Environmental health

Insomnia is a risk factor for workplace productivity loss in young workers

Amy C Reynolds · Pieter Coenen · Bastien Lechat · Leon Straker · Juliana Zabatiero · Kath J Maddison · Robert J Adams · Peter Eastwood

To the Editor: The flavivirus Murray Valley encephalitis virus (MVEV) was isolated in 1951 from the brain tissue of fatal cases of encephalitis.1 Subsequent work by Australian investigators established MVEV as the likely aetiological pathogen of the severe encephalitis “Australian X disease”.1 MVEV is enzootic in northern Western Australia and the Northern Territory, resulting in sporadic human cases.2 In south‐east Australia, however, MVEV activity can be absent for decades only to reappear with significant human outbreaks. The three most recent outbreaks in Australia were in 1951 (45 cases), 1974 (58 cases) and 2011 (17 cases).1,2,3 The case fatality rate is about 18% in hospitalised patients, reflecting the severity of disease.4 Since 1974, Victoria has employed vertebrate and invertebrate surveillance methods to detect MVEV activity before human cases.5 Until 2021, sentinel chicken flocks were placed along the Murray River and tested weekly for MVEV seroconversion during the mosquito season, which runs from November to April. The most recent seroconversions were in 2011, along the Murray River, in Greater Bendigo, and in Greater Shepparton.6 This testing strategy was limited by biological and logistic delays, diminishing the system as an early warning tool. In 2021, sentinel chickens were retired, with flavivirus testing combined into the long‐standing alphavirus mosquito trapping program when polymerase chain reaction (PCR) assays replaced labour‐intensive and insensitive cell culture methods.7 For the 2022–2023 mosquito season, in the setting of Japanese encephalitis virus activity and historic floods, the Victorian Department of Health supported 15 councils to trap mosquitoes as part of the Victorian Arbovirus Disease Control Program (VADCP). Trapped mosquitoes were pooled and submitted for PCR testing. The size and composition of these varied depending on the number of collected mosquitoes, with a preference for analysis of speciated mosquitoes if possible. Detections were confirmed with sequencing at a reference laboratory. As of 23 January 2023, we have detected MVEV in 14 mosquito traps across four local government areas (Box). The positioning and density of the traps are influenced by proximity to population centres and resource considerations, which may influence the likelihood of virus detection in different localities. The first detection was in mosquitoes collected on 4 January 2023. New South Wales and South Australia have also reported MVEV detections in multiple locations. Subsequently, on 17 February 2023 the first human case of MVEV infection in Victoria since 1974 was confirmed after lengthy investigation of a person with illness onset on 16 January 2023. This represents the first detections of MVEV in south‐east Australia in the 2022–2023 mosquito season, the first surveillance detections in Victoria since 2011, and the first confirmed human case in Victoria since 1974. The timing of these signals is notably earlier in the season than previous sentinel chicken seroconversions, which occurred in February 2011, supporting mosquito PCR testing as a rapid surveillance tool. This difference in timing may, however, be explained by inter‐year environmental or sampling factors, and a controlled comparison between mosquito and sentinel chicken surveillance, in the context of subsequent human cases, is required to demonstrate the most useful surveillance tool. Nonetheless, the presence of virus and capable vectors suggests the risk for human infection is present, and, importantly, informs public health actions. MVEV in south‐east Australia is rare and the time between outbreaks is measured in decades. These early mosquito surveillance signals have preceded a human health event which has not occurred in Victoria since 1974. In the absence of an effective vaccine, prevention relies on vector control and health promotion, while case detection requires clinician awareness. Retrospectively, a serosurvey will be essential to measure the extent of human exposure during this period of MVEV activity. Finally, given our understanding of MVEV in Victoria is limited by a paucity of historical events to analyse, researchers should engage in this rare opportunity to study MVEV epidemiology and ecology. Box – Victorian local government areas (LGA) with the first 14 polymerase chain reaction (PCR) detections of Murray Valley encephalitis virus in trapped mosquitoes in 2023 (shaded in red). LGAs where surveillance was undertaken are outlined. The inset shows the Australian state of Victoria shaded‐in and the dates of mosquito collection and notification to the Department of Health * Greater Bendigo LGA.

Maxwell Braddick · Aidan Yuen · Rebecca Feldman · N Deborah Friedman

There is emerging evidence for increased person-centred care and treatment adaptation

Phillipa J Hay · Rebekah Rankin · Lucie Ramjan · Janet Conti

Older women have been relatively neglected in discussions of reducing alcohol-related harm

Ann M Roche · Jacqueline Bowden

Brief alcohol interventions in diverse clinical settings can reach groups often not recognised as being at risk of harmful drinking

Jasmin Grigg · Victoria Manning · Darren Lockie · Michelle Giles · Robin J Bell · Peta Stragalinos · Chloe Bernard · Christopher J Greenwood · Isabelle Volpe · Liam Smith · Peter Bragge · Dan I Lubman

Maternal influenza and pertussis vaccine coverage rates appear to be increasing, at least in parts of Australia, but significant gaps remain

Jocelynne E McRae · Lisa McHugh · Catherine King · Frank H Beard · Christopher C Blyth · Margie H Danchin · Michelle L Giles · Hassen Mohammed · Nicholas Wood · Kristine Macartney

The Australian Government should review its position and support intellectual property waivers in the pandemic accord

Deborah Gleeson · James Scheibner · Dianne Nicol

With substantial SARS-CoV-2 transmission in the community, early oral antiviral access has become a pillar of our response

Nicole L Allard · Jose Canevari · Nick Haslett · Benjamin C Cowie

Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance

Michelle Kennedy · Janine Mohamed

A 32-year-old woman from a remote Indigenous community in Far North Queensland presented to her local health clinic with a one-day history of odynophagia

Simon Smith · James Stewart · Joshua Hanson · Julian Harris · Fred JJ Chuang · Gavin Quail · Bryan Hawarden · Roshni Lad · Shannon McNee · Benjamin McCartney · Tonia Marquardt · Ian Wilson · Catherine Tacon · Bernard CS Whitfield

Smartwatches can count every step towards a predict–prevent health care system, but clinical regulation is the first leap

Graeme Mattison · Oliver J Canfell · Doug Forrester · Chelsea Dobbins · Daniel Smith · David Reid · Clair Sullivan

Climate change affects skin health and skin diseases; mitigation and adaptation strategies are required and are time-critical

Austen Anderson · Fiona Bruce · H Peter Soyer · Crystal Williams · Rebecca B Saunderson

Australians should be confident that their generalist GP is trained to an acceptable level of competence in skin cancer diagnostics

Cliff Rosendahl · Simon Clark

Bloodstream infection rates in Aboriginal residents of Central Australia remain extremely high, and risk factors must be remediated

Alice Coe · Richard J Woodman · Rob Baird · Lloyd Einsiedel

Pioneering cancer epidemiologist and champion of women in science

Karen Canfell · Bette Liu · Emily Banks

As more concerning data are published, is it time to hit the panic button?

Samuel Harvey

Evidence-based mental health and wellbeing programs for workers in health care organisations are needed

Sarah L McGuinness · Owen Eades · Kelsey L Grantham · Shannon Zhong · Josphin Johnson · Peter A Cameron · Andrew B Forbes · Jane RW Fisher · Carol L Hodgson · Jessica Kasza · Helen Kelsall · Maggie Kirkman · Grant M Russell · Philip L Russo · Malcolm R Sim · Kasha Singh · Helen Skouteris · Karen Smith · Rhonda L Stuart · James M Trauer · Andrew Udy · Sophia Zoungas · Karin Leder

Our findings add to northern hemisphere reports that possibly reflect a worldwide increase in GAS disease

Aleece MacPhail · Wen Jie Isaac Lee · Despina Kotsanas · Tony M Korman · Maryza Graham

To the Editor: We thank Gibney and Steer for their editorial1 in response to our research letter,2 supporting further public health action and research into invasive group A streptococcal (iGAS) disease. However, we are concerned about the statement that the 30‐day risk of iGAS disease for contacts of someone with an index infection is about 2000‐fold higher than background risk. This figure is derived from an English population‐based study3 and cannot be universally applied across circumstances varying in background incidence of GAS‐related disease, which is driven predominantly by socio‐environmental factors. Applying this 30‐day secondary attack rate of iGAS infection in Northern Territory household contacts would translate to about 177 cases per 1000 population (18%) in Indigenous Australian contacts and 2738 per 1000 population (274%) in people receiving haemodialysis.2 In contrast, rates of iGAS infection in household contacts were 3.2 per 1000 population in Canada4 and 0.7 per 1000 population in the United States.5 As described in the NT public health guidelines for iGAS, previous NT and Queensland studies have demonstrated large diversity of iGAS genotypes,6 with less clonality and a greater proportion of sporadic cases rather than transmission directly from another case of iGAS infection. This reflects the stark contrasts in iGAS and other consequences of GAS infection between central and northern Australia and southern states, as seen with so many other health issues linked to socio‐economic disadvantage. Gibney and Steer also note that some authorities recommend antibiotic prophylaxis for close contacts, and others do not.1 We wish to highlight that the NT guidelines for the public health response to iGAS include specific guidance around antibiotic prophylaxis for close contacts (for mother–neonatal pairs, contacts of severe iGAS disease cases, and in other special circumstances), informed by a literature review in the Appendix.6 National guidelines for iGAS are currently being developed and these need to include advice tailored for the vastly different epidemiology seen across Australia, reflecting a contrasting diversity of endemicity of GAS‐related disease. This has also been necessary for the Australian guidelines for diagnosing acute rheumatic fever, with low risk and high risk populations defined.7

Johanna M Birrell · Bart J Currie · Vicki L Krause

Biodiversity in Australia is in steep decline, posing major risks to human health

Katherine A Barraclough · Marion Carey · Kenneth D Winkel · Emily Humphries · Brooke Ah Shay · Yi Chao Foong

A 40-year-old man was referred to the neuromuscular clinic with generalised fasciculations

Dhayalen Krishnan · Matthew C Kiernan

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community. Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4 Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5 Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3 Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3

Rosalie Schultz

A structured diagnostic approach is required when assessing for JEV in patients with encephalitis

Sarah Allen · Celia M Cooper · Ajay Taranath · Allen C Cheng · Philip N Britton

Objective: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e‐cigarettes, vapes). Study design: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top‐up systematic review of published, peer‐reviewed studies in humans examining the relationship of e‐cigarette use to health outcomes published since the NASEM report. Data sources: Umbrella review: eight major independent reviews published 2017–2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 – July 2020 and not included in NASEM review). Data synthesis: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top‐up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e‐cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e‐cigarette or vaping product use‐associated lung injury (EVALI; largely but not exclusively for e‐liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e‐cigarettes can cause dependence or addiction in non‐smokers, and strong evidence that young non‐smokers who use e‐cigarettes are more likely than non‐users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e‐cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable. Conclusion: E‐cigarettes can be harmful to health, particularly for non‐smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E‐cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e‐cigarette use, their safety and efficacy for smoking cessation, and effective regulation. Registration: Systematic review: PROSPERO, CRD42020200673 (prospective).

Emily Banks · Amelia Yazidjoglou · Sinan Brown · Mai Nguyen · Melonie Martin · Katie Beckwith · Amanda Daluwatta · Sai Campbell · Grace Joshy

To the Editor: Over 26000 Australians experience out‐of‐hospital cardiac arrest (OHCA) each year, with almost nine in ten of these patients not surviving to hospital discharge or 30 days.1 Although it is known that swift defibrillation increases the possibility of patient survival in these situations, and that initial defibrillation by first responders (regardless of training) is associated with greater survival than initial defibrillation by emergency medical services,2 in Australia, less than 2% of OHCA cases receive defibrillation by a bystander.1 It is likely that this is driven by the limits to publicly accessible automated external defibrillators (AEDs) in Australian communities.3 On 30 November 2022, South Australia took a major step to deal with this problem and reduce death from OHCA. The SA Parliament passed the Automated External Defibrillators (Public Access) Bill 2022,4 making SA the first state or territory in Australia, and one of few in the world, to mandate the public provision of AEDs. The legislation, introduced by Member of the Legislative Council, the Hon Frank Pangallo of the SA‐BEST party, had bipartisan political support and backing from various organisations, and follows a recent public health campaign to install AEDs in Adelaide. The Bill will come into effect for government and public buildings in 2025 and a variety of private buildings in 2026, with awareness campaigns, grant programs, and communication with organisations being the focus of the interim period. The expected cost to the SA government of $7.2 million across four years is weighed against the $2 billion gross domestic product loss that Australia incurs annually as a result of sudden cardiac arrest.5 The health and economic benefits of public access defibrillation to Australian society are large. For the benefit of all Australians, other states and territories should follow the example set by SA and move to implement similar laws mandating the public availability of AEDs in their communities.

Joshua G Kovoor · Gregory J Page · Pramesh Kovoor