Environmental health

To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.

Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson

Urgent and sustained political engagement is needed to address the health impacts of climate change

Maddie Heenan · Lucie Rychetnik · Elly Howse · Paul J Beggs · Tarun S Weeramanthri · Fiona Armstrong · Ying Zhang

Comprehensive testing, monitoring, and treatment in primary care could save hundreds of Australian lives each year

Lien Tran · Benjamin C Cowie

To the Editor: A recent survey found that 65% of Australians choose cremation over burial, and that, in the context of the coronavirus disease 2019 (COVID‐19) pandemic, cremations could be increased fourfold.1 It seems appropriate to look at the various roles of the medical practitioner in approving cremations. The first crematorium was built in England in 1878.2 Medical practitioners were at the forefront of the movement in Australia, and argued that cemeteries were already overcrowded and in disrepair, that a fear of being buried alive was common, and that cremation was a hygienic way to dispose of the dead when it was still believed that cemeteries were a source of disease in the living.2 The first Australian crematorium was established in Adelaide in 1903, after which progress halted due to ongoing debate;3 however, objections were overcome and many were constructed in the interwar years (Box 1). The most cogent reason for rejecting cremation was that it could be employed to hide homicides. The contrary argument was that having a medical practitioner verify the cause of death would both prevent undetected crime and advance medical knowledge.4 To provide for this verification step, each Australian state and territory introduced legislation setting out a process for the approval of cremations. Where the cause of death is suspicious or unclear, permission is withheld and referral made to a coroner. In Queensland, Tasmania and Victoria, any medical practitioner who did not complete the death certificate may issue a cremation permit (Box 2). In the Australian Capital Territory, New South Wales and Western Australia, only government‐appointed medical referees may issue a permit. Some states and territories also require assessment of cremation safety, verifying that there is no implanted battery‐operated device, which may explode and damage the cremator, and that the deceased has not received radioisotopes, which may create a public health risk during cremation. At the Public Health Unit, we manage the appointment of medical referees for the NSW Ministry of Health. As part of the review of the effectiveness of our procedures, in 2020 we developed a short questionnaire to identify reasons why medical referees may refuse permission to cremate and to seek suggestions for improvement to this administrative process. We emailed it to a 10% random sample of NSW medical referees (n = 77) and received 46 responses (60%). Of these, 29 respondents (63%) had served in the role for more than 15 years, nine (20%) for five to 15 years, and five (11%) for less than five years. The number of permits issued in the previous 12 months ranged widely: 25 had signed zero to ten, and at the other extreme, two provided estimates of 780 and 1200 permits. This large variation is most likely related to varying demands on medical referees by local funeral directors. The reasons for rejecting applications included inconsistencies in the forms (ten), incorrect or unclear cause of death (seven), a reportable death (four), uncertain identity of the deceased (one), and a retained battery‐powered device (one). No suggestions for improvement were made, but three respondents suggested we provide some medical referee training — we have undertaken to develop an online education module. Although roles differ between Australian jurisdictions, medical practitioners have an important responsibility for verifying that a body is suitable for cremation, a decision that they must make independently of the practitioner who certifies the cause of death. Box 1 – Woronora Crematorium, Sydney, constructed in 1934* * Courtesy of Woronora Memorial Park. Box 2 – Roles of medical practitioners in approval of cremation under current legislation for each Australian state and territory State or territory Legislation Final approver of cremation Name of permit Comments Who assesses cremation risk Australian Capital Territory Cemeteries and Crematoria Regulation 2003 Medical referee, a medical practitioner appointed by the Director‐General Certificate of medical referee The medical referee must view and be satisfied with the “Certificate of medical attendant” The “Certificate of medical referee” must state that there is no medical reason why the remains should not be cremated New South Wales Public Health Regulation 2022 Medical referee, a medical practitioner appointed by the Secretary Medical referee's cremation permit The medical referee must be independent of the applicant and of the medical practitioner who attended the deceased A medical practitioner must provide cremation risk advice concerning battery‐operated implanted devices and radioactive treatment Northern Territory Cemeteries Act 1952 Crematorium manager Cremation permit A permit can only be issued by the cremation manager if the certificate provided is signed by two medical practitioners stating that death was due to natural causes No reference to assessment of cremation risk Queensland Crematorium Act 2003 Independent doctor Permission to cremate (independent doctor) The independent doctor is a doctor who has not signed the cause of death certificate or the “Cremation risk certificate” Any other medical practitioner may complete the “Cremation risk certificate” South Australia Burial and Cremation Act 2013; Burial and Cremation Regulations 2014 Registrar of Births, Deaths and Marriages Cremation permit Registrar of Births, Deaths and Marriages must consider the “Death from natural causes certificate of second doctor” Second doctor certifies that there is no reason why the body of the deceased should not be cremated Tasmania Burial and Cremation Regulations 2015; Burial and Cremation Act 2019 Medical practitioner Cremation permit The medical practitioner who issues the permit must not be a partner, employee or relative of the medical practitioner who issued the medical certificate in respect of the deceased person The medical practitioner who signs the permit must be satisfied that any implanted medical device has been removed Victoria Cemeteries and Crematoria Act 2003; Cemeteries and Crematoria Regulation 2015 Registered medical practitioner Certificate of registered medical practitioner authorising cremation The registered medical practitioner is someone who is not the medical practitioner who completed the notice in respect to the death of the deceased The funeral director must take note of any battery‐operated implanted device mentioned on the “Medical certificate of cause of death” Western Australia Cremation Act 1929; Cremation Regulations 1954 Medical referee, appointed by the Governor Permit to cremate The medical referee must not issue the certificate of cause of death or be in partnership with the medical practitioner who does so The “Certificate of medical practitioner” covers battery‐operated implanted devices and radioactive treatments

Mark J Ferson · Reannon Johnson · Toni Cains

Environmentally sustainable equitable digital transformation is central to delivering low carbon health care models

Zerina Lokmic‐Tomkins · Ann Borda · Kimberly Humphrey

E- cigarettes are not predominantly used as smoking cessation tools for older smokers

Alexander Larcombe

An 83-year-old woman of European ancestry had an initial diagnostic consideration of arsenical keratosis

Lachlan DW Lau · Anneliese Willems · Laura Scardamaglia

Universal screening would be cost-effective only if the test cost is low and people receive appropriate clinical management

Yinzong Xiao · Margaret E Hellard · Alexander J Thompson · Christopher Seaman · Jess Howell · Nick Scott

Restrictions should be accompanied by advice about appropriate locations for seeking medical care, by condition severity and type

Amy L Sweeny · Gerben Keijzers · Andrea Marshall · Emma J Hall · Jamie Ranse · Ping Zhang · Gary Grant · Ya‐Ling Huang · Dinesh Palipana · Yang D Teng · Benjamin Gerhardy · Jaimi H Greenslade · Philip Jones · Julia L Crilly

Queensland’s approach to Indigenous health equity planning and implementation should align with existing international frameworks

Maree R Toombs · Caitlin Curtis · Claire E Brolan

A 38-year-old woman presented to the emergency department with a 2-week history of fever, headache and mild dry cough

Arvind Yerramilli · Michelle Sam · Aadith Ashok · Eugene Athan

To the Editor: With the increasing interoperability of electronic medical records across health services, smoking and e‐cigarette use need to be systematically collected on hospital admission, and advice to quit smoking should be automatically included on hospital discharge summaries. Including information on smoking status in the discharge summary, and ultimately on My Health Record, presents an opportunity to address the use of tobacco and e‐cigarette products — the first being Australia's leading cause of preventable death and disease and the second an emerging exposure of increasing concern.1 Evidence from the United States Surgeon General reports that smoking cessation after cancer diagnosis lowers the risk of dying by 30–40%.2 For some patients with cancer, cessation benefits are equal to or exceed the value of state‐of‐the‐art cancer therapies. In addition, the Surgeon General report shows most patients admitted to hospital wish to quit smoking,2 and there are proven, workable but underused interventions to cease smoking. Peak medical bodies such as the Australian National Health and Medical Research Council and the Australian Commission on Safety and Quality in Health Care3 advise that adherence to post‐hospital referral practice guidelines leads to better outcomes, fewer readmissions, and improved patient survival. Australia's National Preventive Health Strategy has a goal of reducing the adult smoking prevalence from 14% to 5% over the next 8years.4 The newly released draft National Tobacco Strategy includes key policy actions to increase the use of cessation services and to support people who use tobacco and e‐cigarettes to quit.5 Around 1.2 million Australian adults are admitted to hospital at least once each year, and it is estimated that about one in five of them would benefit from smoking cessation services.6 Given most hospitalised patients want to quit smoking, providing this recommendation in a discharge summary for appropriate referral to a Quitline (www.quit.org.au) or a general practitioner is a practical solution to provide best practice care to patients, reduce the risk of readmission to hospital, and increase their survival.

Freddy Sitas · Ben Harris‐Roxas · Sarah L White · Fiona A Haigh · Margo L Barr · Mark F Harris

The increase in e-cigarette use by younger people who smoke or have recently quit reflects their presentation and marketing

Becky Freeman · Katherine Owen · Sandra Rickards · Alecia Brooks · Philip J Clare · Anita Dessaix

Many festive films portray a Western diet that can lead to dysbiosis

Olivia Yousef · Stephen De Souza

SARS-CoV-2 infection is associated with higher incidence of hospitalisation with several respiratory and non-respiratory conditions

Stacey L Rowe · Karin Leder · Kylie Dyson · Lalitha Sundaresan · Dennis Wollersheim · Brigid Lynch · Ifrah Abdullahi · Benjamin C Cowie · Nicola Stephens · Terence M Nolan · Sheena G Sullivan · Brett Sutton · Allen C Cheng

Australia has effectively instituted a vaccination mandate while maintaining critical workforce capacity in aged care

Sally Hall Dykgraaf · Jane Desborough · Anne Parkinson · Elizabeth A Sturgiss · Paul Kelly · Michael Kidd

The unacceptably high prevalence among Indigenous people and people who need dialysis warrants a clinical trial of prophylactic antibiotics

Katherine Gibney · Andrew Steer

To the Editor: Molecular diagnostics with whole genome sequencing (WGS) of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has been well described as a method to monitor the evolving epidemiology of the coronavirus disease 2019 (COVID‐19) pandemic and coordinate public health responses.1,2 WGS allows for the accurate identification of COVID‐19 variants, which, when combined with accessible diagnostic testing with polymerase chain reaction (PCR) and rapid antigen tests, supports contact tracing and public health action.1,2 Since January 2022, by agreement with the Forensic and Scientific Services reference laboratory, it has been our practice at the Prince Charles Hospital — a tertiary cardiothoracic transplant centre in Brisbane — to sequence all SARS‐CoV‐2 samples of patients requiring hospital admission for COVID‐19. The rapid turnaround times, averaging 36 hours, supported decisions on variant‐specific therapeutics and optimised bed management. The first case of the Omicron BA.2 subvariant detected at our centre was from a sample collected on 4 March 2022 (Box). This was 17days before public announcements of the dominance of the BA.2 strain by the Queensland Chief Health Officer on 21 March 2022.3 With the anticipated increase in local BA.2 cases, we were able to tailor our hospital level response in real time.4 Initially, even though case numbers were low, from an infection prevention and control perspective, we cohorted BA.1 and BA.2 patients separately to mitigate the risk of nosocomial co‐infection. We maintained the workforce and resourcing surge capacity with a second COVID‐19 ward that opened within days of the initial BA.2 case being identified. Furthermore, genome sequencing for COVID‐19 therapeutics resistance mutations led to alterations in clinical management as BA.2 became the dominant local strain, given its lack of susceptibility to sotrovimab. At the hospital and health service level, access to rapid WGS for identification of emerging variants provides the basis for greater infection prevention and control practices, resource and workforce management, and epidemiological monitoring, and carries implications for clinical management and therapeutics. WGS allows for rapid detection and contact tracing of nosocomial outbreaks, supporting identification of chains of transmission within hospitals. This information augments infection prevention and control by identifying gaps in current practice as well as supporting safer health care environmental design that minimises nosocomial transmission. Furthermore, detection of novel variants at the hospital level can help to predict new waves that require allocation of additional staffing and resources. The Australian Government has recognised the evolving role of microbial genomics in public health surveillance but has not yet committed to further development to optimise personalised medicine, hospital care, and therapeutic decision making.5 We strongly advocate for the inclusion of funding for sustainable rapid WGS that provides real‐time results under the Medicare Benefits Schedule. This will expedite Australia's transition to living with COVID‐19 and will allow us to better prepare our health system to manage new and emerging pathogens into the future. Box – Number of patients admitted and sequenced with coronavirus disease 2019 (COVID‐19) at the Prince Charles Hospital from 1 January to 3 April 2022 by genotype* *Bubble size range, 1–9; total number of patients, 256.

Matthew B Eustace · Ambika Sud · Craig Thompson · Sanmarie Schlebusch · Robert L Horvath

To the Editor: As nicotine prescribers, we welcome much needed advice for doctors on prescribing nicotine. However, we disagree with several recommendations and concerns raised in the article by Ween and colleagues.1 First, in our experience, the recommended starting nicotine concentration of 18mg/mL is inappropriate for most new users. The most popular devices for transitioning to vaping (pod vapes) have small batteries and require higher nicotine salt concentrations to effectively relieve cravings and withdrawal symptoms, typically 20–50mg/mL.2 On the other hand, 18mg/mL would be too strong for a smoker with low nicotine dependence using a more powerful vape pen or mod device. The concentration of nicotine required should be personalised for each user based on the level of nicotine dependence, device type and puffing topography.3 Second, the authors’ concerns about the toxicity of nicotine are overstated in our view. Nicotine is a toxic poison in its highly concentrated form, but the low concentrations used for vaping carry minimal risk of serious harm, although the long term impact of inhaled nicotine on lung tissue is not yet known.4 Third, Ween and colleagues raise concerns about the addictiveness of nicotine. However, most smokers who switch to vaping are already nicotine‐dependent. Dependence on vaping is generally less than for smoking5 because, in many cases, peak nicotine levels from vaping are lower and nicotine delivery is slower. In vitro and animal studies suggest other chemicals in smoke may also increase dependence, but human studies are lacking.6,7 Fourth, a blanket “3‐month prescription maximum” and an “agreed abstinence plan” do not recognise the diversity of the needs of smokers. Switching to vaping and then ceasing smoking can take many months or years for some smokers. Many continue to vape long term to avoid relapse to smoking or for perceived benefits. Therefore, a more flexible and personalised approach is needed. Last, Ween and colleagues are correct that unknown harms from flavours may appear over time and these need to be carefully monitored. However, flavours are an integral part of the appeal of vaping. Flavours encourage the uptake of vaping by smokers and are associated with higher quit rates.8,9 A recommendation to avoid flavours risks inadvertently increasing smoking.

Colin P Mendelsohn · Carolyn Beaumont

Enforceable indoor air quality standards are needed to minimise the risk of airborne infection transmission in shared indoor spaces

Lidia Morawska · Guy B Marks · Jason Monty

When chlamydia is detected, retesting and thorough contact tracing and management can help to interrupt transmission and reduce the risk of reinfection and reproductive complications

Stephanie C Munari · Jane L Goller · Margaret E Hellard · Jane S Hocking

Health professionals must be prepared to address the health risks and impacts of climate change

Hayden Burch · Laura J Beaton · Grace Simpson · Ben Watson · Janie Maxwell · Kenneth D Winkel

If colleges aspire to be leaders in health, they must show leadership on climate

Henry Oakley · Caroline Shaw · Jesse Gale

It is time to reimagine wellbeing and place the future of our children and young people at the centre of public action

Sandro Demaio · Sharon R Goldfeld · Anne Hollonds · George C Patton · Fiona J Stanley · Rosemary Calder · Kate Lycett · Zuleika Arashiro