Infectious diseases

There is little legal recourse in Australia for someone who is denied care on resource grounds, particularly in the context of a pandemic

Michelle A Gunn · Fiona J McDonald

To the Editor: Influenza vaccination of residents and staff in aged care homes is recommended by national guidelines1 and has been demonstrated to decrease transmission and burden of infection.2 During the current coronavirus disease 2019 pandemic, influenza vaccination of both groups potentially also reduces the risk of mortality associated with influenza virus and severe acute respiratory syndrome coronavirus 2 co‐infection. We sought to evaluate uptake of influenza vaccination by residents and staff in public sector residential aged care services in Victoria, where non‐mandatory vaccination programs are currently used. There are 178 public sector residential aged care services in Victoria, with the majority located in rural communities. In 2018 and 2019, infection prevention staff in public sector residential aged care services were requested to complete a point prevalence survey of all residents on a set date and a period prevalence survey of all staff employed during the influenza season, in order to estimate vaccine uptake. A standardised data collection tool was used, with online submission of summary data via a secure portal hosted by the Victorian Healthcare Associated Infections Surveillance System Coordinating Centre. Consistent with quality assurance activities defined according to National Health and Medical Research Council recommendations, non‐identifiable aggregate data were collated by participating public sector residential aged care services to support quality improvement initiatives. Ethics approval was therefore not required.3 Of surveyed residents, 87% were vaccinated in both 2018 and 2019. Small proportions of residents declined vaccination or had unknown status. In 2018, 87% of surveyed staff were vaccinated, with 8% and 6% reported as declining vaccination or having unknown status, respectively. In 2019, 88% of surveyed staff were vaccinated, with 9% and 4% declining vaccination or having unknown status, respectively (Box). Public sector residential aged care services provide services for older people with complex care needs, representing a population at high risk for poorer clinical outcomes in the setting of influenza infection. Reassuringly, we observed high uptake of vaccination among surveyed residents, comparable to recently reported uptake in New South Wales aged care homes.4 Review of successful vaccination strategies would be beneficial to improve and sustain future programs in individual aged care homes. Our findings also reflect high uptake of vaccination by aged care staff. Looking ahead, mandatory vaccination of staff employed in Victorian hospitals and public sector residential aged care services is planned,5 and this will likely result in additional uptake.6 While we observed low proportions of staff to have unknown status or to decline vaccination, implementation of the new policy will require an ethical and legal focus on these groups, including reasons for acceptable declination and required workforce planning (eg, redeployment). Box – Influenza vaccination uptake by residents and staff in Victorian public sector residential aged care services, 2018–2019 Target population Year No. of facilities surveyed No. of residents or staff surveyed Vaccinated Declined Unknown Residents 2018 177 5162 4482 (87%) 357 (7%) 323 (6%) 2019 178 5082 4427 (87%) 302 (6%) 353 (7%) Staff 2018 177 12536 10894 (87%) 948 (8%) 694 (6%) 2019 175 13844 12181 (88%) 1179 (9%) 484 (4%)

Noleen J Bennett · Alex Hoskins · Leon J Worth

To the Editor: As the coronavirus disease 2019 (COVID‐19) pandemic spread across Europe, we worked in the intensive care unit (ICU) of a Swedish university hospital. We share our experiences and offer some thoughts regarding Sweden’s pandemic response. The decentralised Swedish health system works on three levels (Box). These traditional divisions may partially account for the lack of coordination between care services in the initial phases of the pandemic, where large numbers of deaths occurred in care homes. As the pandemic intensified, safety checks were implemented to protect residents of aged care facilities. This resulted in a quick containment of infections, although tragically too late for many. Our health care region received the fourth highest number of hospitalisations in Sweden.1 We were privileged to work in a system that was well organised, without political conflict and with pre‐existing disaster plans that were quickly converted to pandemic plans. A pandemic‐specific leadership established a centralised inventory and oversaw the acquisition and distribution of beds, staffing, medical equipment, essential drugs, personal protective equipment and disinfection agents. An eight‐step plan ensured a rapid escalation of regional ICU capacity. Intermediate care units were opened, reducing demand for ICU beds. Projected numbers of patients were calculated daily, based on models provided from the Public Health Agency of Sweden and local data. Anaesthesia and intensive care are a combined speciality in Sweden. This enabled the rapid deployment of a large workforce of anaesthetists and nurse anaesthetists to ICUs. Despite these resources, our tripled ICU capacity meant significant staffing challenges, with additional difficulties because of staff illnesses and quarantines. Our impression is that the Swedish response has been controlled and planned for the long term. Daily public announcements from the Public Health Agency became a regular part of our lives and Swedes were generally compliant with recommendations regarding physical distancing and hygiene routines. We are perplexed by reports in the media that life went on as usual in Sweden. In fact, life was very different. Most people worked from home, large numbers were furloughed, many institutions were closed and public events were cancelled. Travel was discouraged and fell dramatically.2 What sets the Swedish approach apart from others is that these measures were largely voluntary, with generally good public support. We avoided an overwhelming wave of patients with an undercapacity of ICU beds, as seen in many other countries. We maintained normal criteria for ICU admissions. This is notable given that Sweden has the second lowest number of ICU beds per capita in Europe.3,4 Results from intensive care are encouraging, with mortality rates generally lower than previously reported.5 Challenges included staff burnout, a shortage of usual sedatives and lack of clinical experience with this new disease, resulting in the use of futile and potentially harmful treatments. However, guidance from a national group of senior clinicians provided regular recommendations6 and there was excellent compliance with advice from regulatory authorities. Up to 70% of elective surgeries were cancelled during the first half of 2020. Cancer‐related surgeries continued to be prioritised during the pandemic, but the longer term effects of cancelled surgeries, outpatient clinics and altered illness behaviour are not known. We are heartbroken at our inability to provide enough comfort to relatives of our patients who succumbed to COVID‐19 when hospital visits were prohibited. As two Australian emigrants working in a Swedish ICU, we are humbled by our ability to contribute to the care of patients during the pandemic. Our Australian medical training instilled in us a sense of duty, tempering any feelings of helplessness. We applaud the tenacity of our Swedish colleagues. We wish our Australian colleagues well and hope that Australia will be protected from the horrors of COVID‐19. Box – Decentralised organisation of the Swedish health care system

Michelle S Chew · Thomas Halliday

We must consider how we can support communities hosting vaccine efficacy trials

George S Heriot · Euzebiusz Jamrozik

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

Early control of transmission was successful, but efforts to reduce further transmission remain important

Heather F Gidding · Dorothy A Machalek · Alexandra J Hendry · Helen E Quinn · Kaitlyn Vette · Frank H Beard · Hannah S Shilling · Rena Hirani · Iain B Gosbell · David O Irving · Linda Hueston · Marnie Downes · John B Carlin · Matthew VN O'Sullivan · Dominic E Dwyer · John M Kaldor · Kristine Macartney

Medicare Benefits Schedule (MBS) data indicated that there were 37% fewer screening procedures for breast cancers and 55% fewer for colorectal cancers in April than in March 2020.1 We examined the temporal relationship between coronavirus disease 2019 (COVID‐19)‐related restrictions in Victoria during 1 April – 15 October 2020 and cancer pathology notifications to the Victorian Cancer Registry (VCR), to estimate their impact on cancer diagnoses. Victorian legislation requires pathology services to notify reportable cancer diagnoses to the VCR.2 The E‐Path system, installed in all Victorian pathology services during 2013–2018,3 automatically transmits notifications to the VCR together with pathologist report authorisations. During 2019, 97 313 of 104 025 cancer pathology notifications to the VCR (94%) were received via E‐Path (data supplied by author LB). Changes to the E‐Path system during 2019 meant that we were unable to directly compare notification numbers for 2019 and 2020. We therefore modelled cancer incidence during 2014–2018 by Poisson regression. A spline function was fitted to VCR cancer incidence data for weeks 1–52, adjusted for day type (working or non‐working day/public holiday) and year, and the fitted curve used to predict daily incidence during 7 January – 15 October 2020. Predicted incidence was re‐scaled to estimate expected notification numbers; the scale factor was the number of notifications during the baseline period — 1 February – 16 March 2020, allowing a two‐week washout period before restrictions were formally announced — divided by the predicted incidence during this period. Observed and predicted notification numbers were compared using Poisson regression, with the expected number as an offset term, enabling estimation of relative reductions with 95% confidence intervals (CIs). Differences between predicted and actual notification numbers were estimated, both overall and for specific groups (eg, by tumour or age group), based on the pertinent incidence data. As a single cancer diagnosis can be associated with several pathology notifications, the number of undiagnosed cancers was estimated by multiplying the difference in notification numbers by the ratio of newly diagnosed tumours to pathology notifications in 2018 (Supporting Information, table 1). The confidence interval for the number of undiagnosed cases was based on the Poisson model, keeping the ratio of newly diagnosed tumours to pathology notifications constant. In sensitivity analyses, data were fitted to polynomial models, different baseline periods were used, or data were restricted to reportable cancer diagnoses. The study was exempted from formal ethics review by the human research ethics committee of Cancer Council Victoria. During 1 April – 15 October 2020, there were 5446 fewer notifications of new cancer diagnoses than predicted by our primary model (predicted, 54 609 v observed, 49 163; relative reduction, –10.0%; 95% CI, –10.8% to –9.2%) (Supporting Information, figure 1); we estimated that there were 2530 undiagnosed cancers (95% CI, 2327–2731). The relative reduction was greatest during 1 April – 4 May 2020 (Box 1). By tumour group, the relative reductions were most marked for prostate cancer, head and neck tumours, melanoma, and breast cancer; they were greater for men, people aged 50 years or more, and for people in areas of higher socio‐economic position (Box 2). The pattern of difference in notifications varied between tumour groups (Supporting Information, figure 2). The 6.5‐month period of COVID‐19‐related restrictions in Victoria was accompanied by a 10% reduction in cancer pathology notifications; we estimated that about 2530 cancer diagnoses were either delayed or missed. The impact of delayed diagnosis is greatest for patients with aggressive cancers. Changes in care delivery during the restrictions, including suspension of screening services and outpatient clinics and postponed surveillance of existing cancers, may have affected notification numbers for some tumour groups and consequently the estimated number of delayed diagnoses. Planning for a possible surge in cancer diagnoses over the coming 6–12 months, and media campaigns encouraging people to not further delay seeking medical attention, may ameliorate any negative impact of delayed cancer diagnosis. Box 1 – Cancer pathology notifications to the Victorian Cancer Registry, January–October 2020: observed (red) and predicted numbers (green), by day type LOESS = locally estimated scatterplot smoothing. The grey area marks the baseline period, the vertical dotted lines the analysis period for predicted notifications. A state of emergency was declared in Victoria on 16 March 2020. Stage 3 movement restrictions were applied from 30 March, eased on 13 May, and re‐applied from 8 July. The state of emergency was renewed on 2 August, together with application of stage 4 restrictions to metropolitan Melbourne until their easing from 19 October. For further details, see the footnote to figure 2 in the online Supporting Information. Box 2 – Cancer pathology notifications and estimated numbers of undiagnosed reportable cancers, 1 April – 15 October 2020* table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Notifications Relative difference (95% CI) Absolute difference (a) Tumour to notification ratio (b) Estimated number of undiagnosed tumours (a*b) Characteristic Predicted Observed All notifications 54 609 49 163 –10.0% (–10.8% to –9.2%) –5446 0.465 2530 Sex† Males 15 458 14 190 –8.2% (–9.7% to –6.7%) –1268 0.427 541 Females 10 408 10 367 –0.4% (–2.3% to 1.5%) –41 0.434 18 Age at diagnosis (years) < 50 9981 9674 –3.1% (–5.0% to –1.1%) –307 0.454 139 50–74 30 949 27 555 –11.0% (–12.0% to –9.9%) –3394 0.447 1516 ≥ 75 13 697 11 934 –12.9% (–14.4% to –11.3%) –1763 0.514 906 Tumour group Breast 7923 7130 –10.0% (–12.1% to –7.9%) –793 0.380 301 Colorectal 5063 4838 –4.4% (–7.1% to –1.7%) –225 0.501 113 Haematologic 10 011 9321 –6.9% (–8.8% to –5.0%) –690 0.234 162 Melanoma 7168 6217 –13.3% (–15.4% to –11.1%) –951 0.538 511 Lung 2967 3062 3.2% (–0.4% to 6.9%) 95 0.483 –46 Head and neck 1363 1155 –15.3% (–20.0% to –10.3%) –208 0.504 105 Bladder 2159 2009 –6.9% (–10.9% to –2.8%) –150 0.370 56 Prostate 6417 4770 –25.7% (–27.8% to –23.5%) –1647 0.560 922 All other 11 931 10 661 –10.6% (–12.3% to –8.9%) –1270 0.546 693 Socio‐economic position (quintile)‡ 1 (most disadvantaged) 10 334 9789 –5.3% (–7.1% to –3.4%) –545 0.453 247 2 10 378 9447 –9.0% (–10.8% to –7.1%) –931 0.456 425 3 10 192 9624 –5.6% (–7.4% to –3.7%) –568 0.488 277 4 10 925 9463 –13.4% (–15.1% to –11.6%) –1462 0.455 665 5 (least disadvantaged) 11 385 9714 –14.7% (–16.4% to –13.0%) –1671 0.460 769 Remoteness¶ Major cities 37 506 33 753 –10.0% (–11.0% to –9.0%) –3753 0.461 1731 Inner regional 13 414 12 031 –10.3% (–11.9% to –8.7%) –1383 0.472 652 Outer regional/remote 2553 2457 –3.8% (–7.5% to 0.1%) –96 0.472 45 CI = confidence interval. * Poisson regression (spline function, adjusted for day type [working day or non‐working day/public holiday] and year; baseline period: 1 February – 16 March 2020). † For cancers common in both sexes (melanoma, colorectal cancer, lung, head and neck cancers, haematological malignancies). ‡ Based on residential address, using the Google Geocoding API (https://developers.google.com/maps/documentation/geocoding/overview), spatially joined to Australian Bureau of Statistics Statistical Area 1 (SA1) polygons.4 Area‐based socio‐economic quintiles were based on 2016 Australian Bureau of Statistics census data.5 ¶ Accessibility and Remoteness Index of Australia.6

Luc te Marvelde · Rory Wolfe · Grant McArthur · Louis A Blake · Sue M Evans

To the Editor: The recent article by Hyde1 synthesised the evidence on the role of children (and schools) in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Hyde concluded that the original perceptions that children do not play a role in transmission are unfounded. Current evidence shows that schools carry a risk of transmission that is dependent on the level of community transmission. Hyde emphasised the urgent need for risk‐reduction measures and advanced the Harvard guidelines for schools.2 We agree with Hyde and suggest that health and education authorities urgently implement risk‐reduction measures in schools. The Harvard guidelines put forth are comprehensive,2 but they need to be taken a step further to include an engaging health education campaign to allay fears and misconceptions and ensure behaviour change. Such messaging around coronavirus disease 2019 (COVID‐19) specifically targeting children has been similarly overlooked to date, and while some children’s books are coming out,3 there are limited age‐specific and engaging health education materials currently available and being systematically implemented in schools. An entertainment education approach can provide a highly effective forum for health education interventions targeting schoolchildren, and we consider this tactic should be applied to COVID‐19.4 An example is the cartoon video The Magic Glasses, which has proved successful in preventing intestinal worm infections in children.5 The cartoon enables children to identify with characters and visualise the intestinal parasitic worms and their eggs in people and the environment to reinforce the importance of good hygiene and associated health behaviour.4,5 This is directly applicable to the transmission dynamics of SARS‐CoV‐2 — whereby the virus would be visualised in people and the environment (Box) — and the associated messages for prevention. Key messages of such an intervention (The Magic Glasses: COVID‐19) could include hand washing, care in coughing and sneezing, tissue use and disposal, physical distancing, mask wearing, and what to do when feeling unwell. Health education and promotion are important components of disease prevention, but during disease outbreaks and health emergencies, they play an even more crucial role in an active response by providing a well established method to communicate and engage quickly and effectively with the public and prevent infections. This concept is especially important in the absence of an effective drug, and while it is highly encouraging that several safe and efficacious vaccines against SARS‐CoV‐2 have been developed and are being administered in a number of countries, a few caveats need to be considered: i) they have not been tested in children; ii) their impact on transmission is yet to be realised; and iii) there will be some time before they are rolled out globally.6 Messaging specifically targeting children, who may well be acting as silent transmitters of the virus, is presently lacking. A video or cartoon‐based entertainment education intervention would fill this need and suitably complement the other preventive measures advocated by Hyde.1 With the current debate around school closure and opening, having these preventive interventions in place would help mitigate the COVID‐19 risk and provide greater confidence to authorities and parents alike for re‐opening schools. Box – Cartoon concept — The Magic Glasses: COVID‐19

Darren J Gray · Gail M Williams · Donald P McManus

Guidelines for reporting results from randomised trials have long underscored the importance of confidence intervals

Karla Hemming · Monica Taljaard

If we had a test that was both 100% sensitive and 100% specific for COVID-19, we would have no false-positive and no false-negative results

Katy JL Bell · Fiona F Stanaway · Les M Irwig · Andrea R Horvath · Armando Teixeira‐Pinto · Clement Loy

Models must be supported by a range of qualitative and quantitative assessments and tools to translate their projections into policy

Allen C Cheng

The consequences of removing some restrictions may not be apparent for more than two months

Nick Scott · Anna Palmer · Dominic Delport · Romesh Abeysuriya · Robyn M Stuart · Cliff C Kerr · Dina Mistry · Daniel J Klein · Rachel Sacks‐Davis · Katie Heath · Samuel W Hainsworth · Alisa Pedrana · Mark Stoove · David Wilson · Margaret E Hellard

To the Editor: Restrictions and concerns associated with coronavirus disease 2019 (COVID‐19) have led to decreased routine immunisation coverage in many countries, including the United Kingdom1 and the United States.2 Australian data showing the COVID‐19 pandemic’s impact on vaccination coverage are not yet available, but it has disrupted services provided by the National Immunisation Program, which funds vaccination for children, adolescents, adults and special risk groups. In the face of ongoing COVID‐19 risk and restrictions, maintaining a resilient routine vaccination program is crucial. The COVID‐19 pandemic has heightened barriers to vaccination. Lockdown restrictions have affected immunisation service accessibility. Specifically, some clinics reduced face‐to‐face appointments in favour of telehealth3 or closed due to insufficient space and increased staffing and other requirements.4 Patients may have rescheduled appointments to avoid COVID‐19 exposure in waiting rooms, while school‐based programs have been disrupted by closures. Reduced consultations limit not only opportunities to vaccinate but also opportunities for health care providers to address vaccine questions and concerns and reinforce trust. Employment changes related to COVID‐19 may also exacerbate cost barriers for people at risk of under‐immunisation, such as migrants, international students, asylum seekers and refugees.5 To improve access, some jurisdictions have successfully established drive‐through vaccine clinics, and pharmacists in some states have been granted expanded permission to vaccinate children against influenza. However, some families may have delayed vaccines due to the COVID‐19 pandemic, and governments may need to consider additional resources for catch‐up vaccination and extensions or grace periods for “No jab, no pay” and “No jab, no play” policies. School‐based vaccination programs should be re‐established as a priority when schools reopen. Publicly available vaccination coverage data will not reflect COVID‐19‐related impacts until as late as December 2020. We recommend early release of more timely data to ensure service providers gain feedback on program performance. We also recommend awareness campaigns promoting timely National Immunisation Program vaccination or catch‐up. Information should be culturally and linguistically appropriate and should be developed through consultation and engagement with diverse communities, including Aboriginal and Torres Strait Islander communities. Australia’s immunisation providers are dedicated and adaptable, but we must now respond quickly to the challenges of COVID‐19 and remain vigilant to maintain routine vaccination coverage across the lifespan.

the Collaboration on Social Science, Immunisation (COSSI) Working Group

To the Editor: Pandemic responses across the world have been highly reactive. However, there remain only three strategic options to managing coronavirus disease 2019 (COVID‐19): mitigation, suppression and elimination (Box).2 With the promise of efficacious new vaccines, mitigation is appropriately not considered as part of Australia’s national strategy. However, our stated goal of achieving “no community transmission” remains poorly defined and risks missing important distinctions between elimination and suppression.3 Effective elimination is dependent both on getting to zero local cases and then staying there, with any new transmission chains immediately halted. All jurisdictions of Australia have now achieved elimination over significant periods, even without articulating this as their strategy. By comparison to suppression, greater relaxation of restrictions may well be allowable under an elimination approach if vigilance is maintained, as New Zealand has demonstrated.4 Although the challenges of ensuring quarantine of returning travellers are well recognised, this is an essential aspect of maintaining elimination and increases in importance as distancing restrictions are eased. Australia’s current strategy appears to imply suppression, with some virus circulating but with case numbers at manageable levels. Whether suppression has been achieved can be monitored by maintaining an effective reproduction number of no greater than one, or equivalently by ensuring the epidemic curve of new community cases is not upsloping. Importantly, the reproduction number and the rate of new cases at any point in time are unrelated — we could have effective suppression and a reproduction number of one with daily case rates of five, ten or 50. Our definition of no community transmission appears to imply complete identification of transmission chains with no “mystery cases”, regardless of the number of new cases. These considerations are important in determining whether we have full visibility of the epidemic and effective contact tracing but do not determine the reproduction number. The rapid spread of the virus necessitates a public health strategy that is clear, robust and agile. Improved control combined with the increasingly clear seasonality of the virus5 suggest that control can be maintained throughout the summer. However, if vaccination has not been widely distributed before winter 2021 and we do not make clear choices, further major outbreaks remain likely. Box – Characteristics of coronavirus disease 2019 (COVID‐19) epidemic response strategies (Trauer et al) Elimination Suppression Mitigation Our definition No cases or transmission, except in quarantined arrivals Very low community case rates; limited transmission Higher case rates, but within health service capacity Key metric of success No locally acquired cases Effective reproduction number not exceeding one,* or a horizontal sloping epidemic curve of locally acquired cases Hospital and ICU occupancy within (expanded) capacity Accrual of significant population‐level immunity No No1 Yes, likely to take many months, with considerable morbidity and mortality Need for mobility restrictions and hygiene measures Mobility may return to near normal while cases and transmission remain at zero; vigilance essential; likely need for episodic restrictions if quarantine escape occurs Continuous need for high levels of restrictions; strong possibility of disruptive lockdowns given that community transmission persists Unpredictable Need for restrictions on international arrivals Extremely high, and increases as distancing restrictions are eased Moderate Less important Current appropriateness for Australian jurisdictions† Reasonable Reasonable Not under consideration ICU = intensive care unit. * The effective reproduction number becomes more difficult to quantify precisely as numbers fall. † Given an effective vaccine appears likely.

James M Trauer · Ben J Marais · Romain Ragonnet · Julian Savulescu · Emma S McBryde

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen

Recommendations to guide residential aged care facilities in preparing for and managing infectious disease outbreaks

Georgia E Aitken · Alice L Holmes · Joseph E Ibrahim

Peer support initiatives can help health professionals experiencing mental health and wellbeing challenges during the COVID-19 pandemic and beyond

Tahnee L Bridson · Kym Jenkins · Kieran G Allen · Brett M McDermott

The MJA aims to be an outstanding general medical journal, broadly relevant to all specialties in medicine and health, with a national and global focus, a journal that influences policy and practice

Nicholas J Talley

Adequate capacity — beds, equipment, consumables, and, crucially, trained personnel — is needed to cope with a surge of critically ill patients

Mervyn Singer

The prognosis may not be as poor as overseas, but the intensive care resource burden may be greater

Aidan JC Burrell · Breanna Pellegrini · Farhad Salimi · Husna Begum · Tessa Broadley · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Arul Earnest · Simon J Erickson · Craig J French · John M Kaldor · Edward Litton · Srinivas Murthy · Richard E McAllister · Alistair D Nichol · Annamaria Palermo · Mark P Plummer · Mahesh Ramanan · Benjamin AJ Reddi · Claire Reynolds · Tony Trapani · Steve A Webb · Andrew A Udy

Switching trauma specialist services to pandemic management would be unwarranted

Teagan L Way · Seth M Tarrant · Zsolt J Balogh