Infectious diseases

An emergency imaging pathway based on local and international guidance tailored to the Australian health care setting Imaging in coronavirus disease 2019 (COVID‐19) is primarily helpful in diagnosing COVID‐19‐related complications and identifying alternative diagnoses that may explain a patient’s presentation. It can also be useful in the risk stratification of patients by identifying the presence and severity of comorbidities.1,2 Imaging is of limited use in screening for COVID‐19 in asymptomatic individuals, and in many cases where COVID‐19 symptoms are mild.1,3 Indiscriminate use of imaging in patients with confirmed or suspected COVID‐19 not only exposes the patient to unnecessary radiation but also represents an unnecessary infection risk and logistic demand for medical imaging departments. Existing international COVID‐19 imaging pathways have been derived in clinical environments significantly different from Australia, often where there is high COVID‐19 prevalence and constrained resource availability. Some centres preferentially use chest x‐ray, whereas others perform various types of computed tomography (CT) imaging of the chest. There is also inconsistency in the reporting of imaging studies in suspected or confirmed COVID‐19, with some reports following traditional didactic format, and others using synoptic template reports as recommended by a variety of medical bodies.4,5 Here we describe an imaging pathway developed at the Royal Adelaide Hospital, the designated COVID‐19 hospital in South Australia. This pathway aims to outline the imaging indications, technique and reporting of chest imaging in an emergency setting, at a time of low COVID‐19 prevalence. We incorporate current available international pathways and best practice guidelines for emergency imaging of COVID‐19 patients into a simple pathway relevant to Australian practice. Imaging pathway development We reviewed consensus and position statements from the Royal Australian and New Zealand College of Radiologists, the Australian and New Zealand Society of Thoracic Radiology, the Fleischner Society and the British Society of Thoracic Imaging. Recommendations pertaining to high COVID‐19 prevalence environments and resource‐constrained environments were modified to suit a scenario of low prevalence. When local guidelines conflicted with international organisations, priority was given to local recommendations on the basis of relevance. Recommendations were subsequently integrated into a clinical imaging pathway in consultation with local specialists in radiology, emergency medicine, general medicine, respiratory medicine and infectious diseases (Box). Reporting terminology The pathway incorporates standardised reporting terminology for patients with COVID‐19 as recommended by the Australian and New Zealand Society of Thoracic Radiology.5 Categorisation of study findings as “normal,” “indeterminate,” “typical” or “other diagnosis favoured” improves report clarity and creates actionable imaging outcomes. Appropriate use of CT The main role of CT in this pathway is to exclude complications and alternative diagnoses in patients with confirmed or suspected COVID‐19. The pathway prompts clinicians to consider CT for patients who are hypoxic (or have an oxygen requirement) and who have a chest x‐ray that is either “normal” or “indeterminate for COVID‐19”. In this instance there is a clinicoradiological discrepancy, and either a complication (such as a pulmonary embolus) or an alternative diagnosis is suspected. In keeping with British Society of Thoracic Imaging guidance, a low‐dose unenhanced CT of the chest is the CT scan of choice, with strong consideration given to an additional CT pulmonary angiogram.4 There is accumulating evidence that patients with COVID‐19 are abnormally prothrombotic, and conventional clinical decision rules and blood tests (especially D‐dimer) may not be applicable.3 Clinicians should have a lower threshold than usual for performing a CT pulmonary angiogram. The unenhanced CT functions primarily as a baseline, as the presence of intravenous contrast can artifactually simulate ground glass. Whenever possible, the non‐contrast CT scan and the CT pulmonary angiogram should be performed on the same occasion to minimise infection control risk and operational demands on medical imaging departments. Baseline imaging for patients at risk of deterioration Patients with comorbidities are recognised as being at higher risk of deterioration. Defined risk factors vary between institutions but include older patients, requirement for oxygen supplementation, significant comorbidities (especially cardiac or respiratory) and immunosuppression. The consensus statement from the Fleischner Society supports imaging in patients who have a positive test result for COVID‐19 and risk factors for disease progression, regardless of their clinical status. The use of imaging in this situation is to establish a baseline for future comparison and determine the extent of comorbidities. Imaging may also inform the intensity of follow‐up monitoring, either in the community or an inpatient setting.1 Incidental findings suspicious for COVID‐19 Although there are no radiological findings pathognomonic for COVID‐19, there are radiological findings commonly associated with infection.5 When imaging findings typical for COVID‐19 are seen in a patient who is not suspected of having infection, the pathway prompts the radiologist to discuss the findings with the referring emergency physician. Patient isolation and COVID‐19 testing may be required. This is intended as a safety net for patients who may not be identified by current clinical screening processes, acknowledging that patients with COVID‐19 may be asymptomatic, may present with atypical symptoms and do not necessarily have knowledge of close contact with an infected individual. Ultrasound There is some evidence that point‐of‐care ultrasound can be used in the imaging of patients with COVID‐19; however, given variability in specialist expertise and availability, this has not been incorporated in this pathway.1 Conclusion Chest imaging in suspected or confirmed COVID‐19 in a low prevalence environment is best used to detect complications and rule out alternative diagnoses. The pathway described here aims to clarify imaging indications, technique and reporting of studies performed on patients with suspected or confirmed COVID‐19 in an acute care setting. Box – COVID‐19 emergency imaging guidelines AP = anteroposterior; ANZSTR = Australian and New Zealand Society of Thoracic Radiology; COVID‐19 and COVID = coronavirus disease 2019; CT = computed tomography; CTPA = computed tomography pulmonary angiogram; CXR = chest x‐ray; ED = emergency department.

David Ngan · Suzanne McKeen · Meegan Gun · Daniel Haustead · Andrew Low · Brett Lorraine · James Bewes

Putting in place the mechanisms to assess coverage in vulnerable groups is essential to drive optimal uptake and best practice Several targeted vaccine programs introduced to the Australian National Immunisation Program (NIP) in 2020 exposed the limitations of the Australian Immunisation Register (AIR), particularly, its inability to collect information on medical risk factors to monitor vaccine uptake in at‐risk groups. These program changes highlight the need to optimise AIR reporting to improve the accuracy of individual‐level vaccination data for the benefit of patients and treating clinicians as well as the ongoing surveillance of vaccine coverage for medically at‐risk groups. As of 1 July 2020, Bexsero (GSK), the meningococcal B vaccine, was funded by the NIP for all Aboriginal and Torres Strait Islander children aged under 2 years and for other populations with specific medical risk factors, including asplenia, hyposplenia, complement deficiency, and use of eculizumab therapy.1 Additional doses of the pneumococcal 13‐valent conjugate vaccine (Prevenar 13, Pfizer) and the 23‐valent pneumococcal polysaccharide vaccine (Pneumovax 23, MSD) are now funded for Aboriginal and Torres Strait Islander people and for individuals with certain medical risk factors (eg, asplenia, immunosuppressive conditions, specific respiratory disorders).2 While these NIP changes are welcomed, clinicians need access to data that include information on medical risk to optimise benefits to patients. Both patients and medical practitioners need capacity to track receipt, ensuring that the most vulnerable people receive the recommended vaccines, and avoid unnecessary repeat vaccinations. Assessing compliance with these policy changes will be difficult because medically at‐risk individuals are currently unable to be identified on the AIR. The functionality of the AIR needs to change to enable the collection of medical risk factors, including pregnancy, and strive for more complete reporting of vaccinations that will deliver benefits at both a population and individual level. Accurate coverage data are vital for clinicians to be able to offer evidence‐based care and ensure their most vulnerable patients are protected, and to inform strategies to improve vaccine uptake. Globally, the strongest predictor of influenza vaccine receipt in pregnant women and children with medical comorbidities is a health care provider recommendation.3,4,5 Facilitating health care provider recommendations and other effective strategies to improve uptake, such as reminders or prompts for clinicians or text messages from clinicians to patients, will not be optimal without accurate vaccination data. In this article, we aim to highlight the need for optimising reporting to the AIR and increasing its capacity to collect information on medical risk factors, ensuring maximum program reach of targeted programs, and propose potential solutions. Lower uptake of targeted vaccine programs Despite targeted vaccine programs aiming to improve coverage for vulnerable groups, they often have lower uptake than universal vaccine programs.3,4,6,7,8 With the exception of Aboriginal and Torres Strait Islander people, the AIR currently fails to recognise people who qualify as vulnerable because the AIR does not capture “at‐risk” status, rendering the eligible group (ie, denominator) not easy to identify. Before 2016, the Australian Childhood Immunisation Register only recorded childhood vaccines up to 7 years. With the expansion to the whole‐of‐life AIR in September 2016, it was hoped that adult vaccinations, including maternal influenza and pertussis vaccines for pregnant women and vaccines for medically at‐risk groups, would be captured. This is an ongoing priority because the uptake of maternal influenza vaccine remains suboptimal, estimated to be 39% in Victoria between 2015 and 2017,6 with variation nationally across years and jurisdictions — 31.7% (Northern Territory, 2016), 54% (New South Wales, 2016) and 76% (South Australia, 2017).8,9,10 Similarly, influenza vaccine uptake in medically at‐risk children also remains suboptimal (about 40% nationally for 2014–2015 and 2017).3,4 Lack of recording of at‐risk status At present, there is no capacity to link vaccine receipt on the AIR with a person’s at‐risk status, as the register lacks the functionality to do so. There is a need for the AIR to be able to more accurately track vaccine receipt nationally to identify strategies to improve coverage in at‐risk groups. The lack of pregnancy status capture in the AIR necessitates the use of other data sources, such as perinatal datasets in jurisdictions where maternal immunisation is collected, or population surveys to obtain coverage estimates, but these are of no use to clinicians at the individual level. This is also the case for children who are medically at‐risk, with no capacity to link medical risk factors with vaccine receipt for identification and tracking of these children. Parents are known to over‐report vaccination status, particularly for children with complex and ongoing medical conditions.11 Identification of at‐risk status would also enable more targeted estimates of vaccine effectiveness for at‐risk individuals, rather than extrapolating from population‐level data, enabling more comprehensive assessment of targeted vaccine programs. Aside from the few countries that link national or statewide immunisation registers to health data,12 evaluating the uptake of influenza vaccination in medically at‐risk groups is a global problem, with considerable gaps in monitoring coverage due to incomplete identification of these individuals. Requirement to report vaccines to the AIR Until recently, while strongly encouraged, there was no requirement to report vaccinations to the AIR except for pharmacists under legislation in NSW and the Australian Capital Territory.13 However, an amendment to the AIR Act has recently been legislated, making it mandatory for all vaccination providers to report to the AIR vaccines given under the NIP, through school‐based programs and privately, such as for seasonal influenza and vaccines required for travel purposes.14 Under the new legislation, coronavirus disease 2019 (COVID‐19) vaccines must be reported to the AIR. In addition, influenza vaccinations must be reported to the AIR from 1 March 2021 and all other NIP vaccinations must be reported from 1 July 2021.15 The requirement has ramifications, as the completeness of reporting is likely to be lower for vaccines recommended and funded as part of targeted programs on the NIP, previously limiting accurate coverage assessments. While no studies have examined completeness of reporting maternal vaccination to the AIR,6,7 this is exacerbated by incomplete adult vaccination data in the register, especially with the expansion of other vaccine providers, such as pharmacists and workplace programs.16 The COVID‐19 pandemic highlights the requirement for a more adaptable AIR. With more than 200 COVID‐19 vaccine candidates in development,17 the rollout of COVID‐19 vaccines will be complex due to expected availability and the delivery capacity of immunisation providers. With a need to protect the most vulnerable people first, Australia’s COVID‐19 vaccination program will prioritise border and quarantine staff, health care workers and medically at‐risk groups. These vaccination encounters will need to be recorded and tracked, both for coverage and vaccine safety, using active surveillance systems such as AusVaxSafety (www.ausvaxsafety.org.au). Potential solutions to improve vaccine uptake and tracking Improving vaccine uptake in targeted programs requires a multifaceted approach, such as education, reduction of access barriers, and key structural modifications that should focus on core capabilities of the AIR and reporting requirements. While recent NIP changes present a unique opportunity to redefine the core functions of the AIR, there are potential complexities and ethical considerations around reporting pregnancy and medical conditions to the register. One potential solution would be to consider the linkage of AIR data to other national datasets (eg, Medicare, the Pharmaceutical Benefits Scheme, hospitalisations, the Therapeutic Goods Administration adverse event database), as occurs in some other countries.12 This is relevant for the introduction of COVID‐19 vaccines, for which safety monitoring and coverage tracking will be critical. Another solution would be to include pregnancy and medical risk factor data fields in the AIR. This information could be entered directly by providers if reporting on the AIR secure website or reported in a semi‐automated manner via practice management software (PMS), which is how most reporting currently occurs. While pregnancy and medical risk factors are often recorded in PMS, ensuring this is done routinely and updated appropriately would require substantial provider education. To improve access and ensure better integration within immunisation provider settings, particularly in general practice, bidirectional capacity could be developed to enable the AIR to link with PMS to reconcile vaccination status and provide clinical decision support on catch‐up vaccination schedules. The stricter reporting requirements, such as mandated reporting of all vaccinations and linking NIP vaccines with reporting, as outlined in the recent Australian Immunisation Register Amendment (Reporting) Bill 2020,14 will be beneficial, although the implementation and ensuring compliance may be challenging. Under the new AIR Reporting Bill, in addition to education and support, non‐compliant providers may also be subject to financial penalties. However, an incentives approach to reporting, in addition to mandated reporting, could also be implemented. For example, general practitioners and other immunisation providers could receive administrative payments for reporting vaccinations to the AIR (similar to what is done with the NIP childhood vaccines), thus acknowledging the time it takes from their busy schedule. Despite the AIR being internationally recognised and celebrated within Australia, there is opportunity for improvement if the AIR is to fulfil its potential as a lifelong register. The most pressing challenges ahead are the need to continue to optimise reporting to the AIR and build capacity to identify special risk groups (particularly given the new targeted NIP programs), and the need to improve reporting of all non‐NIP vaccines. We welcome the recent AIR Reporting Bill 2020; however, there remains a particularly urgent need to have the ability to identify individuals with risk factors such as pregnancy or medically at‐risk status. This would not only use the full potential of the AIR and optimise vaccine coverage surveillance but would also offer benefits at the individual level. We appreciate that such changes to the AIR and provider practice may be cumbersome. However, we are seeking support from the broader medical community to raise awareness and advocate that these changes should be prioritised, not only to improve accuracy in recording of vaccinations and at‐risk status but also to facilitate providers’ ability to access AIR data for better patient care. NIP vaccine programs tailored to the increased risk experienced by population groups are important, such as those targeted to pregnant women or medically at‐risk individuals. We must ensure that we have the mechanisms to accurately assess coverage in these vulnerable groups, not just the routine childhood NIP‐funded groups, to drive optimal uptake and best practice.

Jane Tuckerman · Christopher C Blyth · Frank H Beard · Margie H Danchin

Careful planning is required to deliver a safe and effective COVID‐19 program Providing a safe and effective coronavirus disease 2019 (COVID‐19) vaccination program is required to mitigate against the current and future negative impacts on the health and wellbeing of all Australians from COVID‐19. An effective vaccination program is a key element required to facilitate economic recovery, safe movement throughout and beyond Australia and a return to the quality of life previously experienced. Development of COVID‐19 vaccines has progressed with incredible speed. Results of phase 3 studies were released in December,1,2,3 11 months after the pandemic was identified. Progress towards a COVID‐19 vaccine program has occurred at pace. Developing a COVID‐19 vaccine program With over 60 candidates in clinical trials, unprecedented efforts are driving vaccine development. Numerous approaches to vaccine design have been utilised, including traditional (inactivated, live attenuated, protein subunit) and more novel approaches (viral vector, nucleic acid). COVID‐19 vaccination program development and registration have progressed in Australia through well established existing pathways and partnerships. The National Immunisation Program was established by the Commonwealth, state and territory governments in 1997 to provide funded vaccines to the Australian population. Partnerships that underpin this program are being used to develop the COVID‐19 vaccination program. Vaccines are assessed through the national therapeutics regulator, the Therapeutic Goods Administration (TGA), which assesses safety, quality and efficacy, with advice from an independent body of experts, the Advisory Committee on Vaccines (Box). The Australian Technical Advisory Group on Immunisation (ATAGI) provides technical and clinical advice on the role of vaccines on the National Immunisation Program and oversees development of the Australian Immunisation Handbook. These existing organisations and committees are being utilised for developing the COVID‐19 vaccine program. Funding of vaccines on the National Immunisation Program usually requires submission to the Pharmaceutical Benefits Advisory Committee. If it is deemed cost‐effective, the Pharmaceutical Benefit Advisory Committee provides a recommendation to government for funding. Given the need for rapid action, the Australian Government established the COVID‐19 Vaccine Taskforce. Potential vaccines are being assessed by government, with advice from the COVID‐19 Vaccine and Treatments for Australia – Science and Industry Technical Advisory Group.4 Ensuring rapid access to COVID‐19 vaccines, the Australian Government secured agreements with suppliers of four lead candidates. A commitment to provide free access to vaccine for all people in Australia has been made.5 Leading vaccine candidates Considering different modes of action and the need for a range of suppliers with international and local manufacturing potential, advanced purchase agreements were signed in 2020 for the University of Oxford–AstraZeneca ChAdOx‐1 nCoV‐19 (AZD1222) vaccine (a viral vector vaccine); the University of Queensland–CSL V451 and Novavax NCX‐CoV2373 vaccines (protein subunit vaccines); and the Pfizer–BioNTech BNT162b2 vaccine (an mRNA vaccine).6 Interim phase 3 results have been published for two of these vaccines. Following randomisation of > 43 000 individuals aged ≥ 16 years (predominantly in the United States) receiving two doses of BNT162b2 or placebo, a 95% reduction in symptomatic laboratory‐confirmed COVID‐19 was reported among vaccine recipients (95% credible interval, 90.3–97.6%).2 Over 23 000 individuals aged ≥ 18 years were randomised into studies conducted in the United Kingdom, Brazil and South Africa. Randomised individuals received two doses of either AZD1222 (albeit utilising different dosing schedules) or a meningococcal vaccine; a 70.4% (95.8% CI, 54.8–80.6%) reduction in symptomatic laboratory‐confirmed COVID‐19 was observed.3 Further results from these trials are anticipated in 2021. Results from a phase 3 study of NCX‐CoV2373 involving more than 15 000 enrolled individuals aged ≥ 18 years were provided (by media release) in January 2021. The first interim analyses reported vaccine efficacy against symptomatic COVID‐19 infection of 89.3% (95% CI, 75.2–95.4%).7 V451, which uses the human immunodeficiency virus (HIV) gp41 protein to maintain the severe acute respiratory syndrome coronavirus 2 spike protein in its pre‐fusion state, generated false positive HIV antibody test results in vaccine recipients in phase I trials. Given potential adverse impacts on the program and the need to modify HIV testing algorithms, further trials of this vaccine were abandoned, with CSL agreeing to increase local manufacturing of AZD1222.8 Of the leading contenders, Australia has secured access to 20 million doses of BNT162b2 and 3.8 million doses of internationally manufactured AZD1222, with CSL also committed to locally manufacture 50 million doses of the latter.7 Much of the global 2021 vaccine manufacturing capacity is tied to pre‐market purchasing commitments, with Australia a leader in terms of the number of courses available per capita and diversity of vaccines.9 In addition, the Australian Government has joined 188 countries in providing funding to the COVID‐19 Vaccines Global Access (COVAX) Facility,10 a key pillar of the World Health Organization (WHO) Access to COVID‐19 Tools Accelerator.11 This enables access to a range of additional candidates but also supports access to vaccines for low to middle income countries. A critical question is the relative efficacy and real‐world effectiveness of current vaccines being trialled. No comparative trials are underway. Despite differences in efficacy point estimates, differences in trial design and study populations preclude any conclusions about their relative impact. For Australians, successful phase 3 studies show that both BNT162b2 and AZD1222 are likely to be effective. Both vaccines are likely to have key roles in the Australian program. Encouraging results from other candidates, including NCX‐CoV2373, suggest that these vaccines may also play a role. Key steps Essential components of the national COVID‐19 vaccine strategy12 include: identifying and supporting research and development; building a diverse portfolio of investments and strengthening local manufacturing; fostering international partnerships to contribute to the global efforts; streamlining regulatory pathways13 and collaborating with international regulators; and working with the ATAGI COVID‐19 Working Group14 to develop a safe and effective vaccination program. Potential candidates have been reviewed in detail by the TGA and ATAGI, a process which will continue as further data emerge. Provisional determination by the TGA for potential vaccines enables preliminary data to be reviewed ahead of submission of the full regulatory dossier.13 Full review of lead candidates by the TGA led to approval of both Pfizer–BioNTech BNT162b2 and Oxford–AstraZeneca AZD1222. Ongoing review of other candidates continues. Advice on priority populations continues to be developed by ATAGI, initially focusing on population groups at greatest risk of exposure, severe outcomes and transmission, in addition to individuals critical to societal functioning such as emergency services, police and public health personnel.15 Key values (as outlined in the WHO Strategic Advisory Group of Experts on Immunisation values framework) including wellbeing, respect, equity, reciprocity and legitimacy have been considered in identifying priority populations.16 Prioritisation must be informed by both the epidemiology (with a focus on locations with current community COVID‐19 activity) and modelling to examine the impact of varying vaccine characteristics (relative effectiveness, duration of protection) and target populations on overall disease control. Health care and aged care workers have been identified as priority groups for early vaccination in all scenarios. In addition to sites of routine immunisation delivery, additional locations including dedicated vaccination clinics and workplace and in‐reach clinics will be required to ensure timely access for all.17 Chosen locations will need to consider logistic challenges including storage conditions (the Pfizer–BioNTech vaccine must be stored at − 60⁰C to − 90⁰C and used within 5 days of defrosting)18 and supply in multi‐vial trays containing multi‐use vials. Workforce development, training and resources (particularly in the safe use of different multi‐use vials) are critical components required for a safe and successful program. Current COVID‐19 vaccine trials include 30 000–50 000 participants, of whom roughly half will receive the vaccine. These large studies can detect common adverse events, but to pick up serious but very rare side effects, ongoing monitoring of vaccine safety will be required. Post‐marketing surveillance, underway in the Northern Hemisphere, will provide additional reassurance about the safety of these vaccines. A COVID‐19 pharmacovigilance plan, incorporating key vaccine safety programs developed since 2009 including AusVaxSafety (http://www.ausvaxsafety.org.au) and vaccine safety reporting programs established in states and territories, will ensure real‐time monitoring of adverse events. Critical to safety and effectiveness monitoring is use of the Australian Immunisation Register. Amendments to the Australian Immunisation Register legislation requiring mandatory reporting of all vaccines have been passed by Federal Parliament.19 Additional data systems to streamline reporting to the Australian Immunisation Register and provider education will be required to ensure all administered doses are captured. These changes will ensure all individuals have a valid, durable and reliable record of vaccination. This will assist program rollout (eg, being able to determine which brand a patient has previously received) and also help inform program evaluation (eg, by providing estimates of vaccine coverage at the population level). Provider and community confidence are paramount to program success.20 Ongoing research to explore the structural, social and behavioural factors that may compromise vaccine acceptance is required. Clear and regular communication with providers and the public by trusted scientific and public health sources about what is known, as well as uncertainties, is required. The development and dissemination of evidence‐based information, along with additional messages for specific target groups and support materials to assist health care providers in discussions with patients, continue to be prepared. A clear and realistic understanding of vaccine effectiveness and expected adverse events are required to combat an anticipated escalation in COVID‐19 vaccine misinformation. As we commence the COVID‐19 vaccination program, we enter a new phase of the Australian response to the pandemic. Although millions of influenza vaccines are distributed each year, the COVID‐19 immunisation program will be more complex than any other immunisation program in Australia’s history. Evidence‐informed public policy, collaboration between governments and between program administrators and providers, along with clear communication, are required to ensure programmatic success. Box – Key steps involved in routine and COVID‐19 immunisation programs Routine immunisation delivered by the National Immunisation Program COVID‐19 immunisation program Initiation of process Sponsor application to the TGA and PBAC Australian Government with advice from the SITAG Regulatory decisions TGA with advice from the ACV TGA with advice from the ACV Purchasing decisions Australian Government with advice from the PBAC Australian Government with advice from the SITAG Clinical and other technical information Statements from ATAGI with support from the NCIRS Multiple providers, including ATAGI statements, NCIRS fact sheets and training materials contracted by Australian Government Department of Health Program implementation Australian Government Department of Health in conjunction with jurisdictions Australian Government COVID‐19 Vaccine Taskforce and Department of Health in conjunction with jurisdictions ACV = Advisory Committee on Vaccines; ATAGI = Australian Technical Advisory Group on Immunisation; NCIRS = Immunisation Research and Surveillance; PBAC = Pharmaceutical Benefits Advisory Committee; SITAG = COVID‐19 Vaccines and Treatments for Australia – Science and Industry Technical Advisory Group; TGA = Therapeutic Goods Administration.

Christopher C Blyth · Katie L Flanagan · Robyn A Gibbs · Nigel W Crawford · Allen C Cheng

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