Infectious diseases

To the Editor: The New South Wales Department of Health has taken necessarily stringent steps to reduce the risk of workplace outbreaks during the coronavirus disease 2019 (COVID‐19) pandemic. Currently, two nasopharyngeal samples, analysed by polymerase chain reaction (PCR), negative for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) are required before asymptomatic individuals can return to high risk workplaces (eg, hospitals, schools and prisons) or close proximity living arrangements (eg, residential aged care facilities, military barracks, and group homes).1,2,3 In Newcastle, existent hospital in the home services have been redeployed as part of a tiered pandemic response under the banner “COVID Care at Home”. COVID Care at Home offers daily telehealth monitoring and efficient clearance certification for patients in isolation or excluded from workplaces. In our experience with 45 patients with COVID‐19 admitted to COVID Care at Home, increased PCR surveillance also uncovered cases of prolonged RNA detection. One passenger from the vessel Ruby Princess tested positive for COVID‐19 52 days after the initial swab and more than 60 days after the first day of symptoms. A review of international data showed that PCR positivity usually persists for 20–30 days regardless of symptomology.4 Cases of SARS‐CoV‐2 RNA detection persisting for 60 or even 80 days have been recorded in the literature.5,6 In the case of our patient, the ongoing exclusion from the workplace created significant psychological and financial burden due to lack of leave entitlement. Similar policies in countries with less worker security are likely to have even greater workforce impact. To tackle the issue of prolonged positivity, we have convened a panel of clinicians in the disciplines of infectious diseases, population health, and microbiology to make informed decisions about patients with prolonged viral RNA detection in regard to their ongoing need for isolation and exclusion from high risk environments. PCR positivity is not synonymous with infectivity.7,8 Regardless, to maintain the good results Australia has enjoyed thus far, we will need to persevere with a high level of vigilance. Making informed and safe decisions about clearance for high risk environments and supporting patients with prolonged exclusions from their workplace will be an ongoing challenge for Australian clinicians during the COVID‐19 pandemic.

Eliza Jane T Milliken · Sarah Browning · Danielle A Rohl

To the Editor: We write in reference to the recommendations published by Brewster and colleagues1 to report our centre’s experience with tracheal intubation in adults with coronavirus disease 2019 (COVID‐19) in Australia. Intubating patients with COVID‐19 requires careful balance between providing adequate pre‐oxygenation while concurrently maintaining staff safety through minimising aerosolisation. Guidelines from the Safe Airway Society (SAS),1 the Australian and New Zealand Intensive Care Society,2 and overseas3 emphasised rapid sequence induction techniques with the minimisation of bag valve mask ventilation. Our institution developed a specific tracheal intubation protocol for the intubation of patients with suspected or confirmed COVID‐19 incorporating the recommendations of the SAS.1 Eight patients with confirmed COVID‐19 have been intubated in our intensive care unit. The demographic characteristics of these patients are similar to those reported internationally,4,5 with a male predominance (seven out of eight) and a mean age of 69 years (range, 52–77 years). Before intubation, each patient was receiving high flow nasal oxygenation, with flow rates of 15–50 L/min and fraction of inspired oxygen (Fio2) 60–100%. All patients were pre‐oxygenated via bag valve mask with a positive end expiratory pressure valve in the assembly, as per the SAS recommended circuit set‐up.1 Video laryngoscopy with indirect view was used and a full view of the glottis was established for six of the eight patients; in the other two patients only the epiglottis was seen. All patients were intubated successfully on the first attempt with a bougie. During intubation, desaturation to peripheral capillary oxygen saturation (Spo2) 70% or less occurred in six of the eight patients, although the Spo2 recovered to more than 90% within one minute of being connected to the ventilator in five patients and within several minutes in the remaining patient. No patient received manual ventilation, and none of the patients developed haemodynamic instability during the intubation period. Our centre’s experience, while modest in number, highlights the significant risk of desaturation during intubation for patients with respiratory failure and COVID‐19 using a conservative approach to pre‐oxygenation and apnoeic oxygenation that minimises aerosolisation. We note the now updated SAS statement saying that “patients with severe disease are likely to require manual ventilation to prevent profound oxygen desaturation”.1 Whether manual ventilation, alternative pre‐oxygenation methods, or other strategies, such as potentially tolerating desaturation as transient and expected, is the most suitable method for patients with COVID‐19 remains to be determined.

Katherine E Triplett · Luke W Collett

In reply

David J Brewster · Christopher J Groombridge · Jonathan J Gatward

Despite a year of floods, fires and pestilence, we approach 2021 with optimism

Nicholas J Talley

Stage 3 lockdown measures in Victoria reduced COVID-19 transmission, but more was required to control the epidemic

Allan Saul · Nick Scott · Brendan S Crabb · Suman S Majumdar · Benjamin Coghlan · Margaret E Hellard

It was mid-morning, halfway through ward round

Jillian Chau

Our findings may help remove the stigma attached to pyjama wearing

David G Chapman · Cindy Thamrin

These days of 2020 Have seen ravages aplenty

Rob D Mitchell

Rapid dissemination of information should not come at the expense of quality, ethical standards or oversight The coronavirus disease 2019 (COVID‐19) pandemic has resulted in wide‐ranging health, social and economic impacts. By October 2020, global cases exceeded 41 million, with 1.1 million deaths.1 Urgent requirements for information were met with data on epidemiology, clinical features and recommended management being circulated on social media and pre‐publication servers. While this has allowed timely sharing of data, it has also brought risk of misinformation, with consequent changes to medical practice and misdirection of scarce resources based on flawed evidence. Medical publishing uses peer review to provide independent and critical assessment to verify data integrity, validity of interpretations, and confidence in conclusions. This process can take many weeks; however, in a rapidly spreading pandemic, speed is a competing priority. We hypothesised that these considerations may have altered the nature of medical publication. Accordingly, we characterised various aspects of COVID‐19‐related articles published in the five leading general medical journals with the highest impact factors (Web of Science) compared with an equivalent period in the preceding year. Procedures for identifying, classifying and comparing publications were specified a priori. Research ethics approval was not required. Publications were identified in the United States National Library of Medicine PubMed database. All articles published between 1 January and 31 May (inclusive) in 2019 and 2020 in The New England Journal of Medicine, The Lancet, JAMA, The BMJ and Annals of Internal Medicine were included. The sampling timeframe was defined by the first public health notification of COVID‐19 in China on 31 December 2019, ending at the time of the conduct of the literature search (Box 1). Within the 2019 search results, 60 articles were randomly selected using a random number generator in Stata 15.1. Publications without abstracts were excluded. Journal websites for each study period were searched for retracted articles. Three reviewers independently abstracted the variables contained in Box 2 and Box 3. The h‐index (a measure of publication productivity and citation impact) of the first and last author was taken from Web of Science. A fourth investigator reviewed all data, harmonising interpretations and resolving any errors. Data were analysed using Stata 15.1. Skewed continuous data were described using medians with interquartile ranges (IQRs) and compared using the Wilcoxon–Mann–Whitney test. Categorical data were compared using the Fisher exact test or χ2 test as appropriate. Exact P values are reported and those less than 0.05 deemed significant. During January to May 2020, PubMed listed 4001 articles, of which 1120 (28%) were related to COVID‐19. There were 134 articles with PubMed‐coded abstracts which were included for full review (Box 4). One additional COVID‐19 article was identified in the search for retracted articles but excluded from quantitative comparisons because it lacked an abstract. During the same period in 2019, 54 articles were ultimately identified as eligible for comparison (Box 4). Compared with 2019, among the COVID‐19‐related publications in 2020, there were more case reports or case series, cohort studies, editorials and commentaries and fewer randomised controlled trials (7/134 [5.2%] v 19/54 [35.2%]) (Box 2). A similar proportion (37/52 [68.5%] non‐COVID‐19‐related articles v 74/134 [55.2%] COVID‐19‐related articles; P = 0.09) reported primary data. Of the 2019 articles, only two of 54 (3.7%) originated in China, whereas 32 of 134 (23.9%) of the COVID‐19 articles published in 2020 were from China. The proportion of COVID‐19 articles in 2020 for which a correction was published was higher than for non‐COVID‐19 articles published in 2019 (28/124 [20.9%] v 4/54 [7.4%] respectively; P = 0.03). Time to the first publication of a correction was no different (median, 6 days [IQR, 4–14] v 7.5 days [IQR, 5–18] respectively; P = 0.53). Three 2020 COVID‐19 articles,2,3,4 but none of the 2019 articles, were retracted after publication. Only one journal, JAMA, routinely reported when a manuscript was submitted. In this journal, the median time from submission to publication fell from 139 days (IQR, 130–144) in 2019 to 23 days (IQR, 12–30) in 2020 (P < 0.001). The median number of authors and their publication productivity and impact, as quantified by their median h‐indices, were similar. There was no statistically significant difference in the number of studies willing to share data under appropriate circumstances (P = 0.19), or those receiving commercial funding (P = 0.97). The measured characteristics of randomised trials related to COVID‐19 were not statistically different to studies of an equivalent type published in the preceding year; however, numerically fewer subjects (median, 199 [IQR, 127–397] v 424 [IQR, 225–1076]; P = 0.07) and centres (median, 10 [IQR, 1–55] v 30 [IQR, 4–168; P = 0.15) participated (Box 3). Similarly, the observational study sample size was significantly smaller (median, 152.5 [IQR, 15–3481] v 191 972.5 [IQR, 1407.5–756 444]; P < 0.001), and the number of participating centres was numerically lower in the 2020 COVID‐19 group (median, 1 [IQR, 1–7] v 26 [IQR, 1–49]; P = 0.07). While not significantly different between groups due to the low numbers, 11 (16.7%) observational studies among the COVID‐19 publications did not report oversight by an ethics committee or institutional review board, and only nine (56.3%) case reports and case series with ten patients or fewer stated that patient consent had been obtained or that an exemption from this requirement had been granted. In the first 5 months of the COVID‐19 pandemic, the five leading medical journals published a substantial number of articles that differed in many respects from their usual material. The journals examined were the clinically focused general medical journals with the top five Web of Science 2019 impact factors, ranging from 21.3 to 74.6, representing the medical literature with the greatest international influence on health policy and clinical practice. As reasonably expected, there was a seven‐fold reduction in the proportion of articles reporting randomised controlled trials, and a compensatory increase in small case series, opinions and editorials. While there were few (n = 2) articles in the random selection of 2019 papers that were published from China, nearly one‐quarter of the COVID‐19 publications came from this country, as anticipated given the location of the earliest cases. There was no difference in the median h‐indices of authors, suggesting experienced academics pivoted rapidly to COVID‐19 research. In circumstances which usually require consent, just under half of the COVID‐19 studies did not explicitly state consent was obtained, despite clear recommendations by the International Committee of Medical Journal Editors.5 The proportion of articles that referenced appropriate ethics committee or institutional review oversight was statistically unchanged; however, it is still a concern that 11 (16.7%) observational COVID‐19 studies lacked any statement to this effect. In addition, several other articles stated that they had been exempted from the requirement for ethical review due to the nature of the pandemic. Respect for personal autonomy and the value of independent oversight have always imposed additional workload on those seeking broader public health benefits. If COVID‐19 has created challenges in adhering to the usual practices of obtaining ethics approval and consent, consideration should be given to whether these processes could be amended to improve speed and accessibility, particularly during global health emergencies. There was a near three‐fold increase in the proportion of studies that published corrections, perhaps reflecting the observed reduction in time from submission to publication observed in the one journal for which these data were available. It is likely this figure is an underestimation, given that corrections and retractions would be expected to continue over time. Three COVID‐19 studies were retracted. The publication of one of these articles4 had important implications, resulting in the temporary cessation of the World Health Organization's trial of hydroxychloroquine.6 While the corrections and retractions may be an artefact of increased speed to publication, it is also possible that their higher number might be the effect of enhanced focus on research related to COVID‐19. Nonetheless, journals must retain the integrity of review processes if they are to offer value beyond alternative online means of information dissemination. This review has found similar results to bibliometric studies relating to the COVID‐19 pandemic, which have identified higher numbers of case series and reviews and fewer randomised clinical trials.7,8,9 We did not examine other articles from 2020 to understand the effect of COVID‐19 on contemporaneous publications, or to be able to comment on whether observed changes were specific to COVID‐19 or true of all 2020 articles. We note the convenience sampling of two similar periods may overestimate the magnitude of our findings. The cohort of 2019 studies for comparison was selected at random, rather than being matched by study type or size. When identifying h‐indices, we had difficulty identifying some Chinese authors, highlighting a bias against researchers without a name that can be distinctively rendered in the English language alphabet. Further implementation of unique author identifiers, such as the Open Research and Contributor ID (ORCID; www.orcid.org) or ResearcherID (Clarivate Analytics) would address this problem. We did not assess the quality of published studies or adherence to reporting guidelines. As part of their early response to the worldwide problem presented by the COVID‐19 pandemic, there was a significant change in the characteristics of articles published by leading medical journals, with some evidence of a tendency towards publishing articles prematurely and those with lower internal validity. While these unique circumstances no doubt warranted such a change, rapid dissemination of information should not need to come at the expense of quality, ethical standards or oversight. Others have suggested several solutions to this challenge, including a two‐track review process for pandemic and non‐pandemic research, rapid preliminary assessment of research methodology by skilled in‐house reviewers before deciding whether to send for peer review, sharing of peer‐reviews between reviewers and journals, and mentored peer reviewing by research trainees.10 As part of pandemic preparedness, planning to facilitate augmentation of resources available to medical publishers, allowing maintenance of standards of review, should occur. Box 1 – Search strategy ((“JAMA”[Journal]) or (“The New England Journal of Medicine”[Journal]) or (“Annals of Internal Medicine”[Journal]) or (“BMJ”[Journal]) or (“Lancet”[Journal])) and (2020/1/1:2020/5/31[Date — Entry]) or and (2019/1/1:2019/5/31[Date — Entry]) Articles related to COVID‐19 were identified by adding and ((“covid”[All fields]) or (“coronavirus”[MeSH Terms]) or (“coronavirus”[All fields]) or (“coronaviruses”[All fields])) Box 2 – Characteristics of publications 2019 non‐COVID‐19 2020 COVID‐19 P Total number of articles 54 134 Article type Systematic review/meta‐analysis/narrative review 8 (14.8%) 16 (11.9%) < 0.001 Randomised controlled trial 19 (35.2%) 7 (5.2%) Cohort study 11 (20.4%) 25 (18.7%) Cross‐sectional study 5 (9.3%) 8 (6.0%) Case–control study 1 (1.9%) 2 (1.5%) Case series 2 (3.7%) 30 (22.4%) Case report 0 (0.0%) 4 (3.0%) Diagnostic evaluation 0 (0.0%) 1 (0.7%) Opinion 7 (13.0%) 33 (24.6%) Other 1 (1.9%) 8 (6.0%) Reported primary data 37 (68.5%) 74 (55.2%) 0.09 Correction published 4 (7.4%) 28 (20.9%) 0.03 Days from publication to correction, median (IQR) 6 (4–14) 7.5 (5–18) 0.53 Retracted 0 (0.0%) 3 (2.2%) 0.56 h‐index of first author, median (IQR) 13.5 (3–36) 11.5 (6–30) 0.54 h‐index of last author, median (IQR) 26 (14–38) 21 (10–38) 0.14 Associated editorial of eligible articles 21 (38.9%) 44 (32.9%) 0.43 Number of masthead authors, median (IQR) 8 (5–19) 7 (4–18) 0.52 Number of total authors, median (IQR) 8 (5–23) 7 (4–19) 0.23 Region of origin China 2 (3.7%) 32 (23.9%) < 0.001 United States 24 (44.4%) 67 (50.0%) Europe 20 (37.0%) 24 (17.9%) Rest of world (high income countries) 3 (5.6%) 11 (8.2%) Rest of world (low income countries) 5 (9.3%) 0 (0.0%) COVID-19 = coronavirus disease 2019; IQR = interquartile range. Box 3 – Characteristics of studies reported table#t3 tbody td:nth-child(n+2) P. Pleft { text-align: center; } 2019 non‐COVID‐19 2020 COVID‐19 P Randomised controlled trials 19 7 Number of subjects, median (IQR) 424 (225–1076) 199 (127–397) 0.07 Participating centres, median (IQR) 30 (4–168) 10 (1–55) 0.15 Studies that received funding of any type from a commercial source 8 (42.1%) 3 (42.9%) 0.97 Studies in which a commercial entity had influence over any aspect of study conduct or reporting 7 (36.8%) 2 (28.6%) 0.69 Studies stating willingness to share data under appropriate circumstances 15 (78.9%) 7 (100.0%) 0.19 Studies stating individual patient consent or waiver was granted 19 (100.0%) 7 (100.0%) 1.0 Studies noting review by ethics committee 19 (100.0%) 7 (100.0%) 1.0 Observational studies* 19 66 Number of subjects, median (IQR) 191 972.5 (1407.5–756 444) 152.5 (15–3481) < 0.001 Participating centres, median (IQR) 26 (1–49) 1 (1–7) 0.07 Studies that received funding of any type from a commercial source 0 (0.0%) 4 (6.1%) 0.27 Studies in which a commercial entity had influence over any aspect of study conduct or reporting 0 (0.0%) 3 (4.5%) 0.34 Studies stating willingness to share data under appropriate circumstances 8 (42.1%) 15 (22.7%) 0.09 Studies not stating individual patient consent was obtained or a waiver was granted 3 (15.8%) 17 (25.8%) 0.37 Studies not noting review by ethics committee 0 (0.0%) 11 (16.7%) 0.06 Case reports/case series (≤ 10 patients) 1 16 Studies stating individual patient consent was obtained 1 (100.0%) 9 (56.3%) 0.40 COVID-19 = coronavirus disease 2019; IQR = interquartile range. * Observational studies included cross-sectional studies, case–control studies, cohort studies and case series reporting data from one patient or more. Box 4 – Publication identification flow diagram COVID‐19 = coronavirus disease 2019.

Kirsty A Whitmore · Kevin B Laupland · Clare M Vincent · Felicity A Edwards · Michael C Reade

Medicine in the pre‐antibiotic era offers lessons still relevant today, particularly regarding the prudent use of valuable medications The handwritten line on an archived envelope stored in a safe in The Children's Hospital at Westmead undercroft — “The first child in Australia to have ‘Penicillin’ therapy” (Box 1) — understates the remarkable story of how an experimental drug was requested, approved and delivered in secrecy during the Second World War for one child. The “Penicillin Papers”, rediscovered in 2018 by the Heritage Committee of The Children's Hospital at Westmead, highlight important questions of ongoing relevance. The story of the fortuitous discovery of penicillin by Alexander Fleming in 1928 has entered popular consciousness. What is less well known is how penicillin, which dramatically changed the course of medicine, came to be given to patients. The patient: a small boy in wartime Sydney On 17 June 1943, Peter, almost 7 years old, was admitted to the Royal Alexandra Hospital for Children with fever and increasing drowsiness. During the following 24 hours he reported headache, and a lumbar puncture found turbid cerebrospinal fluid (CSF) with an “uncountable number of leucocytes”, and Streptococcus pneumoniae “type 18” was cultured, a serotype that frequently caused meningitis.1 Sulfonamide drugs were manufactured in Australia in the 1940s, but between 1942 and 1945 stocks were strictly controlled, being reserved almost exclusively for military campaigns in New Guinea.2 Peter, diagnosed with pneumococcal meningitis, was treated with intravenous sulfapyridine for four days, and his fever resolved (Box 2); daily lumbar punctures showed CSF clearing. Treatment switched to oral sulfapyridine, but his fever and vomiting returned. Further intravenous sulfapyridine for one day was followed by extremely painful subcutaneous sulfadiazine infusions for 18 days, then by oral sulfathiazole for four days. Sulfadiazine was obtained from the 118th General Hospital of the United States Army, based in Herne Bay (now Riverwood) and staffed by health professionals from the Johns Hopkins University Hospital in Baltimore. Access to the restricted sulfa drugs was granted by Major McPherson Brown (1906–1989), a professor at the Johns Hopkins, suggesting early involvement of the US Army. By 10 July, however, Peter's CSF was again culture‐positive for S. pneumoniae and the outlook was “grave”. In 1943, penicillin was a highly experimental drug; clinical trials in US troops in Sicily were underway, and only two scientific articles on its clinical use had been published.3,4 In the US, the unenviable task of rationing the small supply for civilian use fell to Chester Keefer, professor of medicine at Boston University Hospital and chairman of the National Research Council Committee on Chemotherapy. Keefer personally vetted each penicillin request, restricting its use to cases in which all other treatments had failed.5 To better understand its potential and limitations, he collected detailed information on all patients given penicillin. Fortunately for Peter, his father was Lieutenant Commander Leo Harrison, a Navy surgeon working as a base medical officer in Sydney in 1943. It is likely that his father's connections with US Army doctors helped secure access to the treatment that ultimately saved his life. On the morning of Saturday, 10 July, Sir Alan Newton, chairman of the Medical Equipment Control Committee, cabled Washington to request urgent supply of penicillin for Peter. At 4:30 pm, one million units (600 mg) were despatched from Washington to San Francisco, together with documents stipulating that the penicillin was for research purposes only, and on the understanding that clinical notes would be provided to the National Research Council following treatment. The penicillin was transported by Liberator bomber from San Francisco to Hawaii, and from there via Brisbane to Sydney, arriving at the Royal Alexandra Hospital at midnight on Thursday, 15 July. The first dose was administered to Peter intramuscularly at 12:18 am on 16 July. Over ten days he received 15 000 units (9 mg) penicillin intramuscularly every four hours, and 10 000 units (6 mg) intrathecally. Today, 5 million units intravenous benzylpenicillin per day would be recommended for a boy of Peter's weight (almost 22 kg). Although Peter's condition improved dramatically, waking from “a stupor” to eat a full breakfast within 48 hours, the dose and treatment duration were inadequate. By 21 July, Peter was again febrile and CSF cultures were positive. Regretting that type‐specific pneumococcal antiserum had not also been requested, Newton had sent a second cable to Washington on 16 July. Rabbit anti‐pneumococcal (type 18) serum arrived and 100 000 units were administered intramuscularly each day from 23 July to 1 August, and oral sulfadiazine from 26 July to 8 August. On 18 September 1943, Peter was discharged home “cured”. Seventy‐five years later, he and his family (Box 3) were interviewed by ABC News reporter Tracy Bowden,6 after his case had been re‐discovered by The Children's Hospital at Westmead Heritage Committee. Research secrecy There are three references in the medical literature regarding this incredible case. The first was a report published in the Medical Journal of Australia in June 1944 by the treating physicians Donald Vickery and Lindsay Dey.7 The second, a short mention by Newton in a speech to the British Medical Association, was published in July 1944;2 the third, a letter by Dey's son in the MJA in August 1981,8 described his father's recounting of events that “would have made an excellent basis for a film”. The initial publication7 was delayed by the condition that details of the case be released only to the US National Research Council, effectively a non‐disclosure agreement. Discussions about research secrecy are as old as science itself.9 Proponents of openness argue that it promotes innovation and enhances productivity and efficiency of research. Openness is essential for testing hypotheses and fostering collaboration. Sharing information with the public fulfils moral obligations to provide evidence for shaping policy and to be accountable for the use of public funds. Conversely, research secrecy is often justified as protecting credit and intellectual property, shielding scientists and human research participants from stigmatisation or harassment, and minimising threats to national or international security. The financial interests of biotechnology and pharmaceutical companies further complicate the discussion. In 1943, arguments for secrecy about experimental penicillin treatments were compounded by the need to protect the limited supplies of the drug. It is pertinent here that the reverse of the envelope containing the Penicillin Papers was marked “Silence saves soldiers” (Box 1). Under the direction of Keefer, the Committee on Chemotherapy charged “accredited investigators” with assessing thousands of requests for penicillin.5 A strict allocation policy was adopted to ensure that decisions were made on clinical grounds. Only patients with severe infections caused by sulfonamide‐resistant, penicillin‐susceptible streptococci, gonococci and staphylococci, should receive penicillin, and only then if a cure could be expected. Access, compassionate and otherwise Equitable allocation of limited medical resources is a problem that often confronts clinicians and public authorities, particularly in resource‐constrained environments and during wartime, natural disasters,10 or epidemics.11 In 1943, Vickery and Dey did all they could to obtain the experimental drug penicillin for their patient. Wartime priorities in Australia did not include active control of therapeutic substances, although the National Health and Medical Research Council dealt with some medication access questions.12 In the US, the Food and Drug Administration (FDA) first addressed access to investigational drugs for therapeutic purposes in January 1963,13 three months after President Kennedy had approved the amendment of the Food, Drug, and Cosmetic Act that strengthened the FDA mandate to approve medications.14 The process of “expanded access”, the preferred FDA term for compassionate use — that is, of an unlicensed drug or device outside clinical trials — was formalised in 1987 in response to requests for access to investigational anti‐retroviral agents.13 In Australia, the Therapeutic Goods Administration (TGA) was established in 1989 as the national regulatory body; its Special Access Scheme, introduced in response to the 1991 Baume report,15 is the mechanism by which doctors can secure access to unlicensed drugs for selected patients. The 1962 American drug law amendments, passed in the wake of the thalidomide catastrophe, had the potential to make children “therapeutic orphans”, as many drugs have been tested only in adults.16 Paediatricians today regularly use medications off‐label, but the use of unlicensed drugs is less common and usually restricted to neonatal intensive care.17 Fortunately, the importance of including children in clinical trials is increasingly recognised internationally by research institutions and funding and regulatory agencies.18 Further, the FDA was empowered to provide financial incentives for including children in clinical trials and licensing applications by the 2007 Best Pharmaceuticals for Children and Pediatric Research Equity Acts.19 Lessons for the post‐antibiotic era from the pre‐antibiotic era Sulfonamides, the first effective antimicrobial agents, were available from the mid‐1930s, but drug resistance was widespread by the 1940s. One initial control on penicillin use was the requirement for demonstrated penicillin susceptibility and sulfonamide resistance: an early form of antimicrobial stewardship. As we approach the post‐antibiotic era because of rapidly increasing antimicrobial resistance, institutional, national and international antimicrobial stewardship programs are being implemented to protect the limited therapeutic options available for many infections. Multimodal programs incorporate pharmacokinetic and pharmacodynamic principles to avoid treatment failure through undertreatment, as experienced by Peter in 1943.20 In the future, strengthening these antimicrobial stewardship programs by integrating molecular technologies and high throughput screening methods will be critical. We also need to rediscover non‐antibiotic approaches to treating infections, including serotherapy21 and bacteriophage therapy.22 Both were widely and successfully employed in the early 20th century, and Peter's ultimate recovery in August 1943 appeared to require type‐specific anti‐pneumococcal serum treatment. However, our reliance on antibiotics over the past century has led to clinical and research neglect of alternative treatment modalities, although interest has revived in recent years, particularly in bacteriophage therapy.22 Greater investment in alternative treatment options is needed, as well as investigation of novel therapeutic and infection prevention strategies. Box 1 – The “Penicillin Papers”, retrieved from a safe in the basement of The Children's Hospital at Westmead in 2018, include letters and telegrams about the acquisition of penicillin from the United States and its use for treating Peter Harrison Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 2 – Details from transcribed observation charts for the first patient in Australia to be treated with penicillin, 1943 Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 3 – Peter Harrison (right), the first person in Australia to be treated with penicillin, pictured with his family in 2018, together with Bethany Robinson (second from right), the University of Sydney student who rediscovered the “Penicillin Papers”

Ameneh Khatami · Philip N Britton · Glendon Farrow · Megan Phelps · Alyson Kakakios

Artificial intelligence is being used in several different ways to curb the current pandemic while demonstrating its potential to be even more effective for the next one

Ian A Scott · Enrico W Coiera

The response to the largest institutional outbreak of COVID‐19 in health care workers in Australia to date needed to be multidimensional In many countries, high rates of health care workers with coronavirus disease 2019 (COVID‐19) have been associated with inadequate personal protective equipment (PPE), exposure to large numbers of patients with COVID‐19, worker fatigue, and limited access to diagnostic testing.1,2,3 In Australia, during the initial phase of the epidemic, infections in health care workers were largely attributable to international travel, corroborated by genomically distinct severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) lineages.4,5 At the Royal Melbourne Hospital, we observed a marked increase in staff infections during July and August 2020, concurrent with a statewide surge in COVID‐19 cases. To inform future responses in the Australian setting, we present a description of health care worker infections at our institution and the suite of interventions associated with outbreak control. Setting The Royal Melbourne Hospital City Campus is a 550‐bed university‐affiliated tertiary hospital with an additional 150 geriatric and rehabilitation beds at the Royal Park Campus, a large mental health service and four residential aged care facilities, employing about 10 000 staff. Throughout the pandemic, a rapid access COVID‐19 testing clinic was provided for symptomatic staff. To diagnose infection, deep nasal and throat swabs were sampled for nucleic acid testing (reverse transcriptase polymerase chain reaction [RT‐PCR] for SARS‐CoV2). SARS‐CoV‐2 RNA was detected using the Coronavirus Typing assay (AusDiagnostics).5 All positive COVID‐19 tests were notified to the Department of Health and Human Services, with staff members also being notified to the Royal Melbourne Hospital infection prevention services. Infected staff were interviewed by an infection prevention nurse consultant to identify any contacts and enquire about PPE use, work locations in the days before symptoms, nature of their work, characteristics of their patients, and any suspected acquisition events. Contacts with other staff outside work were also explored. Infected staff were required to isolate for 10 days or more after symptom onset and close contacts (≥ 15 minutes of face‐to‐face contact or ≥ 2 hours in a shared space in the 48 hours before symptom onset) were furloughed for 14 days and quarantined, according to state guidelines. Outbreaks (two or more epidemiologically and/or spatially linked staff and/or patients) were managed by a multidisciplinary incident management team. Data regarding health care worker infections were entered into a REDCap 10 (Research Electronic Data Capture) database, a secure web‐based platform, and were analysed using Stata 16. This study was approved by the Melbourne Health Human Research Ethics Committee (QA2020058). Overview Between 1 July and 31 August 2020, 262 cases of COVID‐19 were identified among Royal Melbourne Hospital staff (Box 1 and Box 2). Fifteen individuals (5.7%) required inpatient care and 13 (4.9%) received care by a hospital in the home service. Two were admitted to the intensive care unit (ICU), none requiring mechanical ventilation, with no deaths. Nurses were most commonly affected, followed by support staff (such as food and cleaning services) and doctors (17/21 of these being doctors‐in‐training) (Box 1). The trend in incidence of health care worker infections reflected the prevalence of inpatients with COVID‐19 (Box 3). The ICU had between zero and ten concurrent patients with COVID‐19 over the period (median, 7; interquartile range [IQR], 5.0–8.0), with four ICU staff acquiring COVID‐19. No operating theatre staff and no staff working in affiliated residential aged care facilities were infected. The median turnaround time for health care worker test results (from specimen collection to reporting) was 20.2 hours (IQR, 11.4–29.1 hours). Overt recognised PPE breaches were rarely reported. Contacts with known COVID‐19 cases outside the hospital were infrequent but did occur (eg, health care workers living together). Outbreak linked to geriatric and rehabilitation inpatient wards The Royal Park Campus had the highest number of staff with COVID‐19, making up 40.8% (n = 107) of health care worker infections at the Royal Melbourne Hospital, despite this campus constituting about 10% of the total staff workforce at the hospital (acknowledging that some staff move between sites). Between 12 and 18 July, the Royal Park Campus received a large number of patients from external residential aged care facilities, not affiliated with the Royal Melbourne Hospital, with COVID‐19 outbreaks. These residents were COVID‐19‐positive at admission and were managed with appropriate infection precautions throughout. COVID‐19 cases among staff rapidly escalated across all six wards at the campus after 16 July, peaking on 27 July. The peak number of patients with COVID‐19 at the Royal Park Campus was 60. At the Royal Park Campus there are a variety of buildings constructed from the 1970s to early 2000; most have central air conditioning plants, but one has a local split system. An engineering review of the wards revealed air exchanges met current requirements; however, a more detailed assessment of air movement suggested that some were not as well ventilated as others. Some patients were in single rooms, but many were in multibed spaces. Improved nurse to patient ratios were used to help manage patients. Despite this, because of large numbers of staff furloughs, the remaining staff experienced high workloads. A decision was made on 3 August to close four wards at the Royal Park Campus. Fifteen patients were moved to other health services, while the remaining 45 were moved to single rooms in wards with more modern infrastructure. Outbreaks linked to “hot wards” At the Royal Melbourne Hospital City Campus, most affected staff were working in wards with patients with suspected or confirmed COVID‐19 (“hot wards”) (Box 1). These staff were highly trained in PPE use, PPE was always readily available (ie, gowns, gloves, eye protection, and masks), and use was checked by a PPE “buddy” (usually a colleague) before patient room entry and at doffing. Staff noted that particular behaviour in infected patients appeared to be linked to transmission events (patients shouting, vigorous coughing). The peak combined prevalence of inpatients at the Royal Park and City campuses was 99 on 5 August 2020. As increasing numbers of staff infections were recognised, the density of patients on the COVID‐19 wards was reduced by closing beds in shared rooms and moving each patient to a single room where possible. On 21 July, use of N95 (or P2) masks by all staff at all times on COVID‐19 wards at both campuses was instituted. “Spotters” (supernumerary staff) were deployed to observe PPE donning and doffing, and senior staff ward walk‐arounds and additional cleaning with monitoring were implemented. Staff working on “hot wards” were offered weekly asymptomatic testing to detect any infections early. Outbreaks on “cold wards” On three occasions, clusters occurred outside the designated “hot wards”; that is, in wards not allocated to caring for patients with suspected or confirmed COVID‐19 infection. In some staff, having previously worked at the Royal Park Campus was identified as a potential risk factor. A management plan for these wards was deployed, including closure to new admissions, moving patients to separate rooms (where possible), managing the whole ward using increased precautions, deep cleaning, and voluntary testing of all patients and staff every 3–4 days. Hospital‐wide asymptomatic staff testing was instituted (> 600 staff tested) and whole hospital inpatient testing occurred as a point prevalence activity in late July, with no additional cases identified outside the affected wards. Institutional responses Responses were multifactorial and iterative, with daily review of emerging evidence that informed ongoing decisions. Importantly, a hierarchy of controls was used to manage these outbreaks (Box 4). A proactive approach was used to support infected and furloughed staff wellbeing, with dedicated nursing and medical staff monitoring physical and mental health as well as providing practical supports. This service managed over 680 staff during the outbreak period. Discussion We describe the largest institutional outbreak of SARS‐CoV‐2 health care worker infections reported in Australia to date. Our response was necessarily iterative and pragmatic and advice often pre‐dated formal state and federal recommendations. During these outbreaks, a number of key factors emerged that shaped our responses, extending well beyond a focus on PPE alone. First, the concept of a “critical burden” of infection framed our responses to patient movement and ward closures. Concurrent with large numbers of cases in the hospital and the community, the number of staff who acquired infection rose rapidly. Based on overseas experience,6,7 we hypothesised that large numbers of patients in confined spaces may have created a high density of droplets, aerosols and environmental contamination. This triggered a detailed assessment of ward physical layout, including the possible role of patient placement and air circulation. We elected to use single rooms wherever possible and to physically space infected patients by closing beds on the ward. The intensity of transmission in some wards led to a decision to close wards and move some patients to other health care services. Further, we adopted the use of N95 masks for staff working in areas with large numbers of patients with confirmed or suspected COVID‐19. While use of N95 masks for all COVID‐19 care was not recommended in state or federal guidelines at that time,8,9 this organisational decision was based on our local epidemiology and a need to trial any reasonably available strategy to contain health care worker infections. Second, the availability of rapid and accessible testing for staff was critical to informing real‐time outbreak management, highlighted by international studies.10,11 Rapid availability of data informed our daily incident management meetings and enabled prompt decision making using the best possible information. Finally, the importance of staff communication and wellbeing cannot be understated. Similar to other studies,3,12 many staff reported physical and mental fatigue and stress during these outbreaks. In addition, workforce shortages meant that staff were taking on extra shifts at short notice and working in unfamiliar roles. Accordingly, access to employee support programs was an important element of this response. Box 1 – Demographic characteristics of health care workers with coronavirus disease 2019 (COVID‐19), confirmed by polymerase chain reaction (PCR) testing, at the Royal Melbourne Hospital (1 July – 31 August 2020) Characteristic Number of confirmed cases
(%) Total number of confirmed cases 262 Sex Male 57 (21.8%) Female 205 (78.2%) Median age at diagnosis (IQR), years 32.7 (26.8–44.9) Employee type Nurse 179 (68.3%) Doctor 21 (8.0%) Allied health practitioner 9 (3.4%) Support staff (food services, environmental services) 38 (14.5%) Administrative staff 6 (2.3%) Student 4 (1.5%) Security staff 4 (1.5%) Laboratory staff 1 (0.4%) Location Royal Park Campus (rehabilitation, geriatric rehabilitation) 107 (40.8%) Hot wards* (COVID‐19 wards,† ED, ICU) 57 (21.8%) Cold wards‡ with recognised COVID‐19 outbreaks (3 wards) 20 (7.6%) Cold wards‡ with no outbreaks (1 or 2 unlinked cases; 6 wards) 7 (2.7%) Mental health ward§ 8 (3.1%) Not ward‐based (eg, non‐clinical) 31 (11.8%) Unknown (no campus/ward stated, includes both campuses) 32 (12.2%) ED = emergency department; ICU = intensive care unit; IQR = interquartile range. * Hot wards are wards dedicated to managing patients with confirmed or suspected COVID‐19. † COVID‐19 wards are wards where patients with confirmed or suspected COVID‐19 were managed. ‡ Cold wards are all other wards. § Mental health wards were situated at the City Campus and at other sites. Box 2 – Epidemic curve of health care worker infections at the Royal Melbourne Hospital (1 July – 31 August 2020) RPC = Royal Park Campus. * “Other” includes non‐clinical not ward‐based staff, staff working across several campuses, or ward not known. Mental health wards include off‐site facilities. Box 3 – Prevalence of inpatients with coronavirus disease 2019 (COVID‐19) at both the Royal Melbourne Hospital City Campus and the Royal Park Campus over time (13 July – 31 August 2020)* * Data start on 13 July 2020. Box 4 – Hierarchy of controls used to guide interventions to address health care worker infection with coronavirus disease 2019 (COVID‐19) at Royal Melbourne Hospital Elimination* Public health restrictions to reduce community incidence Testing availability in the community (and for staff) to identify and isolate cases early Rapid turnaround time for test results to identify and isolate cases early Frequent testing of staff and patients in wards with outbreaks for early recognition and management of cases Symptomatic staff furloughed until test results available Furlough asymptomatic staff who are contacts of COVID‐19 cases Work from home policies for staff Telehealth consultations rather than in‐person visits to hospital Visitor restrictions to hospitals (use of phone/iPad to liaise with family) Early discharge of patients not requiring inpatient care, use of hospital in the home services Use of remote meeting technology Engineering controls Attention to ventilation and air circulation in all clinical and non‐clinical areas Availability of negative pressure rooms Physical separation of patient groups (access to single rooms, wards with doors to separate from other wards) Equipment to improve turnaround times for microbiologic testing to enable rapid identification of cases Adequate space for staff to safely don and doff PPE Provision of break rooms with increased space enabling adequate physical separation Physical barriers for public facing non‐clinical staff (eg, perspex barriers) Appropriate cleaning (correct equipment to enable this) Administrative controls Existing policies, procedures and subcommittees (with appropriate governance) in place before the COVID‐19 pandemic regarding infection prevention, PPE, hand hygiene, transmission‐based precautions, cleaning, outbreak management, management of contact tracing, pandemic plan Appropriate governance (Emergency Operations Centre with multidisciplinary representation from all areas) during pandemic Use of national and state guidelines to inform development of hospital COVID‐19 guidelines Regular meetings of key stakeholders to discuss emerging issues Regular communications to staff via email, social media, and remote meetings by hospital executive and managers Policies to encourage physical distancing between staff (staggered breaks, start/stop times, roster redesign) Workflow changes to encourage distancing between staff and patients where possible Use of dedicated “COVID teams” in wards to minimise staff moving between wards Resourcing of staff in “COVID‐19 wards” to ensure manageable workload, improved nurse to patient ratios Bed allocation (avoidance of high density of COVID‐19-positive patients in wards, minimise use of shared rooms) Management of COVID‐19-positive patients in separate wards from COVID‐19‐negative patients Training (baseline and refreshers) and monitoring of PPE use (spotters) for all clinical and non‐clinical staff Increased resourcing of cleaning services and ongoing training in cleaning, using in‐house and not agency staff Monitoring of cleaning (eg, ongoing fluorescent marking programs, spotters) Hand hygiene training and auditing, including development of videos and posters specific to COVID‐19 PPE Universal pandemic precautions (surgical mask and face shields all staff all the time) Masks on patients where possible for source control Use of PPE appropriate to the circumstance (gowns, gloves, surgical masks, N95/P2 masks, eye protection) PPE = personal protective equipment. * Actions to remove or minimise the number of infected people on site.

Kirsty L Buising · Deborah Williamson · Benjamin C Cowie · Jennifer MacLachlan · Elizabeth Orr · Christopher MacIsaac · Eloise Williams · Katherine Bond · Stephen Muhi · James McCarthy · Andrea B Maier · Louis Irving · Denise Heinjus · Cate Kelly · Caroline Marshall

Recent proposals to adopt tenecteplase as the recommended thrombolytic agent for stroke reperfusion will reduce its availability for patients with acute myocardial infarction

Mark Parsons · Leonid Churilov · Aletta E Schutte · Christopher Levi

Children may be more susceptible than originally thought and could play a role in community transmission

Zoë Hyde

Lifting lockdown when numbers are low but not zero means that superspreaders may remain, leading to a further wave of the epidemic

David Kault

A public mental health response that includes universal, selective and indicated clinical interventions is needed

Jane RW Fisher · Thach D Tran · Karin Hammarberg · Jayagowri Sastry · Hau Nguyen · Heather Rowe · Sally Popplestone · Ruby Stocker · Claire Stubber · Maggie Kirkman

Hospitals in the Northern Territory often operate beyond capacity and serve a sparsely distributed population with rates of chronic disease and household overcrowding that are higher than in many other parts of Australia. The NT consequently adopted particularly strict public health measures to avert the potentially catastrophic consequences of community transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), including supervised isolation until viral clearance of all people with confirmed SARS‐CoV‐2 infections (Supporting Information 1). This measure provided a unique opportunity to study the duration and trajectory of viral shedding in relation to clinical illness. In this article, we describe epidemiologic, clinical, and virological aspects of the first 28 cases of coronavirus disease 2019 (COVID‐19) in the NT. The Top End and Central Australian Human Research Ethics Committees approved the study (reference, 2020‐3737). Between 4 March and 4 April 2020, 28 cases of COVID‐19 were diagnosed in the NT, all linked to overseas or interstate travel. The median age of patients was 45.0 years (range, 1.5–75 years); 16 were women (Supporting Information 1, table). Two patients required supplemental oxygen, one of whom also required intubation. There were no deaths. Symptoms had been present for a median 3 days (range, 0–16 days) before oro‐nasopharyngeal swab collection and lasted a median 9.5 days (range, 4–18 days). Viral RNA could be detected by multiplex tandem real‐time polymerase chain reaction (PCR) assay (AusDiagnostics; Supporting Information 1) for a median 25 days after symptom onset (range, 14–41 days; interquartile range [IQR], 21–32 days), and in most patients for more than two weeks after symptom resolution (median, 17.5 days; range, 2–31 days; IQR, 14.5–22.5 days) (Box 1). Within‐patient variability in viral target cycle threshold values during follow‐up was considerable (Box 2; Supporting Information 1, figure), despite adequate and consistent amounts of human biologic material in test samples (data not shown). Prolonged compulsory isolation was distressing for several patients. The phylogeny of the 27 available NT viral genomes was consistent with acquisition in locations on all inhabited continents (Box 3). Five genetic clusters were evident (maximum of one single nucleotide polymorphism within each cluster) that were also epidemiologically linked by shared travel or household contact. The SARS‐CoV‐2 genomes from two independent travellers without epidemiologic connections were identical, but matched other publicly available genomes, highlighting the importance of interpreting genomic analyses in their epidemiologic context. The priority of the strict NT isolation requirements for patients with COVID‐19 was viral containment at a time when data on the duration of viral transmissibility were sparse. More recent evidence suggests that viable SARS‐CoV‐2 is rarely isolated more than 10 days after symptom onset,1,2,3 and requirements have consequently been eased, while maintaining supervised isolation with health management during the period of greatest infectivity. The high degree of temporal variability in viral shedding during follow‐up indicates that a single assay is not adequate for excluding infection in patients at epidemiologic risk of COVID‐19. The NT implemented particularly aggressive public health measures to contain SARS‐CoV‐2 transmission. Epidemiologic and genomic analyses suggest that this response has successfully prevented local community transmission of the virus. Box 1 – Time course of 28 cases of coronavirus disease 2019 (COVID‐19) diagnosed in the Northern Territory, 4 March – 4 April 2020 Each line represents a single patient. Day zero is the day of collection of the first SARS‐CoV‐2‐positive specimen; thickened sections indicate the period of COVID‐19 symptoms. Closed circles indicate positive SARS‐CoV‐2 assay results, hollow circles negative assay results. Patients 13 and 15 (lighter marking) required supplemental oxygen. The bottom line summarises the median duration of symptoms prior to diagnosis, the median duration of symptoms, and the median time to viral clearance. Box 2 – Multiplex tandem polymerase chain reaction cycle threshold values for detection of the SARS‐CoV‐2 open reading frame 1a gene (ORF1a) Box 3 – Maximum likelihood phylogenetic tree, depicting SARS‐CoV‐2 genomes from the Northern Territory and elsewhere SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. The phylogenetic tree shows that SARS‐CoV‐2 genomes in the Northern Territory (on the inner side of the outer ring) were drawn from across the range of genomes reported elsewhere (outer ring). NT travel‐related cases with epidemiologic links formed genomic clusters. Two cases without epidemiologic links also comprised a cluster, but the genomes were identical with overseas genomes. The context genomes were obtained from GISAID (https://www.gisaid.org), with region based on location of the submitting laboratory; the Wuhan‐Hu‐1 genome was used as an outgroup, and the scale bar indicates substitutions per site.

for the Northern Territory COVID‐19 Response Group

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

Social restrictions reduced the spread of COVID-19 within 14 days of measurable changes in public mobility

Tu Hao Tran · Suraj N Sasikumar · Annemarie Hennessy · Aiden O'Loughlin · Lucy Morgan

To the Editor: Cardiac injury has been reported in about 20% of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital.1 Elevated troponin is associated with higher complications and death rates.2,3 We report our experience in managing the cardiovascular care of all patients with COVID‐19 admitted to our 783‐bed quarternary hospital in Perth between 1 February and 1 May 2020. The hospital approved the data collection for a clinical quality improvement audit and provided an exemption from ethics review and approval to publish the results. Patients with COVID‐19 with an abnormal electrocardiogram (ECG) showed markers of increased disease severity, had a longer hospital stay and intensive care unit (ICU) admission. Eighteen patients (11 males), with a mean age 59 years (standard deviation [SD], 18), were admitted for a mean 14 days (SD, 15) with symptoms of cough (78%), fever (72%), dyspnoea (61%), fatigue (44%), chest pain (22%), and presyncope (5%). The mean presentation was 6 days (SD, 4) from onset of symptoms. Eight patients required admission to the ICU, and we recorded no deaths. The comorbidities included obesity (four patients), ischaemic heart disease (two patients), diabetes mellitus (four patients), and hypertension (six patients). Cardiac investigations included ECGs (72%), high sensitivity troponin (67%), brain natriuretic peptide (7%), and echocardiogram (6%). Upon admission, eight patients (63%) had an abnormal ECG, which included PR depression, biphasic T waves, PR prolongation, Q waves, ST elevation, atrial flutter, right bundle branch block, and atrial trigeminy. Two patients had elevated troponin. All brain natriuretic peptide and echocardiogram results were normal. Patients who did not have an ECG had low risk markers for disease severity. Patients with a normal ECG had a mean heart rate 84 beats/min (SD, 11), mean QRS duration 92 milliseconds (SD, 9), and mean QTc interval 414 milliseconds (SD, 59) compared with patients with abnormal ECGs, who had a mean heart rate 93 beats/min (SD, 11), mean QRS 96 milliseconds (SD, 18), and mean QTc 400 milliseconds (SD, 110). Seven patients had repeat ECG during their admission. Five patients developed new abnormalities on follow‐up ECGs, including transient ST elevation, sinus bradycardia, junctional rhythm, atrial fibrillation, and complete heart block. Our data show a consistent trend of increased disease severity in patients with abnormal admission ECG (Box). Patients with abnormal ECG required longer hospital admission (61% longer), double the incidence of documented arrhythmias, and double the requirement for oxygen, ventilation and inotropic support. Measures of significant inflammatory response (ferritin, C‐reactive protein, D‐dimer) were markedly higher in patients with abnormal ECG. Half of the patients developed an abnormal rhythm during admission: complete heart block (one patient), supraventricular tachycardia (one patient), atrial fibrillation (three patients), sinus tachycardia (three patients), and sinus bradycardia (one patient). Cardiac procedures performed were transesophageal echocardiogram/cardioversion (one patient), and pacemaker implantation (one patient). Our limited experience suggests an ECG may be helpful in prognostication and triaging of all patients with COVID‐19. An abnormal rhythm may arise from cardiac stress due to cytokine response, direct myocardial viral injury, or physiological strain from multi‐organ injury. Pulmonary injury from pneumonia, acute respiratory distress syndrome and pulmonary emboli can lead to significant right ventricular strain that predisposes to arrhythmia. Sepsis, and related cytokine response, is associated with atrial fibrillation. Myocardial inflammation and subsequent scarring can lead to ventricular arrhythmia and conduction disorders. ECG is a low cost test that can be performed easily and rapidly with minimal risk of viral exposure to staff. ECG should be an essential test in the COVID‐19 pandemic. Box – Characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital Total Abnormal ECG Normal ECG No ECG Total number of patients 18 8 5 5 Age (years), mean (SD) 59 ± 19 67 ± 14 52 ± 15 53 ± 24 Admission (days), mean (SD) 14 ± 15 21 ± 19 13 ± 11 3 ± 2 Ferritin (μg/L), mean (SD) 1594 ± 1658 2328 ± 2141 1089 ± 620 970 ± 1206 Creatinine (μmol/L), mean (SD) 103 ± 64 110 ± 71 86 ± 33 110 ± 82 CRP (mg/L), mean (SD) 166 ± 165 255 ± 198 124 ± 108 39 ± 42 D‐dimer (mg/L), mean (SD) 4.17 ± 6.23 7.03 ± 8.29 1.99 ± 1.39 0.64 ± 0.42 Arrhythmias 9 7 < 5 na Number of patients requiring oxygen 10 6 < 5 < 5 Oxygen use (days), mean (SD) 19 ± 14 23 ± 15 15 ± 11 4 ICU admission (days), mean (SD) 19 ± 11 23 ± 11 12 ± 9 Nil Ventilation (days), mean (SD) 14 ± 10 18 ± 10 7 ± 5 Nil Inotropic support (days) mean (SD) 13 ± 12 18 ± 12 5 ± 6 Nil CRP = C‐reactive protein; ECG = electrogardiogram; ICU = intensive care unit; na = not applicable; SD = standard deviation.

Kaitlyn Lam · Sarah McClelland · Michael J Dallo

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

To the Editor: The MJA and Madden and colleagues1 display foresight and leadership in advocating for a transition to environmentally sustainable health care. The current coronavirus disease 2019 (COVID‐19) pandemic exposes dual sustainability challenges: uncertain provision of personal protective equipment (PPE) in the face of a fractured global supply chain and burgeoning waste from single‐use materials. Australia has an opportunity to respond to both challenges by accessing local capability and switching to reusable PPE as appropriate. An apt place to begin is PPE gowns. Personal experience at an Australian hospital in March 2020 saw intensive care of one patient with COVID‐19 requiring more than 50 single‐use gowns during a 24‐hour period. This quantum highlights the need to reconsider the source and composition of PPE materials. The National Health and Medical Research Council (NHMRC) guidelines2 state that gowns should be impervious to fluid, with no standards or levels applied. The oft‐used system from the American Association for the Advancement of Medical Instrumentation (AAMI) grades gowns, single‐use or reusable, within a range: level 1 being splash‐resistant, and levels 2–4 being impervious to water columns placed upon them of 20, 50 and 100 cm respectively.3 Application of these levels is at the discretion of Australian health care providers, rather than mandated in the NHMRC guidelines. Fluid impervious level 2 provides an ample barrier to respiratory‐borne pathogens. A transition to reusable level 2 gowns, when appropriate, provides an opportunity to reduce waste because they can be repeatedly sanitised by clinical laundry practice (detergent and > 60°C hot water). One reusable gown has been estimated to replace 50 disposable gowns.4 By way of reducing reliance on distant supply chains, Australia currently has capacity to mill the fabric and manufacture reusable fluid impervious level 2 gowns today, and these gowns could be registered by the Therapeutic Goods Administration. Current experience suggests policy makers and clinicians are unaware of this possibility. The perception that single‐use is the best choice indicates education is needed to assure clinicians that reusable gowns can provide at least equal protection for many clinical and intensive care unit tasks (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2] endures less on cloth than plastic).5 Activating local manufacture of reusable gowns would assure availability and potentially provide more environmentally and financially sustainable health care, while maintaining patient care and staff PPE supply.

Forbes McGain · Meriel Chamberlin · Jane Milburn

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

Lessons learnt from COVID-19 outreaks in residential aged care facilities could limit future impacts

Gwendolyn L Gilbert