privacy Impact Assessment and Privacy Policy failing to mention the collection of the devices’ make and model.14 In comparison, Singapore's TraceTogether is based on the same codebase and its frequently asked questions section notifies of such data collection.15 Efficacy and risks of using Bluetooth Bluetooth Low Energy (BLE) is designed to be a low power communication technology, it was not designed to facilitate range finding. Accurately measuring the distance between two devices based only on the received signal strength is a challenge, with error margins often in the metres.16 The signal strength is relative not absolute, and thus, the scale of the reported values differ by manufacturer. Furthermore, the signal strength is influenced by many external factors, including the angle at which the device is held, whether it is in a pocket or a bag and any objects around or between it and the other device. Whether BLE can deliver the necessary accuracy remains an open question. While the use of Bluetooth avoids direct location tracking, many other risks remain. There are vast networks of Bluetooth beacons distributed around cities, which facilitate location tracking. Security advice is to disable Bluetooth when not in use. While the public might be expected to compromise for the common good, legislation could also move to limit Bluetooth beacons during the crisis. However, the Privacy Amendment (Public Health Contact Information) Act 202017 passed on 14 May provides no such protections.18 It provides an exemption to those accidentally collecting COVIDSafe data as part of a wider collection of non‐COVIDSafe data. This appears to be aimed at protecting commercial tracking, rather than protecting privacy. Legal and social implications are as important as the technical ones Given the many risks of using technology, the contemplation of any technological solutions to alleviate the impacts of COVID‐19 needs to be not only technical but also legal and social. Making the code open for audit provides some technical guard rails, much as providing open and transparent proof of test results ensures that no risks are overseen. But beyond technical questions there are also legal questions, including with whom the data may be shared. A recently published article refers to the multiple legal regimes potentially applicable to the app in Australia, as experts scramble to review the legal protections for individuals using COVIDSafe.19 Enacting emergency measures in the face of catastrophes is easy. Rolling back changes to technology, habits and even culture is far more difficult. If they are to be used, technological tracking solutions must have sunset clauses to ensure that human rights are protected. But even with sunset clauses, the large quantity of data collected are effectively out in the world, where they can be accessed and misused. Protections and limits for these data and their providers need to be contemplated before use, not only to protect individuals but also for group privacy. Increasingly, there is a risk of data being accessed by overseas agencies, which could have an impact on national security. It is vital that the technical, legal and social challenges are addressed in coordination. Any new legislation must be written within the context of existing technological practices, particularly around Bluetooth tracking. Likewise, where technical compromises are made, they must be justified to the public with clear, concise explanations, in a manner that is transparent and open to scrutiny. While many liberties have been curtailed during COVID‐19, all modifications to existing rights are required, under law, to be legal, necessary and proportionate. These same standards apply to the use of technology. Legal protections need to be in place to ensure that rights are protected, including the right to privacy. Without sound legal protections and safeguards, tracing apps will not only fail but will embed values that may not be those that represent the society we wish to be. Box 1 – The centralised approach of contact tracing wherein the central server learns user contact details Box 2 – The decentralised approach to contact tracing wherein no central authority learns user contact details

Kobi Leins · Christopher Culnane · Benjamin IP Rubinstein

All countries must increase medical capabilities and adopt a concerted whole-of-government approach to combat COVID-19

Ray Junhao Lin · Tau Hong Lee · David CB Lye

Combatting the resurgence of measles requires vigilant clinicians and sustained, high level vaccination coverage At the beginning of 2020, Samoa was in a state of emergency due to a measles outbreak. It resulted in over 5700 cases and over 80 deaths, the majority being in children under 5 years of age.1 There were concurrent outbreaks regionally, in New Zealand, Tonga, American Samoa and Fiji. Globally, there has been a massive resurgence of measles with over 360 000 cases reported to the World Health Organization between 1 January and 31 July 2019 — almost three times the number reported over the same period for 2018. We have also seen the re‐establishment of endemic measles in some countries, such as the United Kingdom, where it was previously eliminated.2 In 2019, Australia had 285 confirmed measles cases, the highest number reported since 2014, the year that it was verified by the Regional Verification Commission for Measles Elimination in the Western Pacific to have eliminated measles.3 Most infections occurred in, or were secondary to, unimmunised or underimmunised individuals returning from countries where measles is endemic or that have active outbreaks.4 Australian doctors cannot afford to become complacent about measles, particularly while large outbreaks affect popular tourist and business destinations in the region. Why must we care about measles? Measles is the most highly communicable human virus known, and has a basic reproduction number (R0; the average number of secondary cases generated from a single case in a fully susceptible, freely mixing population) between 9 and 18 — double that of smallpox and quadruple that of Ebola virus.5 It can therefore result in devastating and explosive outbreaks where immunity gaps exist. It is transmitted by respiratory droplets, and aerosolised particles can remain airborne for up to 2 hours, making infection possible well after a patient has left an enclosed space such as a clinic waiting room. Cases are infectious from 24 hours before prodrome onset until 4 days after onset of rash. As the characteristic, maculopapular rash does not appear until 3–7 days into the illness (Box 1), each case may unwittingly expose hundreds of contacts by the time of diagnosis.5,6 Although the majority of patients recover from measles, up to one child in every thousand infected in wealthy countries will die, usually due to pneumonia or encephalitis.5 The immunosuppression caused by the measles infection may last months to years, and rare but devastating neurological complications include acute disseminated encephalomyelitis, measles inclusion body encephalitis and subacute sclerosing panencephalitis.5 The dramatic decrease in subacute sclerosing panencephalitis in Australia since 1990 is a testament to the impact of effective immunisation programs.7 There is no specific antiviral therapy for measles. Management remains supportive, with fluids, vitamin A, and antibiotic therapy if secondary bacterial infections arise.5 The importance of preventing measles through vaccination cannot be overstated. Breakthrough infection While most measles cases still occur in underimmunised individuals, some countries, including Australia, have seen a small but increasing proportion of cases occurring in adults reporting previous measles vaccination.5,8,9,10 At the time of elimination verification in Australia, the estimated efficacy of measles vaccine was 96.7% for one dose and 99.7% for two doses.11 Thus, about one in 300 fully vaccinated people who are exposed to measles are vulnerable to “breakthrough” infection, resulting from either an inadequate response at the time of vaccination or waning of immunity over time.8,9 The latter is particularly seen in post‐elimination settings where regular immune‐boosting from circulating wild strain virus is absent, and there is concern that this may become more common as the time since elimination increases.10,12 Measles should therefore be considered in all patients presenting with fever and rash, particularly if there is a history of travel, exposure to a confirmed case, or when measles is known to be circulating locally, even if the patient has received two doses of measles vaccine. Breakthrough infections often present as modified measles with a mild to moderate rash and less pronounced prodrome.8,9,10 Virus burden and transmissibility appear to be lower in modified cases than in a typical infection; however, onward transmission may still occur, making isolation of cases and public health responses still necessary.8,10 Attenuated symptoms, alongside often undetectable IgM antibody levels, make diagnosis considerably more challenging and definitive laboratory testing using polymerase chain reaction all the more relevant. Advances in laboratory testing Detection of measles IgM antibodies through serological testing is a commonly used diagnostic method but relies on optimally timed specimens. IgM is detectable in 75% of cases 3 days after rash onset, and in almost 100% after one week, but may not be present early in the illness or in the setting of waning immunity.4,8 Specificity varies from 60% to 97% and serology cannot distinguish wild‐type infection from recent vaccination.13 Nucleic acid testing of respiratory and urine specimens using polymerase chain reaction has revolutionised measles diagnosis. Sensitivity and specificity approach 100% from the first day of rash but decrease after 2 weeks, at which point serology remains useful.4,13 Preliminary results may be available within 4 hours of receipt by an accredited laboratory, and can distinguish between wild‐type virus and vaccine strain (genotype A).6 Nucleic acid testing is now the preferred method of diagnosis (often in conjunction with serology), and has the additional advantage that swabs are often easier to collect than blood in young children.4 Virus genotyping enables source and cluster identification, tracking of global transmission and detection of emerging strains, and provides supportive evidence to confirm elimination of endemic measles. For epidemiological purposes, breakthrough infections may be differentiated by avidity analysis of IgG antibodies in serum.8 Avidity is the strength with which antibodies bind to antigens. Low avidity suggests an inadequate immune response at the time of vaccination, while high avidity suggests an initially adequate response to vaccination followed by waning immunity.14 Public health management If measles is suspected, the patient should be isolated at home or under airborne precautions in a health care facility until the diagnosis is excluded by laboratory testing or the case is no longer infectious. A public health unit should be notified on clinical suspicion of measles before laboratory confirmation is received.4 Public health management includes vaccination of susceptible contacts within 72 hours following exposure, and passive immunisation of susceptible high risk contacts (immunocompromised patients, pregnant women and infants under 12 months of age) with intramuscular normal human immunoglobulin within 144 hours of exposure.4 With such a highly transmissible virus, any delay in notification and initiation of public health actions can result in large scale outbreaks. Vaccination importance and update Vaccination remains the key to control and prevention of measles cases and complications. A population immunity of 95% is required to eliminate ongoing measles transmission, and every year a new, susceptible cohort is born, mandating that high quality immunisation efforts be maintained.12,15 While childhood vaccination coverage in 2019 was above 90% for all Australian states and territories, few met the 95% target for measles (Box 2).16 Further, national and state/territory rates can conceal pockets of low vaccination coverage where the introduction of a single case can be the catalyst for an outbreak. As of April 2019, infants travelling to a high risk setting can be given measles vaccine from 6 months of age. They still require the further two doses routinely given at 12 months and 18 months of age as part of the current National Immunisation Program.4 Previously, measles vaccination was not recommended for infants aged under 12 months because of the presence of maternal antibodies, which provide protection in early life and render the vaccine less effective. This immunity now appears to wane earlier in infants born to vaccinated mothers in an elimination setting.5 In Australia, the second dose of measles vaccine was first recommended in 1993, initially for 10–16 year olds, and introduced into the National Immunisation Program for 4–5 year olds in 1998.15 Thus, adults born between 1966 and 1982 may be susceptible, being born after circulating measles began to decline but unlikely to have received two doses of vaccine. Measles vaccine should therefore be offered to anyone aged 12 months or older (or 6 months or older as detailed above), born after 1965, who does not have formal documentation of immunity or receipt of two doses of measles vaccine, particularly before travelling overseas. It is safe to give an additional dose if it is unclear whether two doses have been previously administered. Because it is a live attenuated vaccine, measles vaccine is contraindicated in pregnancy and in immunocompromised patients.4 Although vaccine hesitancy is a concern and receives substantial media attention, access to services and other practical factors remain important barriers to vaccination uptake.17 Conclusion Measles virus is the ultimate opportunist and will capitalise on any gaps in immunity. National programs are important, but measles control cannot be achieved without effective local prevention and control measures, including diligent vaccination and prompt diagnosis by alert clinicians. With outbreaks occurring regionally, concerted effort is required to maintain Australia's elimination of measles and continue progress towards the goal of global measles eradication. Box 1 – Typical measles rash Photograph showing skin rash on a patient's abdomen 3 days after the onset of measles infection. Image captured at New York Hospital–Cornell Medical Centre. Photograph courtesy of CDC/Heinz F. Eichenwald, MD from Centers for Disease Control and Prevention Public Health Image Library ID# 3168 (https://phil.cdc.gov/details.aspx?pid=3168). Box 2 – Australian state and territory immunisation coverage rates for 1‐year‐olds at 31 December 2019 Data source: Australian Immunisation Register. Infographic courtesy of Australian Government Department of Health.16

Kirsten M Williamson · Tony Merritt · David N Durrheim

The number of tests for vitamin D deficiency in Australia rose steeply between 2000 and 2011, from 0.4 to 36.5 tests per 1000 population; the cost to Medicare increased from $1.1 million in 2000 to $95.6 million in 2010,1 and peaked at $151 million in 2012–13.2 Consequently, the Medical Benefits Schedule (MBS) items for testing (66608, 66609) were replaced in November 2014 by new items (66833–66837) with the aim of restricting testing to people at particular risk of vitamin D deficiency, including those with a history of osteomalacia or osteoporosis, elevated alkaline phosphatase levels, hyperparathyroidism, hypo‐ or hypercalcaemia, hypophosphataemia, malabsorption, chronic renal failure, deeply pigmented skin or chronic and severe lack of sun exposure, or a diagnosis of vitamin D deficiency, and people who used medications that reduce 25‐hydroxyvitamin D levels.3 The immediate effect of the new criteria was that the rate of vitamin D tests was 47% lower during 2014–16 than during 2013–14.4 However, the proportion of people tested who met none of the new MBS criteria increased from 71.3% to 76.5%, while the proportion with moderate to severe vitamin D deficiency increased only from 5.4% to 6.5%.4 Medicare data5 indicate that the testing rate has since increased, by 34% between 2015 and 2019, from 119 to 159 tests per 1000 population; the cost to Medicare rose 42%, from $73.7 million to $104.7 million (Box). The testing rate increased in all states; the rate for women increased by 30% (from 164 to 214 tests per 1000 population), and for men by 40% (from 74 to 105 tests per 1000 population) (Supporting Information, figures 1A,B). The most marked increases were for people aged 85 years or more, for whom the 2019 testing rate (women, 447 tests per 1000 population; men, 364 tests per 1000 population) exceeded the 2012 levels (women, 388 tests per 1000 population; men, 276 tests per 1000 population). Testing rates for people aged 0–25 years did not markedly change between 2015 and 2019 (Supporting Information, figures 1C,D). The Royal College of Pathologists of Australasia,6 like most medical authorities, does not recommend screening for vitamin D deficiency. The marked overall increase in testing since 2015 is not explained by changes in demographic or clinical factors, suggesting that at least some screening is unnecessary and that ordering doctors are either unaware of or do not support the new MBS vitamin D testing criteria. Evidence‐based guidelines6 and MBS policy, accompanied by education and audit activities, have failed to contain the level of vitamin D testing. Further, people who are socio‐economically disadvantaged or at particular risk of vitamin D deficiency, including Indigenous Australians, are still tested less frequently than other Australians.4 Finally, people at clear risk of vitamin D deficiency could be treated without testing, especially as the cost of supplementation ($2.25 per month) is only a fraction of that of a vitamin D test ($30.05). High quality research is needed to provide evidence for informing interventions that curb the use of low value tests in a health system that encourages a high volume of services, but not necessarily better value care. Box – Cost to Medicare of vitamin D testing (MBS items 66608 and 66609, 66833 to 66837), January 2000 – December 2019 MBS = Medical Benefits Schedule. Source: Medicare item reports.5 Our estimated rates for 2001 (2.3 per 1000 persons) and 2011 (140 per 1000 persons) differ from those estimated by Bilinski and Boyages1 using a different source of Medicare data. * The MBS items 66833 to 66837 were listed on 1 November 2014.

Louisa Gordon · Mary Waterhouse · Ian R Reid · Rachel E Neale

Iron deficiency anaemia, which affects 14–22% of women of reproductive age,1 has adverse effects on pregnant women and their infants. Oral iron supplementation is the first‐line treatment, but intravenous iron therapy is sometimes preferred because of gastrointestinal effects, low patient adherence, and the delayed effect of oral iron therapy. Further, guidelines now recommend intravenous iron therapy in certain situations,2 and more rapidly infusible intravenous iron preparations have recently become available in Australia. We investigated the use of intravenous iron by women of reproductive age, analysing dispensing data for a 10% random sample of Australians eligible to receive subsidised medicines under the Pharmaceutical Benefits Scheme (PBS).3 We included data for all women aged 18–44 years with a dispensing claim for intravenous iron during January 2013 to December 2017. Three preparations were available: iron polymaltose and iron sucrose during 2013–2017, and ferric carboxymaltose from June 2014. We calculated the annual number and rate of intravenous iron dispensing claims and iron preparation types by age group, using Australian Bureau of Statistics 2017 population data,4 and estimated overall dispensing rates by extrapolating these numbers to the national level (Supporting Information). The study was approved by the New South Wales Population and Health Services Research Ethics Committee (reference, 2013/11/494) and the federal Department of Human Services External Request Evaluation Committee. An estimated 259 700 intravenous iron dispensing claims were made for 190 490 women of reproductive age during 2013–2017; the annual number of dispensing claims increased from 17 920 in 2013 to 97 040 in 2017, and the annual rate of intravenous iron dispensing rose from 0.4 per 100 women in 2013 to 2.1 claims per 100 women in 2017 (Box). By iron type, 187 800 dispensing claims were for ferric carboxymaltose (72.3%), 71 110 for iron polymaltose (27.4%), and 790 for iron sucrose (0.3%). Most preparations were prescribed by general practitioners (111 870 claims, 43%), specialists (54 640 claims, 21%), and other medical practitioners (50 868 claims, 20%). The number of dispensing claims increased with age (18–24 years, 1.6 per 100 women; 35–44 years, 2.5 per 100 women). In 2017, intravenous iron was dispensed to one in fifty Australian women of reproductive age, five times the proportion in 2013; in 2017, 90% of these women received ferric carboxymaltose. The optimal rate of intravenous iron treatment is unknown, and there are no comparable overseas data. As possible adverse outcomes include permanent skin staining and the risk (albeit rare) of potentially fatal anaphylaxis,5 intravenous iron should be administered in settings where allergic reactions can be treated promptly, but whether this is generally the case is not known. Intravenous iron therapy for women of reproductive age also has considerable financial implications: based on average PBS prices,6 its total annual cost increased 35‐fold, from $0.75 million in 2013 to $26.9 million in 2017. However, we have probably underestimated the use of intravenous iron therapy, as we included only PBS‐subsidised dispensing, which may not include preparations administered to public hospital inpatients. The reasons for the rise in the use of intravenous iron are unclear, but may include increased awareness of patient blood management guidelines, the ease of treatment, and the perception that its side effect profile is more favourable than for oral iron therapy. The rapid growth raises concerns about whether it is being employed appropriately and cost‐effectively, given the potential harms and the lack of strong evidence for its value for improving quality of life and reproductive health outcomes. Box – Pharmaceutical Benefits Scheme dispensing claims for intravenous iron preparations for women aged 18–44 years, Australia, 2013–2017 *The small numbers of dispensing claims for iron sucrose are not separately depicted, but were included when calculating the rates of dispensing.

Antonia W Shand · Jane Bell · Amanda Henry · Luke E Grzeskowiak · Giselle Kidson‐Gerber · Sallie Pearson · Natasha Nassar

The response to COVID-19 in Australia has been impressive, but our laboratory capacity must be used wisely

David W Smith

Clinical record A 70‐year‐old man with multiple myeloma was admitted to our hospital in 2018, having been hospitalised 10 months previously in the United Kingdom. Following admission to our facility, routine collection of clinical specimens was performed in the setting of an episode of febrile neutropenia. Candida auris was isolated in a urine specimen collected in the presence of an indwelling urinary catheter, without accompanying pyuria. Screening of ward contacts (n = 73) was subsequently performed by collection of composite axilla and groin skin swabs, together with swabbing of possible clinical sites of infection (eg, wounds, catheter sites). Swabs were plated onto Candida chromogenic agar and incubated aerobically for 48 hours at 35°C. Any colonies not typical for C. albicans or C. tropicalis were identified using matrix‐assisted laser desorption ionisation time‐of‐flight (MALDI‐TOF) mass spectrometry. The routine regimen of daily cleaning and disinfection of rooms with 1000 ppm sodium hypochlorite solution was continued. Enhanced infection control measures, including contact precautions and single‐room isolation were instituted. A multidisciplinary taskforce coordinated screening, laboratory and prevention strategies. Review of laboratory reports for the preceding 12 months confirmed this to be the first documented C. auris isolate at our facility. One ward contact, a 38‐year‐old man with diffuse large B cell lymphoma, was identified as colonised with C. auris. The organism was detected in a urine specimen collected in the presence of a long term indwelling urinary catheter. This patient had been admitted to a health care facility in the United Arab Emirates, before direct transfer to our facility about 3 months earlier. Colonised patients had been located in a common ward for 19 days, each in a single room with dedicated bathroom and patient care equipment. They had also been managed on an outlying ward for brief periods (3 and 2 days, respectively) separated in time by 2 days. Neither patient developed clinical features of urinary tract or disseminated C. auris infection and antifungal therapy was not administered. Isolates were confirmed as C. auris by MALDI‐TOF mass spectrometry (each with score of 1.75). Antifungal susceptibility testing by broth microdilution demonstrated isolates were resistant to fluconazole (minimum inhibitory concentration [MIC] > 256 mg/L) and susceptible to caspofungin (MIC, 0.25 mg/L) and anidulafungin (MIC, 0.12 mg/L for Patient 1 and 0.25 mg/L for Patient 2). To investigate relatedness of isolates, whole genome sequencing and bioinformatics analysis were performed. Phylogeographic analysis demonstrated that both were related globally to those contained in the India–Pakistan clade. The median pairwise single nucleotide polymorphism distance between the two isolates was 167, suggesting that while these isolates were related, it was not possible to confirm whether transmission had occurred. Discussion Candida auris is an emerging, drug‐resistant yeast, responsible for hospital outbreaks internationally.1 First recognised as a new species of Candida in 2009, cases have been reported in over 30 countries, including the United Kingdom and United Arab Emirates.1,2 In outbreak settings, bloodstream, urinary tract and deep tissue infections have been reported, in addition to colonisation. The majority of isolates are fluconazole resistant,3 with variable resistance to amphotericin B and the echinocandin class of antifungal agents. Infection is associated with a crude mortality of 30%.3 Key differences between C. albicans (the most frequently identified Candida species in Australia) and C. auris are summarised in the Box. Risks for C. auris acquisition include admission to a high dependency unit, presence of invasive medical devices, underlying immunocompromise or chronic disease and receipt of antibiotic or antifungal agents.4 One case of C. auris invasive disease has previously been reported in Australia,5 but to our knowledge the two cases identified at our facility represent the first possible transmission of C. auris in Australia. Identification of C. auris is challenging, with potential misidentification by routine biochemical methods. If C. auris is included in the reference profile database, MALDI‐TOF mass spectrometry may be used to confirm diagnosis. DNA sequencing also provides confirmation, together with data regarding origins and potential transmission in health care settings.3 Collection of bilateral axilla and groin skin swabs as a combined screening specimen is recommended for optimal yield.6 European and United States guidelines recommend screening of all room contacts of patients with C. auris.6,7 Screening of additional patients (eg, whole ward) is necessary where more than one case is identified. Targeted surveillance of patients who have recently had at least one overnight stay in an overseas facility is also recommended, especially if from a country reporting C. auris cases.6,7 Our experience highlights the importance of this strategy. Clinicians should be aware of risks for C. auris acquisition, including overseas health care encounters. In high risk settings, and where a case of C. auris infection has been identified, timely screening of patients is required to ensure that appropriate control measures are instituted. Lessons from practice Candida auris is an emerging drug‐resistant yeast, now reported in Australian health care facilities. In contrast to C. albicans, which is commonly isolated in community and health care settings, C. auris is generally only identified in high risk hospitalised populations. Risks for acquisition include intensive care or high dependency unit admission, presence of invasive medical devices, underlying immunocompromise or chronic disease, and receipt of broad spectrum antibiotics or antifungal agents. Strict infection control measures, including contact precautions and isolation, are required to reduce risks of transmission. Screening for colonisation is an important element of infection control strategies, and a composite skin swab of axilla and groin is recommended. Timely detection requires laboratory identification. MALDI‐TOF mass spectrometry may be used for confirmation, and whole genome sequencing may provide additional information on possible transmission events. Health care facilities must ensure processes are implemented for screening of patients who have received health care in overseas hospitals. Box – Comparison of clinical and epidemiological characteristics of Candida albicans and Candida auris Candida albicans Candida auris Colonisation Colonisation of patients in community and health care settings is common; a commensal of skin and gut of immunocompetent and immunocompromised hosts Colonisation of patients associated only with hospital outbreaks or transmission, also identified in environment and equipment in hospital outbreak settings Infection Infection most frequently at mucosal sites (eg, oropharyngeal, vulvovaginal); bloodstream and urinary tract infections less frequent Bloodstream, urinary tract and wound infections reported Risks for infection ICU or HDU admission, invasive medical devices, major abdominal surgery, solid tumours, haematological malignancies, broad spectrum antibiotics ICU or HDU admission, invasive medical devices, underlying immunocompromise or chronic disease (eg, diabetes, chronic lung disease, renal failure, cardiovascular disease, or malignancy), broad spectrum antibiotics or antifungal agents Geographical distribution Ubiquitous, community and health care settings Reported only in health care settings, expanding global distribution Laboratory identification Culture using selective chromogenic media Culture together with MALDI‐TOF or DNA sequencing Antifungal resistance Generally susceptible to fluconazole Resistance to fluconazole is likely* HDU = high dependency unit; ICU = intensive care unit; MALDI‐TOF = matrix‐assisted laser desorption ionisation time‐of‐flight mass spectrometry. *Note: agreed fluconazole minimum inhibitory concentration breakpoints for C. auris have not been established

Leon J Worth · Simon J Harrison · Michael Dickinson · Annaliese Diemen · Jennifer Breen · Susan Harper · Caroline Marshall · Deborah A Williamson · Karin A Thursky · Monica A Slavin

The prevalence of food allergy among Victorian children is rising.1 In Victoria, children with suspected food allergies can be on hospital outpatient clinic waiting lists for months before being assessed.2 This may lead families to consider alternative avenues, which can lead to poor allergy management and the need for emergency care. Increasing numbers of Victorian children are presenting to emergency departments,3 but we do not know whether the number visiting with food allergy is also rising. We analysed Victorian Emergency Minimum Dataset (VEMD) data for the period 2005–06 to 2014–15. The VEMD is a statewide administrative dataset that includes non‐identifiable patient‐level data for all Victorian public emergency department encounters. We included all food allergy‐related presentations by children and young people aged 0–19 years, selected according to International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) codes: T78.0 (anaphylactic shock due to a food reaction), T78.1 (other adverse food reactions, not elsewhere classified), T78.4 (allergy, unspecified: includes non‐food‐related allergies), and L27.2 (dermatitis due to ingested food). Presentation rates by age group were calculated using Australian Bureau of Statistics (ABS) age‐stratified population data for Victorians aged 0–19 years;4 rates for regions were calculated using ABS population data for Statistical Areas 2 (SA2).5 The study was deemed exempt from the need for formal ethics approval by the Royal Children's Hospital Human Research Ethics Committee. The number of children presenting to emergency departments with food allergy‐related problems increased from 2368 in 2005–06 to 4263 in 2014–15; the presentation rate increased from 18 to 29 per 10 000 population (Box 1). About half the children who presented with food allergy‐related problems were aged 0–4 years, the rate for this age group increasing from 38 to 55 per 10 000 population (Box 2). The proportion of presentations triaged as being more urgent (triage categories 1–3) also increased, from 51% to 63% (Box 1). The rate of presentations to metropolitan hospitals increased more (from 18 per 10 000 in 2005–06 to 32 per 10 000 in 2014–15; 78% increase) than did the rate for rural hospitals (26 per 10 000 in 2005–06 to 36 per 10 000 in 2014–15; 38% increase) (Box 1). Hospitals in the North‐West Melbourne region received about one‐third of all allergy‐related emergency department visits, and the number in this region doubled over the study period (706 in 2005–06; 1536 in 2014–15) (Box 3). These data indicate that the demand for emergency services associated with food allergy‐related problems in children increased during 2005–15. The increase was particularly marked for children aged 0–4 years and for children and young people in the North‐West Melbourne and Southern Melbourne regions. While the reason for the increased burden is not clear — that is, whether the prevalence of allergy had increased (including because of a change in population composition), management plans had changed, or access to community services was reduced — the consequence is greater demand on emergency services across Melbourne. Box 1 – Presentations to Victorian public emergency departments by childen and young people (0–19 years) with food allergy‐related problems 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 All food allergy presentations Number 2368 2680 2754 2991 3082 3159 3185 3422 3881 4263 Rate (per 10 000 population)* 18 20 21 22 23 23 23 24 27 29 ICD‐10‐AM diagnostic codes T78.0 141 (6.0%) 152 (5.7%) 154 (5.6%) 168 (5.6%) 233 (7.6%) 283 (9.0%) 289 (9.1%) 339 (9.9%) 437 (11.3%) 501 (11.8%) T78.1 800 (33.8%) 948 (35.4%) 962 (34.9%) 1127 (37.7%) 1167 (37.9%) 1152 (36.5%) 1117 (35.1%) 1288 (37.6%) 1464 (37.7%) 1624 (38.1%) T78.4 1234 (52.1%) 1351 (50.4%) 1441 (52.3%) 1488 (49.8%) 1552 (50.4%) 1597 (50.6%) 1633 (51.3%) 1702 (49.7%) 1881 (48.5%) 2031 (47.6%) L27.2 193 (8.2%) 229 (8.5%) 197 (7.2%) 208 (7.0%) 130 (4.2%) 127 (4.0%) 146 (4.6%) 93 (2.7%) 99 (2.6%) 107 (2.5%) Age Number 0–4 years 1202 (50.8%) 1364 (50.9%) 1424 (51.7%) 1537 (51.4%) 1520 (49.3%) 1595 (50.5%) 1593 (50.0%) 1759 (51.4%) 2015 (51.9%) 2152 (50.5%) 5–9 years 466 (19.7%) 515 (19.2%) 521 (18.9%) 573 (19.2%) 673 (21.8%) 608 (19.3%) 660 (20.7%) 702 (20.5%) 813 (21.0%) 967 (22.7%) 10–14 years 305 (12.9%) 335 (12.5%) 355 (12.9%) 405 (13.5%) 403 (13.1%) 426 (13.5%) 383 (12.0%) 433 (12.7%) 515 (13.3%) 561 (13.2%) 15–19 years 395 (16.7%) 466 (17.4%) 454 (16.5%) 476 (15.9%) 486 (15.8%) 530 (16.8%) 549 (17.3%) 528 (15.4%) 538 (13.8%) 583 (13.7%) Rate (per 10 000 population)* 0–4 years 38 42 43 45 43 45 44 47 53 55 5–9 years 15 16 16 18 21 18 19 20 22 26 10–14 years 9 10 11 12 12 13 12 13 15 16 15–19 years 12 13 13 13 14 15 15 15 15 16 Sex Number Boys 1284 (54.2%) 1435 (53.5%) 1476 (53.6%) 1625 (54.3%) 1663 (54.0%) 1723 (54.5%) 1779 (55.9%) 1867 (54.6%) 2158 (55.6%) 2388 (56.0%) Girls 1084 (45.8%) 1245 (46.5%) 1278 (46.4%) 1366 (45.7%) 1419 (46.0%) 1436 (45.5%) 1406 (44.1%) 1555 (45.4%) 1723 (44.4%) 1875 (44.0%) Rate (per 10 000 population)* Boys 19 21 21 23 24 25 25 26 29 32 Girls 17 19 20 21 21 22 21 22 24 26 Hospital region Number Metropolitan† 1560 (65.9%) 1860 (69.4%) 1907 (69.2%) 2008 (67.1%) 2071 (67.2%) 2194 (69.5%) 2186 (68.6%) 2345 (68.5%) 2781 (71.7%) 3149 (73.9%) Rural‡ 808 (34.1%) 820 (30.6%) 847 (30.8%) 983 (32.9%) 1011 (32.8%) 965 (30.5%) 999 (31.4%) 1077 (31.5%) 1100 (28.3%) 1114 (26.1%) Rate (per 10 000 population)* Metropolitan† 18 22 22 23 23 25 24 25 29 32 Rural‡ 26 27 27 32 33 31 32 35 35 36 Triage category Categories 1–3 1198 (50.6%) 1429 (53.3%) 1568 (57.0%) 1707 (57.0%) 1830 (59.3%) 1861 (59.0%) 1807 (56.8%) 2047 (59.8%) 2365 (61.0%) 2694 (63.2%) Categories 4, 5 1170 (49.4%) 1251 (46.7%) 1186 (43.0%) 1284 (43.0%) 1252 (40.7%) 1298 (41.0%) 1378 (43.2%) 1375 (40.2%) 1516 (39.0%) 1569 (36.8%) ICD‐10‐AM = International Classification of Diseases, tenth revision, Australian modification. * All presentation rates are per 10 000 children in Victoria aged 0–19 years in the corresponding category. † Victorian Emergency Minimum Dataset (VEMD) regions: North‐West, Southern, and Eastern Melbourne. ‡ VEMD regions: Loddon Mallee, Gippsland, Barwon South West, Hume, Grampians. Box 2 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems: rates per 10 000 population, by age group Box 3 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems, by hospital campus region

Rachel O'Loughlin · Harriet Hiscock

Coronavirus disease 2019 (COVID‐19) poses extraordinary challenges for health care in Australia. One of the greatest will be the pressure on hospitals to support people with severe disease. Modelling studies can provide valuable insights into the likely course of the epidemic, and can be particularly useful for anticipating resource requirements, including demand for intensive care services at the peak of the epidemic. In this report, we extrapolate the findings of the Imperial College model of the pandemic1 to the New South Wales population. We also developed a simple SEIR (susceptible–exposed/incubating–infected–removed) model to explore the effect of varying the infection reproduction number (R), which can be reduced by effective social distancing measures, on the timing of the peak of the epidemic. The two models are described in the online Supporting Information. Applying the Imperial College model, the peak demand for intensive care in NSW would be at least 6965 beds if mitigation efforts — isolation of people with confirmed COVID‐19, household quarantine of their contacts, social distancing from people over 70 years of age — are implemented, or almost eight times as many as the baseline number; without mitigation, more than three times as many ICU beds (21 283) could be required (Box 1). Applying our SEIR model to a scenario without social distancing measures (R = 2.4), the number of people requiring hospitalisation in NSW would peak at 450 per 100 000 population (35 375 beds), and the number requiring critical care at 150 per 100 000 population (11 792 ICU beds, or 1349% of baseline ICU capacity). In this scenario, viral transmission would peak during late June and ICU bed occupancy in early July. About 16% of people would be potentially infectious at this point, although a smaller proportion was modelled as exhibiting symptoms (Box 2; Supporting Information, table 3). In a scenario of increased social isolation (R = 1.6) and an assumed hospitalisation rate for people with confirmed COVID‐19 of 6.7%, case numbers would peak in early October and ICU occupancy in mid‐November; about 180 people per 100 000 population would require hospitalisation (14 150 beds) and 65 per 100 000 intensive care (5110 ICU beds, or 585% of baseline ICU capacity) (Box 2; Supporting Information, table 3). That is, the peak figures would be about one‐third the size of those in the no mitigation scenario. Sensitivity analyses in which the proportion of hospitalised patients was varied (5–15%) similarly found that increasing social isolation markedly reduced demand (Supporting Information, table 4). We have used two modelling methods to estimate peak demand for critical care services in NSW during the COVID‐19 epidemic. Both approaches identified that COVID‐19 would impose a major burden on the health care system, and the mismatch between the estimated numbers of ICU beds needed and their availability is stark. Our modelling shows the critical importance of effective COVID‐19 containment strategies, as well as the urgent need to invest in resources that support the surge capacity of critical care services in NSW. Box 1 – Estimated number of intensive care unit (ICU) beds required at the peak of the initial wave of COVID‐19 cases, applying the Imperial College model to New South Wales, by Local Health District (LHD) Mitigation strategy Population (2016)2 No mitigation Close schools, universities Case isolation Case isolation, household quarantine Case isolation, household quarantine, social distancing of people over 70 ICU beds needed per 100 000 population1 — 275 240 190 125 90 ICU beds need, by LHD Sydney 656 460 1805 1576 1247 821 591 South Western Sydney 964 342 2652 2314 1832 1205 868 South Eastern Sydney 914 021 514 2194 1737 1143 823 Western Sydney 948 584 2609 2277 1802 1186 854 Northern Sydney 914 233 2514 2194 1737 1143 823 Illawarra Shoalhaven 405 534 1115 973 771 507 365 Central Coast 335 309 922 805 637 419 302 Other LHDs 2 600 791 7152 6242 4942 3251 2341 All NSW (proportion of baseline bed number)* 7 739 274 21 283 (2435%) 18 574 (2125%) 14 705 (1682%) 9674 (1107%) 6965 (797%) * Estimated number of ICU beds prior to COVID‐19 epidemic: 874.3 Box 2 – The estimated number of patients with COVID‐19 admitted to hospital or to intensive care units (ICUs), according to a SEIR model of the epidemic * For main curves, 10% case hospitalisation rate assumed; shaded areas show range for hospitalisation rates between 5% and 15%.

Gregory J Fox · James M Trauer · Emma McBryde

The coronavirus disease 2019 (COVID‐19) pandemic is pushing health systems to, and possibly beyond, their limits.1 In Italy, the exponential rise in case numbers has caused a corresponding rise in demand for intensive care unit (ICU) beds.2 To determine how many ICU beds will be required in Australia, we propose a simple model of an uninterrupted pandemic process based on the local situation in late March 2020, and compare this model with recent data from the Lombardy.3 The uninterrupted exponential growth scenario In queueing theory, Little's law4 describes the relationship between the number of patients in a system (L) and the mean arrival rate (λ) and length of time the patient remains in the system (W) as: L = λW If a tertiary hospital has a steady state rate of 20 new admissions of patients with confirmed COVID‐19 per day, of whom one requires ICU admission5 (λ) for a mean 10 days (W), the hospital ICU will need at least 10 beds to accommodate these patients. If, however, the number of new confirmed cases increases by 20% each day (in late March 2020, the number was increasing in Australia by 23% each day6), and 100 cases are confirmed on one day, about 120 will be confirmed on the next. This increase in the daily rate of 20 new cases will mean one extra ICU admission per day, and the need for at least 10 further ICU beds. That is, the total number of ICU beds needed will be about 10% of the number of confirmed cases, or 50% of the number of new cases during the exponential growth phase of the epidemic. Approximately 2300 ICU beds are available in Australia;7 if public health measures fail to curb the rate of growth in case numbers, the national ICU capacity would be exceeded when the number of COVID‐19 cases reaches 23 000. Other sources8 have estimated that Australia could cope with as many as 44 580 COVID‐19 cases, but this would grant only a 3‐day extension before ICU capacity was exceeded. In our exponential growth scenario, commencing with 100 confirmed cases on day 1, 31 ICU beds would be required by day 7 and 119 by day 14 (Box 1). In sensitivity analyses, ICU bed capacity is sufficient even after 30 days if the ICU admission rate is reduced to 2.5%, but would be exceeded by day 26 were the ICU admission rate as high as 10%. It is important to note that our model describes a particularly serious scenario, and that actual outcomes will be modified by parameters not included in the model, including potential lags between diagnosis, hospital admission, and transfer to intensive care, and the proportion of true positive results among people tested for infecton. Is the modelled scenario plausible? To evaluate how realistic the uninterrupted exponential growth scenario is, we compared exponential and linear growth models with recent data for the Lombardy in Italy.9 Using piecewise regression models, the increase in the number of ICU patients during days 1–14 was exponential (R2 = 0.96); from day 15, ICU admissions continued to rise steeply, but the increase was linear (R2 = 0.99) (Box 2). To determine the reason for the change in growth rate at day 15, we compared the ICU admission and mortality rates for patients hospitalised with COVID‐19. The mortality rate during days 1–14 was fairly constant at about 8.8%, but rose dramatically from day 15 to a mean 23%. Most deaths during the first 14 days were probably of patients in intensive care, but we suspect that from day 15 patients died partly because of the lack of access to ICU beds as demand exceeded the capacity of the system to provide them, as indicated by the fall in ICU admission rate (Box 3). Conclusion While the assumptions of our model can be debated, the exponential increase in Australian cases until late March suggested that it described a realistic clinical scenario consistent with overseas data available at that time. The exponential increase in case numbers and subsequent demand for ICU beds could have overwhelmed the capacity of even the largest Australian hospitals if SARS‐CoV‐2 transmission had not been as drastically reduced as it appears to have been by the successful public health measures enacted by the federal and state governments and the adherence to these measures by the Australian public. The rate of ICU admissions per positive case may be lower in Australia than reported for Italy and China — because of healthier underlying demographic conditions, a greater number of detected milder cases, or both — but this would not change the overall implications of the model. Australia must maintain measures to strictly control the rate of new cases and continue to improve our ICU surge capacity, lest we squander the chance to avoid an Italian fate. Box 1 – Intensive care unit (ICU) bed demand, by time and proportion of patients with confirmed COVID‐19 who require intensive care Box 2 – Intensive care unit (ICU) admission rate in the Lombardy: actual and modelled Box 3 – Intensive care unit (ICU) admission rate and mortality for all patients with COVID‐19 admitted to hospitals in the Lombardy

Hamish DD Meares · Michael P Jones

The maintenance of sustainable low cost physical distancing and enhanced hygiene may decrease the number and severity of cases It is estimated that about two‐thirds of cases of coronavirus disease 2019 (COVID‐19) exported from China between 1 and 13 January 2020 were undetected globally.1 Most of these exported cases were mild and were only detected after several hundred cases had accumulated and severe or fatal cases were recognised 5–8 weeks later, as likely occurred in the COVID‐19 outbreaks in Iran, South Korea, Italy and Seattle, United States.2 The spread of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission globally has been very rapid. The basic reproduction number (R0) is estimated at between 2 and 3.3,4 The mode of transmission is thought to be droplet and contact infection, although opportunistic or close range airborne infection may be involved.4 The transmission dynamics of the early cases of COVID‐19 were significantly different to those during the severe acute respiratory syndrome (SARS) epidemic in 2003. In particular, the proportion of COVID‐19 cases from health care settings was low and the proportion with no known risk exposures was high.4 Another significant factor is that viral loads in nasopharyngeal and respiratory secretions are highest soon after symptom onset in patients with COVID‐195 compared with a peak of around 10 days in patients with SARS,6 making transmission before entering health care facilities and in the pre‐symptomatic phase more likely.7 Even though the understanding of transmission dynamics is at an early stage, they do suggest that the stepwise introduction of stringent measures will be necessary to control this epidemic and highlight the importance of early community control. Australia and other countries have experienced a first wave of disease and managed to effect a decline in cases.8 Quarantine; city lockdowns; complete childcare, school, university and workplace closures; and cancellation of mass gatherings and events have a significant social and economic impact and were not often implemented until significant transmission was confirmed — when they may be less effective. Countries are now challenged with identifying which of these various controls can be relaxed to allow some routine societal and economic activities to return. However, there are low cost, sustainable interventions that may be maintained over what may be many years of continued mitigation9 (Box 1). These low cost enhanced hygiene and physical distancing measures are applicable pre‐emptively before confirmation of local community transmission or where transmission of SARS‐CoV‐2 appears to be under control. The purpose of these interventions is to slow the transmission of disease and limit the impact on health services, particularly on hospitals and intensive care units, to ensure access to high level care when needed. The interventions are based on the following assumptions, which require further exploration: community‐wide SARS‐CoV‐2 transmission may be occurring undetected or may only be recognised after containment is no longer feasible; interventions implemented after community‐wide transmission is detected will be less effective; reduction of the force of infection, particularly early, will delay the epidemic peak, blunt the epidemic peak, spread cases over a longer time, and help limit the potential for critical care services to be overwhelmed, which may be lifesaving;12,13 low cost sustainable interventions will assist in the relaxation of more economically costly interventions, and enhanced hygiene and physical distancing interventions should: ▸decrease the total number of cases per week; and ▸decrease the severity of cases through reducing viral inocula. Box 2 illustrates the concept of limiting the peak in cases so that health services are less likely to be overwhelmed and there is less unmet health service need. Unmet need may include inability to admit patients to a hospital or to provide hospitalised patients in critical condition access to intensive care. Interventions to reduce infection lead to longer but less peaked epidemics. A slower evolution in the epidemic also allows time for health care staff to provide better care, for recovery of infected health care workers, for learning and adapting to the evolving situation by administrators, and for vaccines and treatments to be developed. This principle is validated in simulations for influenza14 and appears to be validated with the reduction in COVID‐19 cases in Australia and the relative lack of overburden on clinical services.8 Measures to decrease the number and severity of cases Pre‐emptive and ongoing maintenance of low cost interventions (such as enhanced hygiene and physical distancing measures) (Box 1) may not only decrease the total number of cases but may also decrease the severity of cases. The R0 is the average number of secondary cases of an infectious disease that arise from cases in a totally susceptible population and reflects the epidemic potential of a pathogen.15R0 is a function of the number of contacts an infectious person has, the risk of transmission per contact, and the duration of infectiousness. Physical distancing mostly acts on the first factor by reducing the number of contacts each person makes. Hygiene measures mostly act on the second factor, as they reduce the risk of transmission if a contact occurs. It is difficult to disentangle the effectiveness of the multiple control measures implemented in pandemic‐affected areas. The World Health Organization–China Joint Mission on COVID‐19 determined that widespread community transmission and outbreaks occurred in Wuhan before the implementation of comprehensive control measures.4 However, in other parts of China, community transmission has been limited and after public gatherings were cancelled and people were restricted to their homes, most transmission occurred in families. For example, among 344 clusters involving 1308 cases (out of a total 1836 cases reported) in Guangdong Province and Sichuan Province, 78–85% have occurred in families.4 Community‐wide interventions may decrease the average viral exposure dose encountered in the community. People exposed to a higher viral dose (inoculum) are more likely to become infected and have more severe disease. Animal models for other coronavirus infections demonstrate that increased viral inocula lead to more severe disease and higher viral loads in the lungs and other organs and fluids.16 The SARS outbreak in Amoy Gardens, Hong Kong, in 2003 provided evidence that patients with presumed higher exposure to the index case had higher nasopharyngeal viral loads and more severe illness.17 SARS‐CoV‐2 cases with more severe disease have been found to have around 60 times higher viral load than those with mild disease.18 Modelling of the 2009 influenza pandemic also supported a hypothesis that severe illness was due to a higher infectious dose of the virus mediated by the number of simultaneous infectious contacts.19 Viral loads in severe patients with Middle East respiratory syndrome (MERS) were higher than those in a mild group, and the patients in the severe group had more prolonged viral shedding in respiratory secretions, beyond 21 days after the onset of symptoms, whereas viral RNA was no longer detected by 21 days in the mild group.20 Therefore, it is proposed that early measures that lower the number of contacts, the likelihood of transmission, and average viral infective dose in an area of transmission may have a multiplier effect leading to fewer cases and fewer severe cases that are less infectious. Maintaining the early reduction of the R0 would result in fewer cases overall and have a significant negative multiplier effect on the overall impact of the epidemic, including the number of deaths (Box 3). The higher case fatality rate in Wuhan, compared with other provinces in China, may partially relate to health care resource availability and shortages in the face of overwhelming community transmission as well as greater severity of disease due to higher infection doses.12,17 These interventions will be particularly important for people over 60 years of age and those with underlying medical conditions. The costs of intervention The suite of low cost interventions, other than a working from home policy, is unlikely to affect work productivity and may provide the community with some reassurance that all is being done to prevent the epidemic and that maintenance of the low cost measures may allow earlier opening of some workplaces. WHO is supportive of pre‐emptive interventions to prevent COVID‐19 in workplaces.21 Some may see it as being overreaching, but thus far, communities seem to voluntarily adopt low cost interventions, and acceptance may be enhanced through consultation and trust building.22,23 Influenza co‐benefits For regions approaching their influenza season, optimal prevention and control of seasonal influenza, such as vaccination, in the face of potential COVID‐19 cocirculation is also crucial to minimise the double burden on health services. The measures discussed here (enhanced hygiene and physical distancing) are also effective against influenza, resulting in potential co‐benefits for both pathogens. Early indications from Flutracking.net (https://info.flutracking.net/reports-2/australia-reports) indicate that physical distancing and hygiene enhancements have markedly decreased influenza‐like illness in Australia. Limitations While physical distancing and enhanced hygiene interventions in Australia appear to be working, the evidence on the effectiveness of individual interventions in preventing COVID‐19 is not yet available. However, there is evidence from observational and simulation studies for the effectiveness of physical distancing measures in controlling seasonal influenza.13 Other measures, such as hand hygiene and cleaning surfaces, have a long history of use in infection prevention and control.24 Despite the lack of robust evidence of effectiveness for these measures, their relative low cost means that there is little harm and much potential benefit in maintaining and optimising them. We have made no recommendations in regard to masks. The use of masks outside of health settings is controversial and it is important that medical grade masks not be diverted from health care supplies. Nevertheless, surgical masks are protective of large droplet spread, have about half the effectiveness of N95 masks for small droplet transmission, and are suggested to be cost‐saving in some modelled pandemic influenza scenarios.25 The use of masks may have a role in the community setting if there are adequate supplies.10 There is evidence suggesting that community use of masks may have reduced the risk of contracting SARS.26 It is clear that masks should be used in households caring for patients with COVID‐19 at home. Policy development and scientific review of the literature on community use of masks is very dynamic at this time. The US Centers for Disease Control and Prevention has made a recent recommendation that cloth masks be used at the community level and many recent reviews have come to divergent conclusions about the usefulness and risks of community mask use.27,28,29,30 Coherent policy development in this space will rely on transparently articulating the scientific evidence on community mask use with a public conversation on the potential risks in implementation. The interventions discussed here should be tailored to individual settings and communities, in partnership with members of those communities. In particular, these interventions should be adapted to the unique circumstances of groups, such as Indigenous communities; vulnerable groups, including homeless populations; and culturally and linguistic diverse communities. Conclusion SARS‐CoV‐2 continues to disseminate globally and there are likely to be recurrent waves of infection into the foreseeable future. We would argue that these low cost interventions, although formulated at an earlier stage of the epidemic, have increasing relevance. They will protect against the emerging concern for pre‐symptomatic transmission and their optimisation will better enable the more restrictive and economically damaging constraints to be relaxed.7 Box 1 – Low cost hygiene and physical distancing interventions Settings Interventions Workplace No handshaking policy Promote cough and sneeze etiquette, but focus is on excluding ill staff Videoconferencing as default for meetings Defer large meetings Signage for all offices/meeting rooms advising of maximum occupancy based on 4 m2 per person and 2 m distancing Enforced sanitisation of hands at entrance Regular hand sanitation schedule reminders via email Avoid gathering in lunch and break rooms Gamifying hygiene rules, for example, to discourage touching face Ill* people should stay at home and ill workers immediately isolated Hold necessary meetings outside in open air if possible Staff with ill household contacts should stay at home† Disinfect high touch surfaces regularly and between users Work from home where possible and consider staggering of staff Consider opening windows and adjusting air conditioning to increase air flow and maintain warmer more humid environments‡ Limit food handling and sharing of food in the workplace Assess staff business travel risks§ Enhance hygiene and screening for illness among food preparation (canteen) staff and their close contacts Analyse the root cause of crowding events on site and prevent through rescheduling, staggering or cancelling Mark floor areas to indicate 2 m distancing points in areas where staff spontaneously gather to prompt distancing Minimise the number of employees in a work vehicle at any one time School Supervised sanitisation of hands at entrance and at regular intervals Defer activities that lead to mixing between classes and years Promote cough and sneeze etiquette, but focus on excluding ill persons Strict stay at home policy if ill Gamifying hygiene rules, for example, to discourage touching face Regular handwashing schedule Disinfect high touch surfaces regularly and between users Outdoor lessons where possible Consider opening windows and adjusting air conditioning Enhance hygiene and screening for illness among food preparation (canteen) staff and their close contacts Review after‐school care arrangements that lead to mixing of children from multiple classes and ages Commercial, entertainment and transport Sanitisation of hands at building entrance encouraged Tap and pay preferred to limit handling of money Disinfect high touch surfaces regularly Avoid crowding through booking and scheduling, online pre‐purchasing, limiting attendance numbers Enhance hygiene and screening for illness among food preparation staff and their close contacts Enhance airflow and adjust air conditioning to increase air flow and maintain warmer more humid environments Public transport workers, taxi and ride share drivers — vehicle windows opened where possible, increased air flow, high touch surfaces disinfected Household All households Enhanced hand sanitisation Gamifying hygiene rules, for example, to discourage touching face Disinfect high touch surfaces regularly “Welcome if you are well” signs on front door Increase ventilation rates in the home by opening windows or adjusting air conditioning Promote cough and sneeze etiquette Households with ill members Measures listed above Confirmed cases of COVID‐19 should be isolated away from susceptible household members if there are not completely separate bedroom, bathroom and kitchen facilities If care must be provided at home, ill household members are given their own room and only one person cares for them The door to the ill person's room is kept closed10 Wearing simple surgical or dust masks by both infected persons and other family members caring for the patient if needing to be in the same room Consider extra protection or alternative accommodation for household members aged over 65 years or with underlying illness COVID‐19 = coronavirus disease 2019. *Ill person refers to someone with symptoms of respiratory illness or fever, who is not yet under investigation for COVID‐19 but could be an unrecognised case. †This could be costly unless used judiciously while awaiting exclusion of COVID‐19 in the suspected case and should be introduced based on likelihood of local transmission. ‡Evidence that low temperature and low humidity in air‐conditioned environments may enhance the survival of coronaviruses such as severe acute respiratory syndrome (SARS).11 §When international travel restrictions are lifted, sites such as the Centers for Disease Control and Prevention travel risk assessment site may be useful (https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html). Box 2 – Intended impact of enhanced hygiene and physical distancing measures on the coronavirus disease 2019 (COVID‐19) pandemic* *Figure adapted from Fong et al.13 Box 3 – Conceptual model of how pre‐emptive interventions with a negative multiplier effect could affect an impending epidemic

Craig B Dalton · Stephen J Corbett · Anthea L Katelaris

It is time for health professionals to step up and lead to ensure a sustainable environment and health

Nicholas J Talley