Infectious diseases

We must continue to review and document the safety and outcomes of transfers, despite their apparent safety

Peter T Morley

Most children with COVID-19 can be cared for adequately in primary care, relieving the demand for emergency department services

Laila Ibrahim · Catherine Wilson · Doris Tham · Mark Corden · Shefali Jani · Michael Zhang · Amit Kochar · Ker Fern Tan · Shane George · Natalie T Phillips · Paul Buntine · Karen Robins‐Browne · Vimuthi Chong · Thomas Georgeson · Anna Lithgow · Sarah Davidson · Sharon O'Brien · Viet Tran · Franz E Babl

Increased in-hospital mortality may reflect changes in care across the Australian health system that need to be rectified

Sing Chee Tan · Tess Evans · Matthew L Durie · Paul J Secombe · David Pilcher

Awareness that the myocarditis risk in children with SARS-CoV-2 infections differs from that for adults should inform vaccination strategies

Patrick Walker · Timothy C Lai · Silja Schrader · Nigel Crawford · Daryl R Cheng

To the Editor: The impact of the coronavirus disease 2019 (COVID‐19) pandemic continues to affect institutional care, both acute and aged care services. More hidden is the impact on community care, especially community palliative care. Community palliative care aims to enable people to die where they wish. About 70% of the population seek to die at home, but between 4% and 12% actually do.1 During the COVID‐19 pandemic, however, data from three Melbourne community palliative care services indicated a rise in deaths at home of between 30% and 50% (personal communication, John Doran, Manager, Melbourne City Mission Palliative Care; Janet Phillips, Chief Executive Officer, Peninsula Home Hospice; and Kelly Rogerson, Chief Executive Officer, Palliative Care South East; December 2022). This increase has not been recently reported in Australia. One factor may be family reticence to admit their family member for inpatient care because of continued visitor restrictions2 — also reflected in international literature.3,4 Consequentially, the client profile has changed as more people present with complex needs and a higher number need terminal care. This requires lengthier visits from clinical staff — one service employed a registrar to support general practitioners (personal communication, Janet Phillips, December 2022). More emphasis is placed on telehealth, now routine, often substituting every second scheduled visit; and many staff work from home (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). The use of in‐home overnight respite has markedly increased, providing additional support to family carers (personal communication, Janet Phillips, December 2022). Perhaps because of increased workload, locum doctors are less available, meaning that palliative care staff are increasingly called on to support terminal care, including complex symptom management, and to verify death (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). Staff are still required to do regular risk assessment, including COVID‐19 testing, and to wear personal protective equipment, aligned with Department of Health guidelines for health care workers.5 A significant number of inpatient bed‐days are saved when people are supported to die at home, which may reduce the burden of care in institutional settings.6 Further work is required to measure the impact of home‐based care on outcomes for terminally ill people and their families and to understand the value of that care to the health care system.

Margaret O'Connor

Increased prescribing of psychotropic medication for children and adolescents during the COVID-19 pandemic: no cause for alarm

Philip L Hazell

The appropriateness of the increasing psychotropic prescribing to children and adolescents should be further investigated

Stephen J Wood · Jenni Ilomäki · Jacqueline Gould · George SQ Tan · Melissa Raven · Jon N Jureidini · Luke E Grzeskowiak

Prescribing of all psychotropic classes has risen since 2018, and increases were particularly marked during the COVID-19 pandemic

Rae‐Anne Hardie · Gorkem Sezgin · Lisa G Pont · Judith Thomas · Mirela Prgomet · Precious McGuire · Christopher Pearce · Andrew Georgiou

Climate change affects skin health and skin diseases; mitigation and adaptation strategies are required and are time-critical

Austen Anderson · Fiona Bruce · H Peter Soyer · Crystal Williams · Rebecca B Saunderson

Bloodstream infection rates in Aboriginal residents of Central Australia remain extremely high, and risk factors must be remediated

Alice Coe · Richard J Woodman · Rob Baird · Lloyd Einsiedel

Evidence-based mental health and wellbeing programs for workers in health care organisations are needed

Sarah L McGuinness · Owen Eades · Kelsey L Grantham · Shannon Zhong · Josphin Johnson · Peter A Cameron · Andrew B Forbes · Jane RW Fisher · Carol L Hodgson · Jessica Kasza · Helen Kelsall · Maggie Kirkman · Grant M Russell · Philip L Russo · Malcolm R Sim · Kasha Singh · Helen Skouteris · Karen Smith · Rhonda L Stuart · James M Trauer · Andrew Udy · Sophia Zoungas · Karin Leder

Our findings add to northern hemisphere reports that possibly reflect a worldwide increase in GAS disease

Aleece MacPhail · Wen Jie Isaac Lee · Despina Kotsanas · Tony M Korman · Maryza Graham

To the Editor: We thank Gibney and Steer for their editorial1 in response to our research letter,2 supporting further public health action and research into invasive group A streptococcal (iGAS) disease. However, we are concerned about the statement that the 30‐day risk of iGAS disease for contacts of someone with an index infection is about 2000‐fold higher than background risk. This figure is derived from an English population‐based study3 and cannot be universally applied across circumstances varying in background incidence of GAS‐related disease, which is driven predominantly by socio‐environmental factors. Applying this 30‐day secondary attack rate of iGAS infection in Northern Territory household contacts would translate to about 177 cases per 1000 population (18%) in Indigenous Australian contacts and 2738 per 1000 population (274%) in people receiving haemodialysis.2 In contrast, rates of iGAS infection in household contacts were 3.2 per 1000 population in Canada4 and 0.7 per 1000 population in the United States.5 As described in the NT public health guidelines for iGAS, previous NT and Queensland studies have demonstrated large diversity of iGAS genotypes,6 with less clonality and a greater proportion of sporadic cases rather than transmission directly from another case of iGAS infection. This reflects the stark contrasts in iGAS and other consequences of GAS infection between central and northern Australia and southern states, as seen with so many other health issues linked to socio‐economic disadvantage. Gibney and Steer also note that some authorities recommend antibiotic prophylaxis for close contacts, and others do not.1 We wish to highlight that the NT guidelines for the public health response to iGAS include specific guidance around antibiotic prophylaxis for close contacts (for mother–neonatal pairs, contacts of severe iGAS disease cases, and in other special circumstances), informed by a literature review in the Appendix.6 National guidelines for iGAS are currently being developed and these need to include advice tailored for the vastly different epidemiology seen across Australia, reflecting a contrasting diversity of endemicity of GAS‐related disease. This has also been necessary for the Australian guidelines for diagnosing acute rheumatic fever, with low risk and high risk populations defined.7

Johanna M Birrell · Bart J Currie · Vicki L Krause

Biodiversity in Australia is in steep decline, posing major risks to human health

Katherine A Barraclough · Marion Carey · Kenneth D Winkel · Emily Humphries · Brooke Ah Shay · Yi Chao Foong

A 78-year-old man with hypertension, dyslipidaemia, hypothyroidism and gout presented with two weeks of migratory polyarthritis and fever

Hannah Poole · Amy Crowe · John Daffy

A structured diagnostic approach is required when assessing for JEV in patients with encephalitis

Sarah Allen · Celia M Cooper · Ajay Taranath · Allen C Cheng · Philip N Britton

Ongoing surveillance for emerging and re- emerging infectious diseases is essential to assess their impact on blood and breastmilk safety

Philip Kiely · Veronica C Hoad · Claire E Styles · Iain B Gosbell

A 19-year-old man presented with a two-day history of intermittent pleuritic chest pain and associated fevers

Nilanthy Vigneswaran · Elaine Cheong

Streamlined, convenient hepatitis C care promotes engagement with treatment by people at particular risk

Michael B MacIsaac · Bradley Whitton · Adrian Hubble · Shelley Cogger · Matthew Penn · Anthony Weeks · Kasey Elmore · David Pemberton · Jenine Anderson · Rebecca Howard · Una McKeever · Timothy Papaluca · Margaret E Hellard · Mark Stoove · David Wilson · Alisa Pedrana · Joseph Doyle · Nico Clark · Jacinta Holmes · Alexander J Thompson

People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis

Allison Carter · Hamish McManus · James S Ward · Tobias Vickers · Jason Asselin · Greta Baillie · Eric PF Chow · Marcus Y Chen · Christopher K Fairley · Christopher Bourne · Anna McNulty · Phillip Read · Kevin Heath · Nathan Ryder · Jenny McCloskey · Christopher Carmody · Heather McCormack · Kate Alexander · Dawn Casey · Mark Stoove · Margaret E Hellard · Basil Donovan · Rebecca J Guy

The benefits of DAA therapy for children with HCV infection are now attainable in Australia in normal practice

Jessica A Eldredge · Michael O Stormon · Julia E Clark · Scott Nightingale · Brendan McMullan · Brooke Andersen · Christina Travers · Winita Hardikar

To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.

Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson

A man in his thirties presented immediately on return from a one-month trip to Europe with widespread pustular lesions, tender lymphadenopathy, fever, and headache

Adam Stewart · Sanmarie Schlebusch · Susan Vlack · Jamie McMahon · Mitchell Sullivan · Alyssa Pyke · Krispin Hajkowicz

Encouraging public compliance with measures that limit community transmission would benefit everyone, with only minor inconvenience

Gwendolyn L Gilbert

Improving the collection of neurosyphilis surveillance data and integrating neurosyphilis incidence data into syphilis reports may enhance our understanding of the epidemiology of neurosyphilis

Ei T Aung · Marcus Y Chen · Christopher K Fairley · Jason J Ong · Eric PF Chow