Global health

Socio-economic factors may have contributed to the non-homogeneous incidence of SARS-CoV-2 infections across Victoria during 2020

Christine Roder · Callum Maggs · Bridgette J McNamara · Daniel O'Brien · Amanda J Wade · Catherine Bennett · Julie A Pasco · Eugene Athan

Dowry abuse is fundamentally driven by gender inequality and is a lesser known form of family violence in Australia

Manjula O'Connor · Amanda Lee

Cultural participation can be a buffer to racism and a tool to heal

Raymond W Lovett · Makayla‐May Brinckley

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

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

Evidence to inform conversations on Aboriginal health issues — in response to COVID‐19 and beyond Nearly everyone has been affected in some way by the coronavirus disease 2019 (COVID‐19) pandemic, and it is a public health risk for Aboriginal peoples and communities.1 The impacts of the pandemic are pervasive, wide‐ranging and continue to affect people and communities differently. Concerns about the indirect impacts of COVID‐19, caused by missed, delayed and avoided health care — not as a direct consequence of COVID‐19 infections — are shared internationally.2,3,4 While the prevalence of COVID‐19 in New South Wales remains low,5 local data show significant changes in health utilisation across the state. During the 4‐month period from March to June 2020, compared with the same period in 2019, face‐to‐face primary care consultations decreased by 22.1%, breast screen activity by 51.5%, ambulance incidents by 7.2%, emergency department visits by 13.9%, public hospital inpatient episodes by 14.3%, and public hospital planned surgical activity by 32.6%.6 Such decreases are not unique to NSW.7 Before COVID‐19, Aboriginal people faced health disadvantages and inequitable access to health care. Any decrease in health care access for Aboriginal people through missed, delayed or avoided health care may lead to further adverse health outcomes and inequities.1,4,8 In recent months, we came together as a group of 12 Aboriginal community members from across NSW to share our experiences and perspectives regarding the indirect impacts of COVID‐19. We live and work on Eora, Wilyakali, Bundjalung, Yuin and Gumbaynggirr lands. The discussions occurred over three separate sessions, each held a week apart between 24 August and 1 September 2020. Six members of the group (DF, CP, PO, BO, DL and KB) captured the key messages identified from the talks and synthesised the findings into three main themes: community supporting the community; the social determinants of health; and access to health care. These conversations were hosted and supported by the Critical Intelligence Unit established as part of the NSW Health COVID‐19 response and the Agency for Clinical Innovation (TDB). Illustrative quotes shared by the co‐authors have been selected to demonstrate salient points. The term “mob” has been used throughout to identify who we are and where we are from — our connection to our shared identity as Aboriginal people. Community supporting the community is a real strength — in the pandemic, and always In responding to COVID‐19, we see that Aboriginal organisations are coming together, more than ever, to create a movement that will continue to inform positive change to address Aboriginal health issues. Mob are proud of how they are keeping each other safe. It is a point of pride that has strengthened community. Our mob are concerned about the safety of others and our elders. (CP) Aboriginal leaders and Aboriginal community controlled health services are active in responding to COVID‐19, drawing on experiences from the 2009 HINI influenza pandemic and implementing culturally appropriate resources.9 The pandemic has been disruptive, and community events and gatherings have been cancelled because of important and legitimate public health concerns. However, this does impact our community approach to health care, cultural practices and connection to country.1,10 Our mob aren’t able to connect for sorry business and funerals, marriages and births. The provision of our health care, along with the provision of our social and emotional wellbeing, has changed. And connectivity is the main ingredient for our mob to stay healthy. This is the biggest barrier. (CP) Social determinants of health for Aboriginal people Social determinants are the conditions in which people are born, grow, live and age, and how these factors influence our health and determine health inequalities.11 Cultural determinants of health such as connection to country (land and water), traditional practices and kinship systems promote resilience and support social and emotional wellbeing for Aboriginal peoples and communities.10,12 The COVID‐19 pandemic is likely to amplify the social determinants of health,13,14 and our concern is these determinants will continue to affect access to health care and increase health inequalities. Based on our own lived experiences and anecdotal community feedback, we are hearing that food security has increased for some Aboriginal people in response to COVID‐19. People are fearful of going into large shopping centres — fearful of catching COVID‐19. In some rural and remote areas, local shops are pushing up their prices, and people are left with no choice but to buy cheaper (and often less healthy) options to feed their families. Increase in government payments has resulted in the one and only shop in community providing food jamming their prices up. The price of food and water is beyond compare when you are paying $10 for a loaf of bread. Because of COVID‐19, people don’t want to come into town to do their shopping. (DL) We are concerned that restricted access to health care in response to border closures will impact the health and wellbeing of Aboriginal peoples. Some communities are being hit hard. To give a raw example, people are being refused medical treatment and are driving 600–800 km just to get any sort of medication or treatment around their health. (DL) We are also concerned that a lack of cultural safety displayed during COVID‐19 will lead to Aboriginal people being confronted with racism when trying to access health care.15 COVID‐19 has made accessing health care even more difficult Deciding to seek health care is difficult, and for some Aboriginal people, access to care has become more challenging during COVID‐19 with reduced availability of services. Many doctors and services have temporarily shut their doors to new patients, and this is likely to have a profound impact on people’s health. More generally, there have been efforts to overcome access challenges posed by COVID‐19 through the use of telehealth and virtual care. In our opinion, telehealth for diagnosis and e‐prescribing can be useful; however, there are challenges to using telehealth such as limited access to equipment and internet connection, and reluctance from some people to disclose personal information over a device. When we look at the provision of health care for our mob, one of the biggest barriers is having to sit in front of a computer. And talk to a computer, rather than a human connection. Our mob like to connect and have a yarn. (CP) Our view is that paying attention to the intersections of culture and diversity is essential to understanding the indirect impacts of COVID‐19. Within Aboriginal communities, there are minority groups who are significantly affected by COVID‐19. Minority groups include people with existing chronic conditions, people with disabilities, people experiencing homelessness, people living in rural and remote areas, and people who identify as lesbian, gay, bisexual, transgender, queer, asexual and questioning. Sistergirl and brotherboy are terms used for gender diverse people within some Aboriginal or Torres Strait Islander communities.16 If the mob aren’t receiving health related treatment, how this is feeding into direct or indirect impacts on disabilities. And how we can pick this up through the health system as disability is not in closing the gap. If we aren’t addressing it at a higher level, we are never going to address it at the ground level. (DL) We are also concerned about an increase in risk for our older people living with disability. These risks have been outlined by Aboriginal people with disability and their representative organisations, advocates and allies in international and national calls to action for governments to ensure Aboriginal disability‐inclusive public health, social and economic responses to the pandemic that put our mob at the forefront of any future planning in the health system.17 The recent drought, bushfires and now COVID‐19 are compounding risk factors for mental health issues and suicide. There is concern that some government measures to control the spread of COVID‐19 are triggering for mob — especially for those with trauma histories.18 We know mental health issues and suicide rates are high for our peoples,8,19 and we are concerned this level of disadvantage will worsen in response to COVID‐19. We support the recommendations made by the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention at the University of Western Australia to manage COVID‐19 recovery and address adverse impacts.19 The recommendations focus on the right to self‐determination, the health and mental health workforce, social and cultural determinants of health, digital and telehealth inclusion, and evaluation that includes Indigenous data sovereignty. These recommendations directly align with our lived experiences and were running themes throughout our discussions and overall assessment of the indirect impacts of COVID‐19 in our communities across NSW. Where to next? We prepared this article to inform future conversations on Aboriginal health issues in response to the COVID‐19 pandemic and beyond. Our view is that drawing on the lived experience and realities of Aboriginal peoples, taking firm action on the social determinants of health and working collaboratively with Aboriginal peoples and communities is the most effective way to address the indirect impacts of COVID‐19.

David Follent · Cory Paulson · Phillip Orcher · Barbara O'Neill · Debbie Lee · Karl Briscoe · Tara L Dimopoulos‐Bick

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

Julie M Marchant · Anne B Chang

To the Editor: We read with interest the article by Koff and Lyons1 and agree that there is a need to develop, implement and evaluate health systems around patient needs and wishes. Implementing value‐based health care is an excellent initiative to address sustainability and patient‐centred care.2 Genuine reform requires a transition away from volume‐based service contracting towards a multidisciplinary approach focused on evidence of improved outcomes.1,2 This would reward doctors and the system for keeping patients healthy and independent in their own homes, with community support, for as long as possible.2 The Leading Better Value Care initiative (2016–2020)1 may be misinterpreted as another set of top‐down policies. It may also have unintended consequences such as reinforcing the silo approach to disease states, diverting finite hospital and local health district resources, such as staff and expertise, to these 13 policy‐driven priority projects. In our work in perioperative health care, we have identified some concerns. First, the sustainability of our health systems is tested by patients who are frailer, who have chronic diseases, and who present for high risk surgery.1,3,4 Second, these patients have a higher incidence of post‐operative complications3,4 and are more likely to be discharged to a higher care facility, rather than back to their home.4 Third, performing surgery on these patients is associated with higher costs and hospital readmissions.4 Fourth, our research has found that past policy for surgical patients5 has led to today's “wicked problem”; that is, frontline perioperative clinicians and managers are dealing with lack of time, increased demand for precision, fragmentation of care, lack of coordination across an episode of care, bed block, complexity of care, and unclear patient outcome measures. In this context, work is required to empower patients and staff in shared decision making to understand the true complexity of risks and outcomes associated with high risk surgery. In conclusion, implementing statewide value‐based care is timely and can be transformational. The high risk surgical patient cohort and the staff providing their care are likely to benefit from, and should be included in, this important reform agenda.

Su‐Jen Yap · Roberto Forero · David Greenfield · Kenneth M Hillman

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

Jaime A Teixeira da Silva

Resource‐limited emergency departments responding to the COVID‐19 pandemic face many challenges — their strength lies in their unique solutions The coronavirus disease 2019 (COVID‐19) pandemic is stretching hospital resources around the world. Emergency departments (EDs) are on the frontline of care and have been impacted significantly by the surge of patients with both suspected and confirmed infection.1,2 Resource‐limited EDs in low and middle income countries are particularly vulnerable. Pre‐existing issues, including a limited workforce supply, have been exacerbated, and new threats, such as a lack of personal protective equipment (PPE) and oxygen, have emerged.1,2 This article explores the impacts of the COVID‐19 pandemic on resource‐limited EDs across the Indo–Pacific. It considers the unique challenges for the region and describes opportunities for building system resilience at a time of unprecedented demand for emergency care. Emergency departments and the COVID‐19 pandemic Emergency care systems are essential for universal health coverage.3 Effective emergency care improves health outcomes, and is critical to achieving the health‐related Sustainable Development Goal targets.4 EDs are the cornerstone of emergency care systems, enabling access to facility‐based care for patients with acute illness and injury. They provide an interface between community and hospital care, and address unmet needs for vulnerable patients. These roles are augmented during communicable disease outbreaks, when EDs fulfil surveillance, triage and clinical care functions.3,4 Since the World Health Organization (WHO) declared COVID‐19 a global pandemic in March 2020, most low and middle income countries across the Indo–Pacific have reported cases. About 20% of patients require hospital admission, and early recognition and resuscitation can help reduce mortality.1 EDs therefore have a key role to play in risk‐stratifying patients, providing initial therapy, establishing goals of care, and identifying patients who may benefit from advanced interventions. Pandemic preparedness The Indo–Pacific encompasses the eastern Indian Ocean and Western Pacific regions, connected through South‐East Asia. The region is characterised by cultural, geographical and economic diversity.5 The Global Health Security Index reflects a country's ability to detect, communicate and respond to a communicable disease outbreak.6 Most low and middle income countries across the Indo–Pacific score below the average preparedness level of 40.2 (on a scale of 0–100) and are among the least prepared countries.6 These findings reflect pre‐existing gaps in health care capacity that are likely to be exacerbated during a public health emergency.7 A historical lack of investment in emergency care systems across Indo–Pacific low and middle income countries means that many EDs have limited resilience in times of increased demand.3,4 Emergency care has not been a focus for international donors,4 and sequential reductions in the Australian Government's development assistance budget for health have further compromised capacity building efforts.8 Although these projections foreshadow a devastating impact on low and middle income countries across the region, the global experience of the COVID‐19 pandemic has illustrated the limitations of preparedness modelling. Several of the most prepared countries are now disease epicentres with overstretched health services, in part reflecting an initial reluctance to follow WHO advice regarding testing and contact tracing.9 Indo–Pacific nations may have strengths that protect against this trend, such as recent epidemic experience.10 Nimble and innovative responses may help build resilience, potentially providing globally relevant lessons that would typically be expected from high income countries. Challenges in public health response A major determinant of the pandemic's impact on EDs will be the success of broader public health interventions. Low and middle income countries, including those in the Indo–Pacific, will face unique challenges in disease containment.2 As demonstrated by several Pacific countries, island states have greater ability to shut their borders and limit inward passage of the virus. However, a freeze on international access will have a significant socio‐economic impact and is unlikely to be sustainable. It may also affect the supply of essential medical equipment, surveillance capacity (given that certain countries rely on foreign pathology services for COVID‐19 testing) and retrieval systems. An important mechanism to disrupt community transmission of COVID‐19 is physical distancing. This is antithetical to many sociocultural practices across the Indo–Pacific, where communal living is common and regular congregation at community meeting places is the norm. Modelling from a Papua New Guinean setting has demonstrated that physical distancing measures in that community were 60–70% less effective compared with Australia.11 Public health responses across the region have already been complicated by extreme weather events and humanitarian crises. Examples include Cyclone Harold, a category 5 cyclone that recently affected the South Pacific, and the climbing infection rate in the worlds’ largest refugee camp at Cox's Bazar in Bangladesh.12 Worsening climate change will further exacerbate the incidence and severity of natural disasters and disease outbreaks. Challenges for emergency departments As community transmission increases, demand for ED care will escalate. The impact may be more pronounced among Indo–Pacific communities as a result of high rates of non‐communicable disease.13 COVID‐19 appears to be more severe in patients with diabetes, hypertension and chronic pulmonary illness, all of which are prevalent across the region.13 Increasing demand is likely to expose pre‐existing deficiencies in ED systems and resources, including scarce critical care capacity.1,2 A survey of emergency care clinicians in the Pacific recently identified minimal integration of surge response with routine emergency care, and a lack of essential processes, such as triage and patient flow.7 Consistent with these data, Box 1 lists key challenges in systems, spaces, supplies and staff that have become evident to Indo–Pacific clinicians during COVID‐19 response planning.2 Emerging data suggest that frontline clinicians are at an increased risk of death from COVID‐19, in part due to suboptimal PPE.14 Limited access to PPE is a major threat and will place ED clinicians at increased risk of infection. Low and middle income countries face challenges in PPE procurement because of supply chain limitations as well as market‐based competition with high income countries.1,2 Illness among health care workers will stretch an already fragile health care workforce. In the event of a surge, EDs will require significant increases in staffing, and the challenge may be exacerbated by high rates of comorbidities, absenteeism and inadequate training.7,13 Additionally, many Indo–Pacific EDs rely on a sole medical leader for clinical and administrative decision making.15 The pandemic may place these clinicians at risk of burnout, illness and death, thereby exacerbating the mismatch between supply and demand for care. Unintended consequences To meet these challenges, EDs will need to make substantial changes to their processes. However, there is a risk that distraction from pre‐existing health priorities will worsen the overall impact. Patients with chronic disease have poor outcomes at times of increased health system stress, as occurred in West Africa during the 2014 Ebola epidemic when resources were diverted away from routine care.16 Lockdown measures will make it difficult for some patients to access emergency care, and fear of acquiring COVID‐19 in hospital may create a further barrier to ED attendance. Additionally, the socio‐economic consequences of public health interventions are likely to contribute to poor health outcomes in the longer term. There is also a risk that donor funding will target resource intensive equipment (such as ventilators) that may be unsuitable in a low and middle income country context. Many resource‐limited ED clinicians are accustomed to a low cost essential care approach.1 Rather than emphasising expensive and high risk interventions, a focus on simple measures such as rigorous infection control and oxygen therapy is likely to be advantageous.1 The pandemic has already had a gendered impact, exacerbating the “triple burden” of productive, reproductive and community work responsibilities imposed on women.17 This has been particularly evident in low and middle income countries, where women make up a larger proportion of frontline workers and are disproportionately expected to fulfil unpaid household duties.17 Addressing immediate needs Addressing these challenges requires urgent action. While high level guidelines such as the WHO Emergency and Disaster Risk Management Framework18 exist, these often neglect the practical challenges faced by EDs. COVID‐19 guidance for Indo–Pacific EDs must complement WHO recommendations, and be culturally appropriate, fiscally responsible and immediately actionable2 (Box 2). Indo–Pacific ED leaders are already implementing COVID‐19 response plans. Examples from across the region are profiled in Box 3. These early success stories highlight the capacity of local clinicians to lead disaster response activities and provide meaningful care in the face of escalating health care demand. The Australian Government has provided some support for this effort by contributing funds to the WHO response plan and deploying specialist advisors to selected Indo–Pacific countries.8 Opportunities An increasingly interconnected world, combined with climate change and mass migration, will result in more frequent communicable disease outbreaks. COVID‐19 provides an opportunity to build resilient EDs that are better prepared for this challenge. The pandemic is also a chance to enhance the sustainability of routine emergency care through system strengthening, facilitated by multisectoral collaboration between clinicians, governments, technical organisations and donors.3 This effort should be informed by existing guidance for the enhancement of human resources, infrastructure, governance and processes to improve regional emergency care capacity.7 Australian agencies, such as the Indo–Pacific Centre for Health Security, have a key role to play in resourcing this activity. The pandemic provides a unique opportunity for the Australian Government to advance its commitment to strengthening health care systems and deliver on the promise of its Pacific Step‐up.5,8 It also offers a chance to leverage Australia's expertise in emergency care for the benefit of the region.3 Conclusion Time will determine the full impact of COVID‐19 on the Indo–Pacific, but global trends suggest that ED capacity may be severely stretched. Responses should target the unique challenges for disease control and emergency care delivery across the region. Although local ED clinicians are already demonstrating leadership and adaptability in their surge planning, the pandemic provides an opportunity to build resilience in emergency care systems and enhance future capacity for both routine care and outbreak response. Australian clinicians, organisations and governments have a key role to play in supporting this effort. Box 1 – Challenges for COVID‐19 preparedness and response in emergency departments (EDs) Variable Challenge (and selected examples) Systems Disaster and surge plans Many EDs and hospitals do not have standard operating procedures for surge events and communicable disease outbreaks: “ED COVID‐19 operations need a focal point of command at hospital executive level so that ED preparatory activities can be prioritised and fast tracked” (Solomon Islands) Triage Some EDs have no formalised triage systems. Implementing a triage system, for the first time, during a pandemic is fraught with difficulty Patient flow Overcrowding, interdepartmental communication barriers and a lack of ward beds can delay care for both COVID and non‐COVID patients Space Isolation and resuscitation areas Many EDs lack the physical space and infrastructure to adequately provide safe and effective routine care. In the context of the pandemic, a lack of dedicated isolation and resuscitation areas will be a major challenge Storage capacity Attempts have been made stockpile essential resources; however, there is a lack of dedicated on‐site storage space at many hospitals Supplies Personal protective equipment (PPE) and cleaning agents PPE supply is a major and ongoing concern: “There is not a standby supply of PPE … in a normal working day. [There is no] process to ensure a consistent supply of PPE in the department” (Fiji) “Our hospital is not a central level hospital, [so] we [were not given] much supplies” (Myanmar) Laboratory testing There is often limited laboratory capacity, and staff have competing priorities beyond EDsMany testing facilities are offsite or overseas, resulting in delayed isolation, identification and treatment of patients with COVID‐19, placing staff and other patients at risk Oxygen There is a lack of portable oxygen cylinders and oxygen concentrators in many facilities. Relatively few facilities have capacity for intubation and ventilation Novel therapies There is uncertainty surrounding the therapeutic benefits of agents such as hydroxychloroquine, azithromycin and remdesivir. In some countries, these medications are difficult to source, and with international demand increasing, supply will become even more scarce. This will impact the availability of these medications for patients who require them for other indications Staff Critical care training There are few formally trained critical care staff in many EDs. Additionally, there are concerns about workforce shortages and the reliance on volunteers Some hospital staff do not appreciate the importance of early recognition and treatment: “[Some staff lack an] initial understanding of the role of ED in the approach to COVID‐19” (Fiji) Staff morale and safety concerns Many staff are concerned about the risk to themselves and their family members if they are required to care for patients with suspected COVID‐19 without adequate protection: “[There are] difficulties in commuting due to strict curfew/modified lock down and restrictions on inter district transport. [There is] COVID phobia created by the media” (Sri Lanka) “I don't want them to infect, I don't want them to exhaust, I don't want them to depress, I want to create safe and less stress environment” (Myanmar) Box 2 – Strategies for optimising emergency department (ED) preparedness and response* Systems Ensure ED processes are consistent with broader public health and hospital management strategies Utilise local case definitions to identify suspected cases Establish a clearly marked screening and triage process at the entrance to the hospital, and stream patients based on the acuity of their presentation. For example, low acuity patients might be redirected to a co‐located surge clinic Maintain infection prevention and control to the highest possible standards. Ensure patients and staff practice physical distancing, cough etiquette and hand hygiene Minimise the volume of patients in the ED and isolate symptomatic patients from others by establishing a respiratory zone Develop clear admission/discharge criteria and establish ceilings of care for the facility Space Establish a clearly marked screening and/or triage station at the entrance to the facility Ensure the ED and surge clinic (if established) have designated waiting areas for patients with respiratory symptoms Allocate separate areas in the ED for the management of symptomatic, medium and high acuity patients Supplies Anticipate equipment needs and stockpile to the extent that is possible, especially disposable items that will be in high demand (oxygen cylinders, antipyretics, personal protective equipment, etc) Follow World Health Organization guidelines on resource stewardship. For example, implement clear thresholds for providing supplemental oxygen, such as SpO2 < 90% on room air for stable patients, SpO2 < 92% on room air for pregnant women, and SpO2 < 94% on room air for patients with respiratory distress Avoid use of therapies that are likely to increase virus transmission (eg, nebulisers) Develop safe processes for cleaning and reusing equipment based on World Health Organization infection prevention and control advice Staff Make sure that all staff feel included, empowered, motivated and supported Update the staff contact list and plan for absenteeism Identify staff who are high risk for infection and reallocate them to other areas Train staff in the systems and processes that have been developed Remind staff that they should not work if they have acute respiratory symptoms Use ancillary staff and other community members for non‐technical tasks Remind others that COVID requires a whole‐of-government, whole‐of-health and whole‐of-hospital response; the ED cannot do it alone Ensure ED staff are involved in the post‐pandemic review process to promote ongoing systems improvement and sustainability * Adapted from Australasian College for Emergency Medicine. Managing COVID‐19 across the Indo‐Pacific: a guide for resource limited EDs. Melbourne: Australia, 2020. https://acem.org.au/getmedia/3930cc60-abb1-4517-b7af-36da918a3f7b/Managing-COVID-19-across-the-Indo-Pacific-(G763) (viewed Aug 2020). Box 3 – Examples of successful COVID‐19 preparedness and response strategies employed across Indo–Pacific emergency departments (EDs) Variable Strategy (and selected examples) Systems Leadership and coordination Many countries have developed national coordinating bodies that include ED clinicians as key stakeholders. This is a recognition of their pivotal role in crisis coordination: “Once there were initial reports of care in China, the Ministry of Health had formed a National Taskforce and … ED was invited to participate in it as stakeholders” (Fiji) Identification of key leaders at each stage of the patient journey has been essential: “The hospital formed its Taskforce and we had devised operating procedures and a flow chart with important contact persons at each stage” (Fiji) Triage, screening and patient flow There has been a rapid development of triage, screening and flow systems based on specific criteria: “For patients with respiratory symptoms and fever … the high acuity patients can be stabilised in the ED respiratory resus and transferred to ICU. Medium acuity patients to be stabilised in the step down area of the respiratory section of the ED. Ambulance will transport patients to the isolation wards and ICU” (Solomon Islands) Space Isolation and resuscitation areas Guided by experience from Africa during the Ebola outbreak, EDs in Solomon Islands, Fiji, Myanmar and Sri Lanka have undergone significant restructuring of limited spaces to facilitate separate areas for screening, isolation, resuscitation and storage Supplies Infection prevention and control, and personal protective equipment (PPE) Drawing on experience during the 2009 H1N1 pandemic, EDs have adapted guidelines for the judicious use of PPE, while emphasising that staff safety is a priority: “Within the storage area in ED of consumables, a cupboard is allocated to store PPE kits and this is tallied and replenished by the Hospital Infection Control team” (Fiji) “Health care worker exposure assessment protocol was designed” (Sri Lanka) “Luckily we have many people who want to donate what we need so we are still ok” (Myanmar) Resource utilisation Early decisions have been made about distribution of limited resources: “No CPR will be done on COVID‐19 high acuity patients who have (deteriorated) despite maximal non aerosol generating treatment” (Solomon Islands) “We decided to do respiratory team with only three people, because … when positive case came to our ED only these three need PPE” (Myanmar) Novel therapies These are not being used until there is proven evidence of benefit. Local guidelines have been developed: “Cautious use of fluids except in shock. Use of metered dose inhalers (rather than nebulisers) for asthma exacerbations” (Solomon Islands) Staff Critical care training Countries have begun re‐training staff in critical care and there has been redeployment and re‐training of staff from non‐essential areas to the ED. Non‐medical staff are also being utilised to assist with operational requirements such as cleaning and transportation Staff morale and safety There is a focus on open communication and staff wellbeing: “We did meeting every night with zoom and discussed the problems faced in their duty time … we asked their working capacity … and redrew duty roster” (Myanmar) “Special quarantine centres with all the facilities were designated for staff members who had problems in home isolation” (Sri Lanka) “Staff are undergoing medical checks. Staff with comorbidities will not be working in the respiratory section of the ED” (Solomon Islands)

Isobelle G Woodruff · Rob D Mitchell · Georgina Phillips · Deepak Sharma · Patrick Toito'ona · Krishantha Jayasekera · Khine Shwe Wah · Megan Cox · Gerard M O'Reilly

Australia needs to improve vigilance in the global endeavour to eradicate poliomyelitis In 1988, there were over 350 000 cases of paralytic poliomyelitis globally.1 In 2018, there were 29 cases and in 2019 there were 112 cases2 — all in the only two remaining countries in the world where wild poliovirus (WPV) is endemic (Afghanistan and Pakistan). We are tantalisingly close to global eradication. What is poliomyelitis? Poliovirus is an enterovirus and exists as three serotypes: WPV types 1, 2 and 3. Spread via the faecal–oral route, poliomyelitis results in subclinical or self‐limited infection in most patients, but causes acute flaccid paralysis (AFP) due to anterior horn cell damage in about one in 200 cases.3 Ubiquitous distribution of polioviruses and epidemics of paralysis caused widespread panic throughout the world in the early 20th century. With an ambitious and unprecedented level of international public and private collaboration and funding, the Global Polio Eradication Initiative (GPEI) was launched in 1988.2 In recent years, significant achievements have been recorded (Box 1), but the target of global eradication is yet to be reached. The GPEI currently faces two main global issues. Firstly, addressing the eradication of WPV1 in Afghanistan and Pakistan, and secondly, dealing with the growing issue of vaccine‐derived poliovirus (VDPV).1 Vaccine strain virus can slowly accumulate mutations over time, which eventually result in reversion to neurovirulence — these strains are known as VDPV. Although extremely uncommon, this phenomenon becomes increasingly prominent in areas where there are long term low vaccination rates, allowing continued circulation of the attenuated poliovirus contained in the Sabin vaccine. Ironically, the modern prominence of VDPVs is a consequence of the GPEI's successful endeavours to reduce WPV. Poliomyelitis close to home VDPVs are appearing in areas with low immunisation rates in Africa, and recent emergence in closer neighbours puts poliomyelitis back on our doorstep. In 2018, there was an outbreak in Papua New Guinea involving 26 VDPV type 1 AFP cases, including a death.4 In late 2019, the Philippines reported 15 VDPV cases, and Malaysia reported three cases in 2019 and one in 2020.5 These countries had previously been declared poliomyelitis‐free.6 Between 2012–13 and 2017–18, the median number of annual arrivals for Philippine citizens to Australia was 141 813, with 8% of these arrivals being children younger than 15 years.7 Screening individuals at our borders is not an economically viable option to prevent poliomyelitis, thus highlighting the importance of optimal immunisation and high quality surveillance. Australia's commitment to World Health Organization targets Australia and all other Western Pacific region countries were certified as poliomyelitis‐free on 29 October 2000.6 As a signatory to the World Health Organization's International Health Regulations (2005),8 Australia reports annually on its compliance, with obligations to prevent and respond to acute public health risks of international consequence. This includes observing temporary recommendations issued when the WHO declared the risk of international spread of poliovirus a public health emergency of international concern in 2014, poliovirus containment activities, and reporting to the WHO Regional Certification Commission providing evidence that Australia's poliomyelitis‐free status has been maintained. This evidence requires Australia to meet WHO‐specified surveillance standards. The Australian National Enterovirus Reference Laboratory plays an important role in providing enterovirus testing and environmental surveillance for Australia and the Western Pacific region to meet these requirements. Environmental surveillance for polioviruses is costly and labour‐intensive and involves sampling sewage for detection and then characterisation of enteroviruses. There is currently inadequate capacity to routinely conduct environmental surveillance throughout Australia. Therefore, this capacity is currently directed at monitoring during high risk episodes; for example, when there is a cluster of AFP cases or after the importation of a confirmed case. The detection of any poliovirus in Australia is considered a likely importation event, as Australia stopped the use of the oral polio vaccine in 2005. Adequate clinical surveillance is based on two key WHO indicators. Firstly, achieving an AFP detection rate of at least one case per 100 000 children younger than 15 years. Secondly, the WHO requires enterovirus culture on two stool samples collected at least 24 hours apart, both within 14 days of onset of paralysis, for at least 80% of reported AFP cases.9 Submission of two samples ensures adequate sensitivity, required due to intermittent viral shedding.10 Meeting these targets provides national and international reassurance that there is timely investigation that excludes poliomyelitis as the cause of AFP. However, for Australian clinicians, awareness of this surveillance and its purpose is often not well understood. An overview of the AFP surveillance structure is provided in Box 2. Importantly, AFP cases need to be notified and investigated even if another diagnosis (eg, Guillain–Barré syndrome) is likely. Australia's performance in meeting World Health Organization targets While Australia has met the surveillance target for AFP notification for the past 11 years, we consistently fail to reach the WHO benchmark for stool submissions (Box 3).11 This is in marked contrast to many of our closest neighbours. Only New Zealand, the small Pacific Island countries and Papua New Guinea have a similarly low performance over recent years. In 2018, adequate stool collection was achieved in only 44% of Australian AFP cases and 2019 results are currently at 65%.12 The most populous states of New South Wales and Victoria consistently underperform, with rates of 33% and 42% respectively for 2018 (Bruce Thorley, Head of Victorian Infectious Diseases Reference Laboratory, Australia, personal communication, September 2019). In 2018, three cases of AFP and anterior horn cell abnormality on magnetic resonance imaging in young children were reported to WHO by Australia as “poliomyelitis compatible” because of a lack of adequate clinical information and appropriate stool sample collection (David Isaacs, Chair of Polio Expert Panel, Australia, personal communication, September 2019). In addition to providing robust public health surveillance, ensuring adequate investigation of AFP can produce relevant diagnostic information for an individual. A 3‐year‐old child with permanent significant disability following AFP in 2018 had the neuropathic enterovirus D68 (EV‐D68) in faeces sent for AFP surveillance purposes.13,14 The converse may also apply. Detection of a non‐polio enterovirus by polymerase chain reaction (PCR) in a clinical sample does not preclude the possibility of dual infection with poliovirus. Co‐infection and subsequent recombination of species C non‐polio enteroviruses with Sabin‐like poliovirus is an important precursor event in the development of VDPVs.15 Barriers to improvement A number of logistical issues affect successful stool sample collection; for example, late presentation of patients, discharge before sample collection, and constipation may all have an impact on stool collection rates.16 In some instances, pre‐examination by microbiology laboratories using enterovirus reverse transcriptase PCR (RT‐PCR) may occur. This does not exclude poliovirus infection and testing at the WHO reference laboratory is still required. Due to the extended viral shedding in the gastrointestinal tract, stool samples are the specimen type most likely to facilitate enterovirus identification. The collection of rectal or throat swabs is discouraged by WHO due to reduced sensitivity compared with faeces samples. Pragmatism may dictate that the former may be preferable to no testing at all in a particular child if barriers to faeces collection exist. Recognising poliomyelitis in a low prevalence community Cases of poliomyelitis present as acute and often painful weakness in affected limbs. The weakness is often asymmetrical, affecting lower limbs more frequently than upper limbs, with rapid onset and usually no further progression after 48 hours. Sometimes patients may present atypically, reinforcing the need for any AFP to be reported and investigated. Alternative presentations may include dyspnoea or dysphagia due to weakness of bulbar or respiratory muscles. Cerebrospinal fluid findings are suggestive of viral meningitis. There are usually no systemic symptoms, although a recent history of a mild upper respiratory tract infection with or without headache may be elicited.3 A history of exposure to a high risk area (eg, Central Africa, Pakistan, Papua New Guinea or Afghanistan) and/or lack of previous immunisation is important. A history of distant past immunisation will not exclude the diagnosis, particularly if this was received overseas.10 Call to action There appears to be a level of complacency among physicians due to the rarity of clinical poliomyelitis in Australia. In addition, there is a lack of awareness in the diagnostic chain regarding the importance of laboratory surveillance. In 2020, a comprehensive action plan was implemented by the Paediatric Active Enhanced Disease Surveillance (PAEDS) network to improve faeces collections across the country. Clinicians should not fear that they are being alarmist in notifying AFP cases that they believe have negligible risk of poliomyelitis. The emphasis on detection and investigation of AFP cases despite an alternative diagnosis may seem pointless for an individual case, but at a national level, it allows confidence in the integrity of surveillance and, ultimately, achievement of poliomyelitis eradication. Conclusion The recent VDPV outbreaks in Papua New Guinea and the Philippines and the ongoing WPV1 circulation in Pakistan and Afghanistan emphasise the possibility of poliomyelitis re‐introduction into Australia. Clinical acumen is unlikely to provide a timely diagnosis. Clinicians are reminded that poliomyelitis as a diagnosis should be excluded in all cases of AFP; faeces collection from all AFP cases independent of age should be viewed as a priority to ensure the country remains poliomyelitis‐free and as an opportunity to maintain surveillance, even when another diagnosis is confirmed or highly likely. Box 1 – Selected achievements relevant for Australia in the history of the Global Polio Eradication Initiative2 Year Milestone 2000 Australia declared poliomyelitis‐free 2005 Inactivated polio vaccine replaces oral polio vaccine in Australia 2014 South‐East Asia declared poliomyelitis‐free 2015 Wild poliovirus type 2 declared eradicated 2017 99% of poliomyelitis eradicated globally 2019 Wild poliovirus type 3 declared eradicated Box 2 – Schematic overview of acute flaccid paralysis surveillance structure in Australia APSU = Australian Paediatric Surveillance Unit (www.apsu.org.au); PEP = Polio Expert Panel; PAEDS = Paediatric Active Enhanced Disease Surveillance Network (www.paeds.org.au); VIDRL = Victorian Infectious Disease Reference Laboratory (https://www/vidrl.org.au/surveillance/afp-surveillance1); WHO = World Health Organization. Box 3 – Percentage of acute flaccid paralysis notification with adequate stool sample collection, Australia, 1995–2018* WHO = World Health Organization. * Data reproduced, with permission, from Roberts et al.11

Meryta May · David Durrheim · Jason A Roberts · Rhonda Owen

To the Editor: Climate change is this century's greatest global health threat. As the MJA considers the role of the health care sector in climate change, we urge readers to consider hospital food environments. Australia's health care system should be promoting diets that are healthy for both humans and the planet. A growing body of evidence suggests that healthier human diets have significant environmental co‐benefits. For example, reduced consumption of processed discretionary foods and red meats and increased consumption of fruits, vegetables and legumes have been shown to reduce the risk of certain non‐communicable diseases while also reducing diet‐related greenhouse gas emissions.1,2 Hospital food environments provide a useful intervention point to model and promote healthy, sustainable diets to Australians, as millions of meals are served to patients and their families in hospitals each year. Hospital food retailer guidelines have recently been developed by state governments and health care providers.3,4 To optimise health care food environments, a first step is to remove fast food outlets, vending machines and sugar‐sweetened beverages from hospitals. Inpatient food guidelines, however, are mostly outdated and sustainability is rarely considered. Inpatient food services should prioritise the delivery of fresh, locally sourced, unrefined foods with minimal packaging. Meals should adhere to dietary guidelines, be personalised to patients’ health needs, and minimise food waste. A recent audit by the Victorian Government into inpatient food services may provide an important opportunity to initiate reform.5 The Mater Group hospitals’ “at your request” room service exemplifies a cost‐effective food service model, showing improvements in patients’ nutrient intake, clinical outcomes, food waste reduction and patient satisfaction.6 Australia can also learn from the growing number of global initiatives to improve hospital food, including the New Zealand Ministry of Health's sustainability commitments, which include recommendations to encourage plant‐based eating, sustainable food sourcing and reductions in food waste.7 We should also look to innovative programs such as hospital rooftop gardens, hospital teaching kitchens, and traffic light labelling systems. To protect the health of humans and the planet, we urge state governments and health care providers to urgently evaluate hospital food quality, inpatient food services and retail food environments and implement new mandatory standards.

Genevieve Moseley · Luke Spajic · Georgia Behrens

It is imperative that we prepare for the worst, and that we do it now As the Editor‐in‐Chief of the MJA, I'm in the very privileged position of being among the first to critically evaluate early and emerging data forwarded to the Journal. I can also talk to experts around the world because of my medical and academic links. In January 2020, early on in what is now the SARS‐CoV‐2 pandemic, I remember seeing the first data on the outbreak of COVID‐19 in China, the estimated R0 values, and the initial models of exponential spread. Evidence from past outbreaks provides many lessons, including the importance of public health responses going very hard and very early, well before all the epidemiologic data are in.1,2 I therefore watched with increasing alarm that, despite early warnings from the World Health Organization, the initial responses of many governments around the world were limited and slow. I remember when I first saw the disturbing Imperial College modelling for the United Kingdom and the United States, including the different impacts of mitigation and suppression strategies in terms of hospital deaths from COVID‐19.1 In Australia, the messages have yet to fully sink in. On 26 March we published a new model of COVID‐19‐related mortality and hospital admissions, validated against Italian data.3 The model is simple and grim; it describes a hypothetical Australian hospital admitting new cases of confirmed COVID‐19 infection day after day, assuming that one in 20 patients require intensive care for 10 days, and that the COVID‐19 community case load increases by 20% each day. From day 15 — about the time when it is expected that available ICU beds run out — mortality steadily increases, as has happened in Italy. Those familiar with outbreak modelling know how complex such models can be and how many unknowns need to be imputed, especially early in a new outbreak; some employ supercomputers for their calculations, and can take months or years to build their model. Further, the predictive validity of complex models in an outbreak may not apply in other locations because human behaviour is complex and unpredictable.4,5 For this reason, simple models may be more robust; at least early on, when they matter most.6 Many have spoken out about the public health measures needed to slow the spread of SARS‐CoV‐2, and bolder action has recently been taken in Australia and elsewhere; those medical leaders who have stepped up and the political leaders who have heeded their advice early enough will have helped save lives. The next wave of heroes will soon emerge as frontline clinicians in hospitals care for patients during the COVID‐19 surge. At the time of writing (26 March), major preparations are underway to increase ICU bed and ventilator capacity, and personal protective equipment (PPE) is being donned to protect staff. According to current COVID‐19 surge modelling, however, it won't be enough. The health workers who will be on the COVID‐19 frontline and manage the sickest patients will need our greatest support, every single one of them. We will need to ensure that PPE stocks are not wasted and that they are replenished quickly, a clear government priority supported by the suspension of non‐urgent elective surgery announced by the federal government. I hope that manufacturers will be directed to produce everything we need, and quickly; we would re‐tool factories in wartime and not rely alone on private companies to step up (although some have). Some may dislike the wartime analogy, but it resonates with me. We will need to work together to support our medical teams. For families with two health professionals and dependents, we should not place both carers at high risk of exposure and severe disease. This will not be a straightforward rostering task, particularly outside major hospitals and in rural Australia. We need a statewide, and preferably a national plan; closing our internal borders must not impede sensible rostering and medical team deployment. Training needs to ramp up for all staff, and consist of more than simple online videos. We need a clear plan if PPE runs low or out. And we need clear triage rules about which patients should be ventilated if beds run short; health professional leaders and the community must together discuss the complex medical and ethical problems involved, and guidance needs to be finalised as soon as possible. Mental health support will be important, as post‐traumatic stress disorder will be a serious risk for ventilated patients and for staff; I suggest resting staff as much as possible now so that they are healthy, physically and mentally, when they are really needed. We will also require our health system leaders to understand that at a time like this every hospital should have a strict command and control structure led by senior clinicians and health professionals, with a designated clinician leader; bureaucrats primarily concerned with finances and political considerations must move to the sidelines. The Australian Health Practitioner Regulation Agency (AHPRA) is working to determine the role of medical students in this hour of need. Those close to graduating could play direct clinical roles under close supervision if they volunteered, but we need to start upskilling them now if this is to be worthwhile; it takes time to transition from being a medical student to a fully functioning, safe and competent intern. Doctors are being recalled from retirement in the UK and parts of Australia. I hope that this strategy will not be needed, as it places the most vulnerable in the profession in the wrong place. We must also protect staff financially and professionally. The indemnity implications for doctors required to work outside their scope of usual practice are unclear and must be resolved quickly. I am a gastroenterologist, and I am fully prepared to work on COVID‐19 wards or fill gaps in non‐COVID wards if required. But what if I make mistakes? And if I die, will insurance cover my family? The MJA has stepped up to play its part in meeting this crisis, including ultra‐rapid review of SARS‐CoV‐2 manuscripts and pre‐print publication of unedited papers, to ensure that the newest data and viewpoints are available as soon as possible. In addition, all SARS‐CoV‐2 articles will be fully accessible without fee. Our medical and structural editors are working from home, carefully reviewing every submission, but the MJA will continue to publish as usual in these extraordinary times. The ultra‐rapid review and publication model entails a risk of error, but sharing important information too slowly is a much greater hazard. We will transparently correct and update the preprints if appropriate, and we will of course apply our usual high standards of review and editing to refine them before we publish their final versions online and in print. Models matter, even if they are imperfect representations of the real world.7 While the projections reported in this issue3 may represent a worst case scenario and may not come to pass, it is better that we prepare for the worst, and now. Over the coming months it's going to take courage, brains, and a concerted and unified effort by the medical profession and other health professionals to manage SARS‐CoV‐2. Let's not leave anyone behind.

Nicholas J Talley

As a leading general medical journal, the MJA recognises the importance of very rapidly sharing accurate health information

Nicholas J Talley

To the Editor: Nearly all industries profit from today's 25 million slaves and 150 million child labourers.1 The results of their work, including medical disposables, are sold worldwide. Unfortunately, there is not a comprehensive analysis identifying exactly where slaves are involved in the medical products supply chain. From the hazardous work forging surgical instruments in Pakistan to the manufacture of gloves in Malaysia,2 slavery permeates the manufacture and supply chains of medical products. Slaves are involved in the direct manufacture of medical products and in the generation of raw materials used to make medical devices, including cotton, rubber and metals.3 Some companies, have made a public effort to review their supply chains;4 however, many organisations are failing to monitor human rights abuses in their supply chains.5 As countries legislate Modern Day Slavery Acts, a few companies are moving to eliminate slavery. As an act of radical transparency in the long‐discussed issue of child labour in the cocoa industry, in 2017, Nestlé published the number of child labourers aged 5–17 years known to be working on cocoa farms that supply their cocoa.6 Nothing similar to Nestlé's effort has been done in the medical industry. However, notable efforts to regulate procurement have been demonstrated in the United Kingdom and Sweden.2 Few health professionals are responsible for the direct sourcing of medical products. Nonetheless, when speaking with managers, executives, and representatives of medical suppliers, we have the opportunity to share our concerns for the origins of the products we use. While a conversation with a medical representative on this topic may demonstrate scant knowledge of the manufacturing processes of the goods they are selling, that initial conversation is an important first step towards transparency, and we know that the influence of health professionals on industry is significant.7 Modern slaves are forced to work under threat of harm or by coercion or deception. Unable to refuse or leave, they earn little to no pay for extensive working hours in unsafe conditions, which may cause injury, sickness and, at times, death. Reports of harassment are common. In the medical industry, we must do all we can to address modern slavery because, above all, we should “first do no harm”.

Sharon Sitters

What is value in health care and how can the system deliver it at scale?

Elizabeth Koff · Nigel Lyons

Greater investment is needed to support eye health coordinators, community-based liaison officers, and family members and carers

Aryati Yashadhana · Ling Lee · Jessica Massie · Anthea Burnett

The current Ebola outbreak is a public health emergency of international concern, and while international risk remains low, we need to remain vigilant for symptomatic travellers

Luke J Vos

What should the health care community do when faced with major human rights abuses?

Ryan Essex · David Isaacs

W here there is no psychiatrist, 2nd edition

Mathew Coleman

To help PNG prevent and respond to infectious disease outbreaks of domestic and international concern, Australia must continue to provide high level technical and financial support

John J Hall · Tabian Ambang · Augustine Asante · Pili Mapira · Adam Craig · Elisabeth Schuele · Maha Pervaz Iqbal

Australia needs a coordinated nationwide plan to reduce preventable deaths and disability from sepsis

Luregn J Schlapbach · Kelly Thompson · Simon R Finfer