Infectious diseases

To the Editor: There has been recent important discourse about the adverse impact of coronavirus disease 2019 (COVID‐19) on mental health, with modelling from the Brain and Mind Centre predicting increases in suicide in the wake of the pandemic.1 Links with the economic downturn have been emphasised, with financial stressors and loss of productivity among the youth and working adults playing a large part, leading to a call for proactive investment in mental health services.1 This is of undisputed, urgent importance. However, there has been relative silence about the effects of the pandemic on suicide risk in older adults, especially men aged 85 years or over, who have the highest rate of suicide of all age groups in Australia.2 Older adults are particularly vulnerable to the social ramifications of the pandemic, including social distancing, if not frank social exclusion by quarantine, exacerbating pre‐existing loneliness,3 particularly for those in residential care. Management of older people with pre‐existing mental illness as well as the expected increases in depression and anxiety3,4 have been confounded by changes in service provision and access to mental health services.3 Similarly, delays in presentation and management of physical illness combined with the suspension of elective procedures4 may contribute to untreated pain and other distressing physical symptoms, also identified as risk factors for suicide.5 Furthermore, calls to reopen the economy knowing the risk this poses to older people — seen by some as “expendable” — reflects societal ageism and adds to older people's own internalised ageism.6 Perceptions of disconnection from society and feeling burdensome and devalued are already known associations with late‐life self‐harm and suicide.5 In addition to fuelling active self‐harm, there has been speculation regarding links between the pandemic and increased requests for voluntary assisted dying.7,8 These reports suggest that such requests have been driven by anxiety about dying, fears of loss of control, and inability to access help for distressing symptoms. This is not unfounded, given the complexity of providing appropriate palliative care to older patients who are dying, particularly to those in nursing homes, ever more so during the COVID‐19 pandemic.4 We add to the call to act urgently and flatten the mental illness and suicide curve1 for Australians of all ages.

Anne P F Wand · Carmelle Peisah

To the Editor: In Australia, gestational diabetes mellitus is diagnosed by 75 g oral glucose tolerance test (OGTT). The diagnostic criteria are fasting plasma glucose (FPG) ≥ 5.1 mmol/L, one‐hour glucose level ≥ 10.0 mmol/L, and/or 2‐hour glucose level ≥ 8.5 mmol/L.1,2 International consensus favours OGTT over single measures of glucose because, in the pivotal Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, hyperglycaemia at each time point was independently associated with adverse outcomes, individual measures were not well correlated with one another, and no single measure was clearly superior in predicting adverse outcomes, such as birthweight above the 90th percentile, shoulder dystocia and pre‐eclampsia.2,3 To reduce contact time at pathology collection centres during the coronavirus disease 2019 (COVID‐19) pandemic, measurement of FPG alone has been advocated.4,5 One guideline advised that a result below 4.7 mmol/L may not merit a follow‐up OGTT.4 Another advised diagnosing gestational diabetes mellitus by stand‐alone FPG greater than 5.1 mmol/L.5 To determine the proportion and characteristics of gestational diabetes mellitus cases that would be missed by using alternative criteria, we extracted the results of all obstetrician‐referred OGTTs performed by our private community‐based laboratory between January 2017 and April 2020. The analysis, including determination of Wilson score confidence intervals (CIs), was performed with SAS 9.4 (SAS Institute). Of 16 169 patients, 1790 (11.1%) were diagnosed with gestational diabetes mellitus by OGTT. A rule‐out threshold of FPG below 5.1 mmol/L would have resulted in 1202 cases (67%; 95% CI, 65–69%) being missed, and a threshold below 4.7 mmol/L would have resulted in 831 cases (46%; 95% CI, 44–49%) being missed (Box). Women with gestational diabetes mellitus and normal fasting glucose did not have significantly lower one‐ or 2‐hour concentrations than those with increased fasting glucose (data not shown). Missing the diagnosis of gestational diabetes mellitus exposes women and their newborns to significant risks, including birth weight above the 90th percentile, primary caesarean delivery, neonatal hypoglycaemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinaemia and pre‐eclampsia. Use of fasting glucose to screen for gestational diabetes mellitus would miss a large proportion of cases, with the potential for significant harm to mothers and their offspring. Clinicians must recognise the substantial limitations of stand‐alone FPG so that pregnant women can be adequately counselled and, if opting out of OGTT, considered for careful monitoring for consequences of undiagnosed gestational diabetes mellitus, such as accelerated growth or polyhydramnios. In regions without significant community spread of COVID‐19, modifying sample collection procedures to ensure strict physical distancing and having dedicated collection centres for vulnerable populations may be better than using deficient diagnostic criteria. Box – Distribution of fasting glucose results at 24–28 weeks’ gestation in patients with (n = 1790) and without (n = 14 379) gestational diabetes mellitus* (GDM) The vertical grey lines denote thresholds below which new guidelines propose that oral glucose tolerance testing is not required during the coronavirus disease 2019 (COVID‐19) pandemic. * Diagnosed using oral glucose tolerance test.

Ranita Siru · Johan H Conradie · Melissa J Gillett · Emily Gianatti · Michael M Page

The pandemic has highlighted some important challenges in our health care system, but system reform can occur rapidly when needed

Gabriel Elan Blecher · Grant A Blashki · Simon Judkins

Compared with the mitigation and suppression approaches of most Western countries, elimination can minimise direct health effects and offer an early return to social and economic activity

Michael G Baker · Amanda Kvalsvig · Ayesha J Verrall

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has required rapid adjustments in health service delivery.1 The Victorian COVID‐19 Cancer Network (VCCN) is a joint initiative of the Victorian Comprehensive Cancer Centre and Monash Partners Comprehensive Cancer Consortium. Through expert groups, the VCCN aims to provide support and advice to clinicians and health care services treating cancer patients during the pandemic. The VCCN Telehealth Expert Working Group conducted a survey to understand the barriers and enablers to the rapid adoption of telehealth in health services during the first week of April 2020. Seventeen cancer services from across metropolitan and regional Victoria and Tasmania responded. Notably, all respondent cancer services had implemented some form of telehealth since the pandemic. Healthdirect, the Victorian Department of Health and Human Services’ supported telehealth platform, was used in 40% of services, with 25% using phone only and others using platforms such as Skype, FaceTime and doxy.me. With the unprecedented increase in the uptake of telehealth,2 there is a tremendous opportunity to integrate telehealth into routine practice, potentially improving inequities and inefficiencies in the delivery of cancer care for suitably selected patients. Our survey results suggest several areas for attention to support telehealth, including the need for further investment in information technology infrastructure across health services and administrative support to facilitate changes in practice and workflow (Box). The survey results also highlight the educational and training needs of consumers and health professionals during telehealth implementation. Aboriginal and Torres Strait Islanders, people from culturally and linguistically diverse backgrounds and of lower socio‐economic status, and older patients may have greater needs and will require additional support from both government and relevant organisations to ensure equity of access to cancer care via telehealth. We strongly advocate the need to establish evidence‐based, patient‐centred and sustainable telehealth in cancer management. Research into the experience of patients and clinicians should be prioritised to ensure the consistent quality of telehealth consultation with face‐to‐face consultation in appropriate clinical circumstances. Box – Barriers to implementing telehealth: survey results

Zee Wan Wong · Hannah L Cross

To the Editor: A recent article highlighted a case where self‐collection enabled detection of an early cervical adenocarcinoma and curative treatment in a previously underscreened woman.1 This case underlines the important benefits from self‐collection making cervical screening more accessible and acceptable to women who have previously declined or delayed screening. Unfortunately, self‐collection is currently very underutilised in Australia. Although it is currently restricted to women aged 30 years and over who are 2 or more years overdue for cervical screening, potentially around a million women are eligible.2 In contrast, data from Medicare, VCS Pathology, and the National Cancer Screening Register suggest that fewer than 6000 self‐collected tests were processed over 2018 and 2019, indicating that less than 1% of eligible women have had a self‐collected test. What drives this discrepancy? Self‐collection is highly acceptable to underscreened Australian women, and very high uptake can be achieved with appropriate clinical support.3 A recent survey reported that many practitioners, especially outside Victoria, do not yet feel comfortable discussing or recommending self‐collection, and lack confidence that self‐collection is a reliable test.4 Potentially, this is due to an initial delay in self‐collection being available, confusion about eligibility, and current restrictions giving the false impression that self‐collection is less sensitive. Self‐collection is now available to eligible women nationally (provided samples are sent to one of two accredited laboratories, which accept samples from anywhere in Australia), and updated evidence demonstrates that polymerase chain reaction‐based human papillomavirus (HPV) testing is equally sensitive for detecting pre‐cancer in self‐collected and clinician‐collected samples.5 Another barrier may be difficulties for providers in checking whether women are eligible. The rollout of the provider portal into the National Cancer Screening Register, allowing providers to view a woman's screening history at the point of care, will be important in addressing this issue. Many screening‐eligible women who have not had their first HPV test are now overdue and could be eligible for self‐collection. Self‐collection is a reliable test now available nationally to eligible women, which can have a transformative effect in the lives of underscreened women, as shown in the recent case study.

Megan Smith · Marion Saville · Karen Canfell

To the Editor: In Australia, 2020 began with raging bushfires, and we now confront the coronavirus disease 2019 (COVID‐19) pandemic. While health protection is currently at the top of the public policy agenda, can we rise from these huge ruptures and “build back better”? The full health costs of the bushfires, including the mental health toll, are yet to be quantified. No sooner had the bushfires abated than the battle against the COVID‐19 pandemic began. The immediate public health response has been well managed in Australia.1 Although Victoria is currently grappling with a second wave of infections, by international comparisons the number of cases and deaths around the country has remained low.2 Government leaders have listened to health experts and acted on evidence, including the need for strict physical distancing in the absence of a vaccine, supplemented by universal masking in Victoria. As governments move to revitalise the economy with financial stimulus, what guidance can health experts provide to inform this stimulus? One clear priority is that stimulus accelerates the decarbonisation of the Australian economy. Climate change is a recognised health issue. Published as the bushfires erupted, the 2019 MJA–Lancet Countdown on health and climate change report3 found that Australia is extremely vulnerable to the impacts of climate change on health. There are also health co‐benefits from action on climate change. The clearest example is the transition to renewable energy generation. Globally, in 2015 alone, more than 460 000 preventable deaths were attributable to coal burning.4 An urgent transition to renewable energy would be an evidence‐based public policy response to these deaths and assist a global green recovery from the pandemic which is called for by the World Health Organization.5 Australia is well placed to lead such a recovery as indicated in a recent report by ClimateWorks Australia,6 which provides a blueprint to achieve net zero emissions by 2050 through accelerated uptake of mature zero emission technologies and the rapid development and commercialisation of emerging zero emission technologies in harder to abate sectors (Box). Beyond stimulus for decarbonisation, investments in affordable housing, mass transit infrastructure, safe routes for walking and cycling, regeneration of degraded ecosystems and infrastructure to support working from home would also benefit health through reduced homelessness, improved levels of physical activity, and improved urban air quality. Australia has, thus far, avoided the high COVID‐19 case numbers and death rates seen in some other countries because of evidence‐based decision making. It is essential that decisions about the stimulus for economic recovery are similarly grounded in evidence. The health and wellbeing of current and future generations of Australians depend on it. Box – Summary table of key emissions‐reduction solutions by sector CCS = carbon capture and storage.

Selina N Lo · Anna Skarbek · Anthony Capon

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

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

Engaging First Nations peoples in public health emergencies is critical to reducing health inequities

Kristy Crooks · Dawn Casey · James S Ward

A 48-year-old man presented with a 3-month history of increasing diarrhoea 8–10 times per day, cramping abdominal discomfort and weight loss of 8kg

Andrew S Vanlint · Patricia Kaazan · Marco Kwok · Robert V Bryant · Marie Ooi · Narin Bak · Sam Costello

A 23-year-old woman was referred to the ophthalmology clinic with sudden onset unilateral paracentral scotomas

Sarah Chan

Introduction: The coronavirus 2019 disease (COVID‐19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Pre‐existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID‐19, and COVID‐19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. Main recommendations: Common acute cardiac manifestations of COVID‐19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five‐ to tenfold higher case fatality rate with COVID‐19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. Changes in management as a result of this statement: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID‐19 among CVD patients, upskill in the management of COVID‐19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS‐CoV‐2 infection.

Sarah Zaman · Andrew I MacIsaac · Garry LR Jennings · Markus P Schlaich · Sally C Inglis · Ruth Arnold · Saurabh Kumar · Liza Thomas · Sudhir Wahi · Sidney Lo · Carolyn Naismith · Stephen J Duffy · Stephen J Nicholls · Andrew Newcomb · Aubrey A Almeida · Selwyn Wong · Mayanna Lund · Derek P Chew · Leonard Kritharides · Clara K Chow · Ravinay Bhindi

To the Editor: Before the coronavirus disease 2019 (COVID‐19) pandemic, we had been thinking about how best to re‐imagine our university medical program to enhance student experience and learning outcomes. Globally, questions have been raised regarding the utility and format of the pre‐clinical content taught in medical programs in the junior years,1 particularly lectures, which have increasingly low attendance rates. There is emerging evidence that blended approaches to education meet the connectivity, flexibility and interactivity expectations of learners,2 and have potential to combine the best of both online and face‐to‐face teaching. Packaging content in digestible chunks, combined with active learning activities online such as adaptive tutorials, discussions and reflections, results in more meaningful educational experiences for students than didactic lectures.3,4 The COVID‐19 pandemic forced a rapid transition to entirely online teaching for junior medical students. Even components of clinical teaching (other than physical examination) had to proceed in this format. Despite the pace of this transition, both formal and informal student feedback indicated that students have an extremely high level of satisfaction and engagement with online learning activities. The clinical training components of the program have, by necessity, also become more streamlined. COVID‐19 has forced us to examine all elements of our medical program. This is an opportunity to review the curriculum for future doctors, especially its alignment with the skills and capabilities they will need in their careers. Clearly, we need to facilitate the development of teamwork and communication skills, which will prepare students for effective patient care and multidisciplinary, interprofessional practice. Additionally, we have an obligation to support medical students in developing skills in reflection, adaptive problem solving, leadership and lifelong learning, all of which are needed to adapt to a rapidly changing health care environment.5 Some important aspects of university life, such as such as friendships, personal identity development, exposure to diversity and self‐care skills, will be much harder to achieve in a solely online environment, but as we develop plans to reintroduce elements of face‐to‐face teaching, we need to ensure that these are integrated with, and informed by, the advances made in medical education during the past few months.

Adrienne J Torda · Gary Velan · Vlado Perkovic

To the Editor: Australia's social distancing policies to contain the spread of coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), have had social consequences. Social distancing and school disruptions have increased parental responsibilities. There has also been an increased opportunity for parents to use alcohol to cope with increased stress.1 Parents, especially mothers, have taken to social media to share “memes” about needing a drink to survive staying at home (Box). These posts are mostly shared with the aim of creating an online environment for peer support and stress relief, but they risk normalising the use of alcohol as a coping strategy and promoting the false belief that alcohol is good for mental health.2 Alcohol is a central nervous system depressant that may relieve stress in the short term, but regular drinking increases psychological distress and the risk of alcohol‐related harm.3 A review of recent advertising complaints indicated that some alcohol advertisers have been quick to capitalise on COVID‐19.4 An investigation of a social media account found an average of one alcohol advertisement every 35 seconds, with themes of easy access without leaving home (58%), buy more (35%), drink during COVID‐19 (24%), and drink to cope (16%).5 Australia has a regulation system for alcohol advertising, which most people mistakenly believe is government‐funded.6 It is in fact an industry‐funded quasi‐regulatory system that is activated by consumer complaints and lacks systematic independent monitoring.7 Further, regulations do not prevent certain social media platforms from being used by alcohol brands to post advertisements and engage with consumers.8 In light of the alcohol industry's opportunistic advertising through social media, it is questionable how well Australia's regulatory system protects parents and other targeted populations at risk from exposure to constant encouragements to drink during these challenging times. Box – Examples of parental drinking‐related memes during the coronavirus disease 2019 (COVID‐19) lockdown

Janni Leung · Jason Connor · Leanne Hides · Wayne D Hall

While mumps outbreaks involving professional rugby league, rugby union, and ice hockey teams have been reported in the media,1,2,3,4,5 there have been few scientific reports. On 30 January 2018, a general practitioner notified the local Public Health Unit of a mumps outbreak in a National Rugby League team, prompting investigation according to the NSW Public Health Act 2010. Four players and two coaching staff had developed fever and parotitis during 21–24 January (Box). Mumps virus was detected by polymerase chain reaction (PCR) in the buccal or throat swabs of two patients; each had detectable mumps IgG but not IgM (Liaison Mumps IgG and IgM, DiaSorin). In the other four patients, who had fever and parotid swelling, mumps was diagnosed clinically. The patients were isolated and their travel restricted; the Public Health Unit recommended measles–mumps–rubella (MMR) vaccination of all asymptomatic players and support staff. A further six cases were diagnosed during 1–10 February, in five players and an intimate contact of one of the earlier PCR‐positive patients; the contact developed symptoms 18 days after symptom onset in the source patient. Mumps virus was detected by PCR in four of the six new patients; two were diagnosed clinically. In one PCR‐positive case, mumps IgG, but not IgM, was detected. In all six PCR‐positive patients, genotype G mumps virus was identified. The offer of vaccination was extended to the partners of players and staff, and to players from four elite clubs who shared facilities with the team; by 19 February, 178 players and support staff and their partners had been vaccinated. No new cases were diagnosed after 10 February, and the outbreak was declared ended on 31 March. None of the 12 patients (median age, 25 years; range, 18–39 years) suffered complications. The nine players were from a pool of 42 elite and junior players, an estimated attack rate of 21%. Significantly, mumps‐specific IgG had been detected in nine patients (all players) at the time of their joining the club; the other three patients (all non‐players) had not previously been tested. Documentation of past vaccination was unavailable. No players or staff who received MMR vaccine during the outbreak developed mumps. The intimate contact who developed mumps was vaccinated at least 10 days after first exposure, at which point they were probably in the incubation phase of infection. This was the first mumps outbreak in NSW for many years, and nine of the twelve patients had pre‐existing mumps IgG, which does not appear to be a reliable marker of protective immunity.6 Patients who underwent both serology and PCR testing had detectable IgG but not detectable IgM. This pattern, generally understood to reflect waning immunity following vaccination — that is, pre‐existing mumps‐specific IgG does not prevent infection but its concentration rapidly increases after infection — was also reported for a community outbreak in Western Australia.7 PCR testing is consequently preferable for detecting infection in vaccinated populations, and outbreak control should include vaccination of contacts, even if they have previously received two doses of mumps vaccine.8 Apart from hockey, mumps outbreaks in elite team sports other than the rugby codes have not been reported. Intensive exposure to saliva may result in greater force of infection; tackling and scrums facilitate frequent contact with saliva from fellow players’ faces and on jerseys contaminated by the wiping of mouthguards. Ensuring at registration that players have received two documented lifetime doses of mumps vaccine may be a more effective preventive measure than relying on IgG screening. Ethics approval All patients and their rugby league club provided written consent for the publication of this report. Box – Timeline of the mumps outbreak in a New South Wales National Rugby League team, 21 January – 10 February 2018 PCR = polymerase chain reaction testing.

Karen Chee · Cassy Workman · Susan Irvine · Mark J Ferson

During the pandemic, cancer survivors are lost in transition

Bogda Koczwara

COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020. Unemployment alone is associated with a two‐ to threefold increased relative risk of death by suicide compared with being employed,3 and sudden spikes in unemployment are associated with corresponding surges in the population rates of suicide.4 The global financial crisis, which led to the deepest recession since the 1930s and the loss of 30 million jobs worldwide, is estimated to have resulted in at least 10 000 additional economic suicides between 2008 and 2010 in Europe and North America.5 Projections using historical data suggest suicide rates may increase by 3.3–8.4% over the 2020–2021 period in the United States6 and up to 27% in Canada.7 Of course, all this is speculative and although the links between economic recessions and suicide are well documented, what is less clear is how the relationship plays out in the context of larger sociocultural and health events such as COVID‐19. The 1918–1920 influenza pandemic caused around 39 million deaths worldwide and resulted in governments implementing quarantine, public hygiene and social distancing policies, but evidence regarding its impact on world economies and suicide is limited. The severe acute respiratory syndrome (SARS) epidemic of 2003 came at the height of the Asian financial crisis, so disentangling the two is difficult. However, during this period, suicide rates in a number of Asian nations increased in tandem with unemployment, reaching historical peaks in 2003.8 As the situation continues to change daily, an accurate estimate of likely unemployment resulting from the COVID‐19 pandemic is difficult. Even current estimates under‐represent the impact, as individuals who are still employed but at significantly reduced hours are discounted. This is of particular concern when considering the global financial crisis, which saw Australian unemployment take a comparatively minor increase from 4.0% to 5.8% and coincided with an increase in suicide rates of 22% and 12% for unemployed men and women respectively.9 As the present crisis may potentially double the current unemployment rate, one can extrapolate to alarming conclusions, with some (albeit unpublished) modelling reflecting this projection.10 Despite this grim speculative forecast, this is not the whole story. There are marked differences between the present crisis and those that have come before. For instance, the current recession is supply (rather than demand) driven, and the prospect of recovery, although slow, is conceivable and may bolter optimism. Although major industries will be severely affected, there is potential for increased local spending as the borders remain closed. In addition, some hope may be found in the resilience shown by civilians in times of global unrest — for instance, the often cited “Blitz spirit”11 — and the possibility that the shared experience of the pandemic might bring a sense of social cohesion, which may prove life‐preserving. Notwithstanding considerable evidence of the psychosocial impacts of mass unemployment, we argue that the impact of the COVID‐19 pandemic on suicide rates is far from predetermined, and that early and sustained action can prevent many suicides and other adverse mental health outcomes. During prior recessions, Austria, Sweden and Finland have each displayed resilience in the face of substantially increased unemployment.5 In fact, despite sizeable rises in unemployment rates in Sweden and Finland in the early 1990s, the rate of suicide decreased.4 We suggest that, based on the available literature, there are several factors that may moderate the impacts of widespread unemployment. These include both early prevention measures and crisis care: sustained welfare spending; labour market programs and protections; and adequate funding of, and access to, mental health services, including prevention programs and engaging new technologies in the reporting and care response. Firstly, countries with sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job search initiatives for the unemployed.12 Robust social policies to ensure adequate welfare benefits for people with low or sudden loss of income are thought to be central to offsetting the impact of the recession on suicide.13 Where governments expand public welfare spending in the wake of disasters, there is good evidence for a reduction in suicide. The federal government's introduction of the JobKeeper and JobSeeker payment schemes are likely to mitigate suicide risk while simultaneously stimulating the economy and require long term investment. Secondly, countries with active labour market programs, which assist the unemployed to find work or retrain, and those with labour market protections have lower rates of unemployment‐related suicide than countries that do not.12 It has been estimated that, during European recession periods in the past 50 years, each US$100 per capita of investment in active labour market programs reduced the association of unemployment with suicide by 0.4%.4 Thirdly, it is critical that investment is made immediately in mental health, not just in terms of treatment but also in evidence‐based prevention programs. Different approaches are required to reduce attempts, and deaths, involving both public health and clinical services. In terms of direct suicide prevention interventions, there is increasing evidence for multilevel systems approaches — using components ranging from individual‐level (eg, assertive aftercare, psychosocial interventions) to public health interventions (eg, general practitioner and gatekeeper training),14 in addition to indirect interventions (targeting risk factors). Critical to effectiveness is the degree of penetration of these services, based on early population modelling, and the types of factors likely to differentially affect communities, including indigenous communities. Improving quality, availability and access to programs and crisis support services is vital to preventing suicide,14 with the current crisis both creating new challenges and compounding pre‐existing systemic issues. While the mental health sector is rapidly mobilising to improve access and the government has been quick to revise the Medicare rebate in this regard, it is vital that resource allocation and innovation continues beyond the span of the physical distancing measures. While increasing telehealth services is critical, the health professionals available to support them are unlikely to increase to meet need, and blended services that include automatised digital components may be a more efficient solution. The additional $48.1 million in mental health funding announced in May 2020 is a positive step; however, further funding for evidence‐based prevention initiatives is more important than ever to alleviate demand on treatment services. In terms of suicide prevention, digital interventions may hold some utility for both at‐risk and actively suicidal individuals, especially where other health services are lacking.15 Of course, economies undergoing recessions by their very nature have significant financial constraints, and governments will inevitably have to review spending across all services. It is critical that these limited funds are directed toward the most viable and cost‐effective services. Importantly, not all groups are affected equally, and subgroup consideration is vital. In crisis periods, it can be the most disadvantaged groups that are disproportionately affected, and marginalised and at‐risk populations require specific attention. It is also important to consider that many of the adverse consequences of job loss, including house repossession, mounting debt, mental health problems and relationship strain, are delayed and, therefore, long term investment is required.16 Finally, engaging new technologies in the fight against suicide may present a valuable new tool. This includes information technology‐enabled coordinated care and the dynamic reporting of suicide risk using immediate and real‐time data so that developing hotspots can be identified and shut down and local services can be mobilised. Although this field of study is in its infancy, the potential for concepts such as integrated, geospatial mapping, hotspot surveillance, and real‐time reporting could lead to significant advancements in predicting and intervening in suicidal behaviour.17 Ultimately, the economic fallout resulting from the COVID‐19 pandemic represents a threat, requiring urgent mobilisation and planning. There are certain steps required to moderate the mental health impacts of widespread unemployment, including sustained welfare spending; labour market programs; adequate investment in, and access to, mental health treatment and prevention services; and the dynamic reporting of suicide risk to aid regional responses and means restriction. The current economic crisis presents an opportunity to implement policies that would not only mitigate the impact of the recession on suicide but may incidentally reduce the national health and economic burden presented by emotional distress in any economic cycle. In doing so, there may be the ability to emerge from the current crisis stronger and more resilient as a nation.

Mark Deady · Leona Tan · Nathasha Kugenthiran · Daniel Collins · Helen Christensen · Samuel B Harvey

Although infection risks posed by COVID-19 influence all aspects of adult cardiac arrest management, the basic principles of resuscitation remain the same

Simon Craig · Mya Cubitt · Ashish Jaison · Steven Troupakis · Natalie Hood · Christina Fong · Adnan Bilgrami · Peter Leman · Juan Carlos Ascencio‐Lane · Guruprasad Nagaraj · John Bonning · Gabriel Blecher · Rob Mitchell · Ellen Burkett · Sally M McCarthy · Amanda M Rojek · Kim Hansen · Helen Psihogios · Peter Allely · Simon Judkins · Lai Heng Foong · Stephen Bernard · Peter A Cameron

Australian clinicians need to be able to recognise, diagnose, manage and appropriately refer patients affected by COVID-19

Irani Thevarajan · Kirsty L Buising · Benjamin C Cowie

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic is placing increasing pressure on the health care resources of nations. Particular concern is held for supplies of N95 (or P2) masks and surgical masks — personal protective equipment designed to achieve close facial fit and protection from more than 95% of 0.3 μm test particles. These masks are recommended for routine care of patients on airborne precautions, with current guidelines indicating that N95 masks are single use.1 Further highlighting the importance of N95 masks in protecting health care workers during the COVID‐19 pandemic, a recent study of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infection rates among medical staff in Zhongnan Hospital of Wuhan University showed that none of the staff (0/278) who wore N95 masks and followed frequent disinfection and handwashing became infected during the period of 2–22 January 2020 compared with 4.7% (10/231) of staff who did not wear masks, despite the fact that the latter group worked in lower risk areas.2 Previous outbreaks of respiratory viruses, including the 2004 SARS outbreak and the 2009 H1N1 influenza pandemic, have highlighted the risks of shortages of N95 masks during these events.3 If demand for N95 masks outstrips the current supplies, what options will be available for health care workers in Australia and elsewhere? During the 2009 H1N1 pandemic, reusing masks was common practice in Californian hospitals in response to shortages.4 The reuse of masks involves health care workers donning the same mask for multiple close patient contacts and doffing it at the end of each patient contact before eventually discarding it.3 To support the reuse of masks, a growing number of studies have investigated decontamination practices.5,6,7,8 A comparison of decontamination methods has found that physical decontamination methods (eg, ultraviolet germicidal irradiation [UVGI]) are less destructive to the mask filter than chemical methods (eg, bleach).7 UVGI exposure at high doses has been shown to have only a very small impact on particle penetration, but it had a variable effect on mask structural integrity.6 It was suggested that the rate‐limiting step for repeated disinfection cycles would be the physical degradation of the mask material; however, this could also be used as a visual cue to determine when the mask should be discarded. A study into the efficacy of UVGI decontamination of H1N1 influenza‐contaminated N95 masks has also shown that significant reductions in influenza viability could be seen when N95 masks contaminated with viable H1N1 influenza virus and soiled with saliva or skin oils were treated with 1 J/cm2 UVGI for about one minute.5 In terms of useability, after UVGI treatment, differences in the fit, odour, discomfort, or increased difficulty in donning of masks were also found to be minimal.9 In the absence of equipment to perform effective UVGI‐irradiation, what other options are available? While steam appears to have some potential,10 it is safe to say that the answer is currently unclear and may need novel solutions. For example, could solar disinfection — a method that has been shown to be effective for decontaminating RNA virus‐contaminated water in polyethylene terephthalate bottles at high temperatures (eg, 40°C) — be an effective solution to disinfecting N95 masks for reuse in the Australian climate?11 Urgent research is needed to validate current methods and investigate novel solutions for the potential decontamination of N95 masks to protect health care workers and patients. Quality assurance systems to evaluate the performance of a decontaminated mask are an obvious concern. In terms of the efficiency of biological decontamination, available data show that indicator organisms such as Bacillus spores12 or influenza virus substitutes (eg, MS2 bacteriophage13) can be indicators of disinfection. Measuring filter performance, particular particle penetration is less straightforward and may require specialised equipment. In these circumstances, ensuring that published protocols are used only on the N95 masks they have been evaluated on may be important, given that different N95 masks are affected differently by the same decontamination method.8 Furthermore, avoiding the unnecessary use of N95 masks when the use of surgical masks is recommended and improving the potential for local production and sourcing of personal protective equipment will also assist in reducing Australia's reliance on dwindling international stockpiles during the COVID‐19 pandemic and in preparation for any future respiratory viral infection outbreaks.

James M Branley · Adam Polkinghorne · Gwendolyn L Gilbert

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has focused whole‐of‐government efforts on protecting Australia's health. Border closures, case quarantine, public health interventions and social distancing have controlled COVID‐19 case numbers, limiting community acquisition. Workplaces at particular risk of occupational exposure to COVID‐19 — hospitals, aged care facilities and, interestingly, abattoirs — require effective infection control. Presenteeism in this context refers to the occupational transmission risk that employees infected with severe acute respiratory syndrome coronavirus 2 pose by continuing to work despite being symptomatic. Such presenteeism may be an issue common to a number of industries.1 Occupational infection has occurred among Australian hospital staff, notably in North West Tasmania.2 Delayed recognition of COVID‐19 cases leading to infection control breaches, presenteeism with infected health care staff working for up to 7 days with respiratory symptoms, along with other factors all contributed to this hospital outbreak.2 In total, 73 of the 114 outbreak cases were hospital staff.2 Meat processing facility workers have been a notable at‐risk group in the United States, with over 4000 COVID‐19 cases reported, representing up to 3% of affected facility workforces and resulting in 20 COVID‐19 related deaths.3 In Australia, a COVID‐19 cluster was reported among abattoir workers in Melbourne.4 There are meat processing industry work practices that enhance COVID‐19 acquisition risks.4 Commonly, the layout of meat processing facilities challenges implementation of appropriate distancing between workers, who may be spaced as little as 30 cm from colleagues during routine operations. Compliance with wearing face masks is difficult given the pace and physical demands of work. Financial imperatives appear to motivate food processing employees to work even if unwell.3 Australian aged care workers and airline baggage handlers have also experienced COVID‐19 outbreaks. Despite concerns expressed by teachers and early childhood educators, as of 16 June 2020, no major outbreaks had occurred in schools and only one cluster had been reported in a NSW childcare centre.5 A NSW investigation of possible transmission in schools showed only two secondary cases in students.6 Some schools have been closed for deep cleaning after detection of community acquired cases of COVID‐19. Design and implementation of effective, industry specific, infection prevention policies are crucial for employer compliance with the Australian Work Health and Safety Strategy principle that “all workers, regardless of their occupation or how they are engaged, have the right to a healthy and safe working environment”.7 This requires strong, industry group, leadership. Recognition of workplace specific infection risks, provision of reliable personal protective equipment, redesign of work practices, discouragement of presenteeism, and improved access to sick leave must all be attended to for the sake of Australia's workforce.

Damon Eisen

To the Editor: The National Disability Insurance Scheme (NDIS) is one of the largest health reforms in Australia's history.1 The scheme aims to give people with a disability choice and control over their daily lives.2 It is designed to operate as nation‐wide disability “markets” from which services can be “purchased”.2 NDIS participants are allocated a budget from which they purchase the services they require. The NDIS is very different from our previous disability models, which saw people receiving standardised services from a more limited number of government and not‐for‐profit organisations, and a less decentralised workforce. The NDIS is a visionary reform; however, we are now seeing that it is also designed to spread an epidemic such as coronavirus disease 2019 (COVID‐19) to thousands of people with a disability. The NDIS has created a “gig economy” within the disability services sector. Individuals are paid for discrete services, from showering and feeding, to social support activities, to household tasks. This means as many as ten different carers entering a participant's home, performing a care service, and then moving on to another home. The workforce is now predominantly casual, and there are growing numbers of self‐employed.3 This structure is primed to spread infection because: large numbers of carers are moving between homes; carers are not paid if they do not perform care tasks, which deters people from self‐isolating; and much of the workforce is disparate and there is no central registry, which makes it difficult to provide new information such as hygiene practices to all people. Unfortunately, many people who are part of the NDIS have comorbidities,4 making them vulnerable to COVID‐19 by both physiology and system design. Previous research has raised concerns about the readiness of the workforce to handle complex disability under normal circumstances, let alone in the context of a pandemic.5 While government agencies are working to communicate hygiene practices with NDIS participants, challenges such as personal protective equipment shortages and high worker motility need to be addressed. Otherwise, the health care system will need to ready itself for a disproportionate number of people with disability.

Gemma Carey

Our journal remains a source of trusted information in a world awash with wild beliefs and untrustworthy advice

Nicholas J Talley AC

Since COVID-19 emerged in December 2019, over 1100 clinical studies have been registered globally, including over 500 RCTs

Joshua S Davis · David Ferreira · Justin T Denholm · Steven YC Tong

To the Editor: The great complexity and unmet need in rare diseases is highly challenging for the estimated two million Australians with a rare disease.1 The coronavirus disease 2019 (COVID‐19) pandemic has created enormous health, social and economic burdens, exacerbating the challenges and uncertainty facing people with severe, chronic and often disabling rare disease. Systemic, nuanced, flexible and coordinated responses are required. The vulnerability of rare disease patients is evidenced by the preliminary results of a global survey of over 5000 mostly European rare disease patients,2 which found that nine out of ten patients are experiencing interrupted care because of COVID‐19. Issues include frequent cancellation or postponement of surgeries and transplants, allied health and primary care or specialist appointments, and interrupted psychiatric care. There are reports of losing access to in‐home and hospital therapies and diagnostics, and of closures of hospitals and units that provide ongoing rare disease care. Over half of respondents with access to follow‐up care through hospitals chose not to attend in fear of contracting COVID‐19. Despite a relatively smaller Australian COVID‐19 burden, these sentiments are echoed locally. The Australian National Strategic Action Plan for Rare Diseases1 has three pillars: awareness and education; care and support; and research and data. This policy framework underpins rational, evidence‐based and evolving responses for Australians with a rare disease. The peak body, Rare Voices Australia, drew on the Action Plan to formulate a statement3 outlining measures to ensure the rare disease community is protected and considered in the national COVID‐19 response. Issues addressed in the statement include triage; clinical care guidelines informed by rare disease experts; continuity and coordination of care; stricter isolation and enhanced testing; and increased utilisation of digital health, including virtual clinics and telemedicine. Subsequently, Rare Voices Australia also called for governments to exercise flexibility around school attendance for rare disease families. Positively, the European survey2 revealed increased participation in telemedicine, with a high degree of satisfaction. Australian rare disease specialist clinics have historically provided care over vast distances. Australia's transition to telehealth therefore provides an opportunity to connect with families, particularly those with huge disease burden, within their community. This may enable transition to more person‐centred health care, a foundation principle of the Action Plan.

Gareth S Baynam · Carol Wicking · Kaustuv Bhattacharya · Nicole Millis