Infectious diseases

A 21-year-old man who migrated to Australia from Nepal 4 years previously was referred to a dermatologist

Akshay Flora · Priya Garg · Karen Cheung · Deshan F Sebaratnam · Monisha Gupta

During the New South Wales Delta outbreak, social factors caused more hospitalisations than medical reasons

Keith Grimwood · Anne B Chang

To the Editor: We write in response to Reid and colleagues’1 article on congenital cytomegalovirus (CMV). While many countries worldwide have established congenital CMV screening programs, Australia urgently needs to recognise the importance of targeted congenital CMV screening and tracking its outcomes. Our 2019–2020 study tested the feasibility and acceptability of a parent‐completed targeted congenital CMV saliva polymerase chain reaction (PCR) screening program in Victoria.2 Parents of infants who did not pass their newborn hearing screening at four Victorian maternity hospitals completed their infants’ saliva swabs in the hospital or at home. The program was feasible with a 76% participation rate, and all 96 swabs (100%) were completed within the required 21days from birth, despite the majority being completed at home. Furthermore, more than 90% of families found the screen easy to do, thought it was a good idea, and were glad their baby had congenital CMV screening. However, there were challenges: false positive screens due to CMV contamination in breast milk, and excessive time taken from completing the screen to return of results due to reliance on the only laboratory in the state accredited to process saliva CMV PCR. We now have the means to overcome these challenges, determine whether universal congenital CMV screening in Australia is warranted, and systematically track outcomes of targeted congenital CMV screening. For 2years from October 2021, Murdoch Children’s Research Institute’s Generation Victoria (GenV) is recruiting a whole‐of‐state infant–parent cohort, collecting over 110000 saliva swabs from newborns to test for CMV using novel CRISPR technology at the Walter and Eliza Hall Institute of Medical Research.3 Our study, funded by the National Health and Medical Research Council, will determine the population prevalence of congenital CMV, develop a rapid bedside point‐of‐care test for congenital CMV screening, and establish whether universal congenital CMV screening is cost‐effective. In addition, the Australasian Congenital CMV Registry has been recently established to track outcomes of congenital CMV.4 These initiatives will pave the way for Australia to emerge as a leader in congenital CMV screening, better recognise this undetected condition of public health importance, and provide personalised care to affected children.

Emma Webb · Cheryl A Jones · Valerie Sung

No single surveillance system is perfect, but integrating data from multiple sources can provide comprehensive and reliable signal detection

Allen C Cheng · Jim P Buttery

The long term consequences of myocardial injury with vaccine-associated myocarditis warrant further investigation

Suraj K Varma · Ari E Horton · Anna L Taylor · Michael R Ditchfield · Sarah A Hope · Srinidhi JV Rao

Community support for children with special care needs could reduce the number of COVID-19-related hospitalisations

Phoebe Williams · Archana Koirala · Gemma L Saravanos · Laura K Lopez · Catherine Glover · Ketaki Sharma · Tracey Williams · Emma Carey · Nadine Shaw · Emma Dickens · Neela Sitaram · Joanne Ging · Paula Bray · Nigel W Crawford · Brendan McMullan · Kristine Macartney · Nicholas Wood · Elizabeth L Fulton · Christine Lau · Philip N Britton

To maximise its health benefits, self-testing for infectious diseases must be reliable, accessible, and affordable

Deborah A Williamson · Sharon R Lewin

A 48-year-old female health care worker of European descent, who was otherwise well and on no regular medications, developed cough symptoms the day before testing positive for coronavirus disease 2019

Nicole Seebacher · Julie Kirkham · Saxon D Smith

Kindness can help to ground us as clinicians and reconnect with what makes us human

Anneliese Willems

Evidence-based respirator selection, fit testing, fit checking, and proper use are all vital for staff and patient safety

Micah DJ Peters

An otherwise well 45-year-old sheep farmer presented to her general practitioner following a one-week history of tender reddish-blue nodules on the dorsal surface of her left hand

Joshua Farrell · Thomas J Stewart

The Australian health system can respond effectively to monkeypox, especially with good surveillance, testing and tracing and rapidly procuring third generation vaccines and antivirals

C Raina MacIntyre · Andrew E Grulich

Using a multidisciplinary, pragmatic, patient-centred, non-judgemental approach may allow people who inject drugs to achieve improved outcomes for invasive infections and reduce their risk of subsequent admissions

Lucy O Attwood · Megan McKechnie · Olga Vujovic · Peter Higgs · Martyn Lloyd‐Jones · Joseph S Doyle · Andrew J Stewardson

It is important to provide options for obtaining both oral fluid- and blood-based HIV self-tests

Dana YL Lee · Jason J Ong · Kirsty Smith · Muhammad S Jamil · Ruthy McIver · Rebecca Wigan · Kate Maddaford · Anna McNulty · John M Kaldor · Christopher K Fairley · Benjamin Bavinton · Marcus Chen · Eric PF Chow · Andrew E Grulich · Martin Holt · Damian P Conway · Mark Stoove · Handan Wand · Rebecca J Guy

A 65-year-old man presented to the emergency department with right facial weakness and transient dysphagia

Julia Lim · Cameron Shaw

AusVaxSafety active surveillance affirms the short term safety of Comirnaty and Vaxzevria vaccines in a large population sample

Lucy Deng · Catherine Glover · Michael Dymock · Alexis Pillsbury · Julie A Marsh · Helen E Quinn · Alan Leeb · Patrick Cashman · Thomas L Snelling · Nicholas Wood · Kristine Macartney

mRNA vaccine development will continue to accelerate, and further improvements to the technology may mitigate some of the current limitations

Isabella Overmars · George Au‐Yeung · Terence M Nolan · Andrew C Steer

It may be safe to de-label many patients because their reactions do not meet anaphylaxis criteria

Beau Z Carr · Kymble Spriggs · Samar Ojaimi · Elizabeth Leahy · Sara L Barnes

To the Editor: The impetigo burden for Australian Aboriginal children living in remote areas is the highest in the world, affecting 45% at any one time.1 This unacceptable public health crisis contributes to ongoing high rates of rheumatic fever and glomerulonephritis, both sequelae of Streptococcus pyogenes or group A streptococcus (GAS) infection.2 GAS infection is the key immediate driver of impetigo.3 Colonisation, social determinants and inadequate housing are overarching drivers.4 To reduce the skin infection burden, the See, Treat, Prevent (SToP) Trial (registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618000520235) was funded as a stepped wedge, cluster randomised trial in partnership with Aboriginal service providers and communities to see, treat and prevent skin infections.1 Before commencing, a situational analysis5 was performed in 2017 to describe trends, driving forces and conditions related to skin infections. The situational analysis5 identified the complex, courageous yet under‐resourced environmental health and health promotion activities in the Kimberley that could be included as prevention aspects in the SToP Trial1 and found: • a well established program of health advocacy and collaboration integrating public and environmental health which prioritises prevention; • remote Aboriginal populations remain relatively stable with predictable mobility between communities, in contrast to the high turnover of the predominantly non‐Aboriginal health workforce; and • access to household maintenance throughout Kimberley communities, necessary to prevent skin infections, remains limited and frequently under‐resourced. Despite this need, the resourcing required for this sector to deliver on these services has not occurred.6 Before the SToP Trial, prior skin infection studies focused on biomedical treatments as short term solutions to improve skin health.1 Integration of diagnosis, treatment and prevention activities in a single trial to inform skin disease control is novel and needful. Aboriginal communities and health care organisations highlighted the urgent need to incorporate prevention to reduce the inequitable burden of skin infections. The key findings of the situational analysis are as follows:5 • services are working together to combat the high burden of skin infections in the Kimberley; • the immediate environment continues to contribute to poor skin health and is an area for intervention; • addressing the social determinants of health is critical to reducing skin infections; • partnerships are required to appropriately achieve the healthy living practices; and • the Kimberley has led the way with the development of the environmental health referral form. The SToP Trial includes clinic and school staff training modules for the identification and treatment of skin infections. These include online options to overcome the logistic challenges limiting face‐to‐face professional development in isolated locations and to support continuous training of new staff. The stability of the community is a strength and community requests have led to the incorporation of family training packages. Partnerships between primary health care and environmental health service providers are allowing for the better integration of prevention measures within communities. Capitalising on the advocacy and collaboration demonstrated by Aboriginal leaders across the region has aided SToP Trial initiatives, with results expected in 2023.

Frieda McLoughlin · Vicki O’Donnell · Asha C Bowen

To the Editor: Wu and colleagues1 describe a case of congenital syphilis where the mother had no apparent risk factors and a single negative syphilis serology collected in early pregnancy. The father had an identifiable risk factor. In metropolitan Perth, Western Australia, infectious syphilis among women of reproductive age is rising, with an over 18‐fold increase from 2015 to 2021 (Box). During this period, most cases (229, 74.1%) were non‐Indigenous women. This growth has been accompanied by cases in pregnancy and, concerningly, neonates with congenital syphilis. The authors1 observed that identifying risk factors during pregnancy is challenging. They may be absent, difficult to ascertain, subject to change during the pregnancy, and are dependent on the pregnant woman and her sexual partners, whose risks she may not know. Identification relies on health care providers checking the risk throughout pregnancy and on whether the woman recognises, discloses or feels safe to discuss a risk factor. In Perth, syphilis diagnoses among pregnant women are occurring across cultural backgrounds. While some women have additional risks such as insecure housing or illicit drug use, this is not the norm. Consequently, and because we have likewise observed neonates with congenital syphilis born to women who screened negative early in pregnancy, routine syphilis serology at initial visit and at 28 and 36weeks (or delivery, if earlier) is now recommended for all pregnant women in metropolitan Perth as per the WA sexual health guidelines2 and local obstetric guidelines.3 This was achieved through the collaboration of clinical and public health staff under the Antenatal and Postnatal Working Group of the WA Syphilis Outbreak Response Group, where a decision was made that monitoring risk factors throughout pregnancy has limitations. Three‐test syphilis screening for all pregnant women minimises the risk of congenital syphilis occurring because of an unrecognised risk factor, ensures emerging risk factors are not missed, helps normalise testing and reduce stigma, and recognises that women remain sexually active while pregnant. Notably, screening is not a replacement for good history taking and clinical examination, but syphilis can present in subtle and unusual ways that can be overlooked. Routine syphilis testing at the first antenatal visit is advised by the Australian sexually transmissible infections guidelines.4 A test early in the third trimester is recommended depending on local guidelines.4 As syphilis rates grow in many parts of Australia,5 other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women. Box – Infectious syphilis cases among women of reproductive age, 2015–2021 Data sources: The number of cases were obtained from the Western Australian Notifiable Infectious Diseases Database, Department of Health Western Australia (Jan 2022); and the rate of cases were obtained from the Australian Bureau of Statistics census‐derived population data from the Epidemiology Branch, Public and Aboriginal Health Division, Western Australia Department of Health (Dec 2021).

Hannah MacKenzie · Suzanne McEvoy · Michelle Porter

Higher in-hospital mortality during the third wave may reflect the virulence of Delta or the higher number of ICU admissions

Husna Begum · Ary S Neto · Patricia Alliegro · Tessa Broadley · Tony Trapani · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Simon J Erickson · Craig J French · Edward Litton · Richard McAllister · Alistair Nichol · Annamaria Palermo · Mark P Plummer · Hannah Rotherham · Mahesh Ramanan · Benjamin Reddi · Claire Reynolds · Steven AR Webb · Andrew A Udy · Aidan Burrell

Health practitioners have the opportunity to contribute their expertise to help reduce the health consequences of climate disasters across the prevention, preparedness, response and recovery phases of disaster management

Sotiris Vardoulakis · Veronica Matthews · Ross S Bailie · Wenbiao Hu · Luis Salvador‐Carulla · Alexandra L Barratt · Cordia Chu

A 70-year-old man of non-English speaking background migrated from Vietnam to Melbourne, Victoria, in 2007.

Robert G Stolz · Mark R Dowling · Belinda B Lin · Kylie Mason · Stephen Muhi

A previously well 9-year-old boy presented to the outpatients’ clinic with a tender, swollen occipital scalp lesion progressing over one month’s duration

Abhinav Rajkumar · Philip N Britton

Fit test results and performance evaluation by health care workers should be incorporated into respirator procurement decision making

Irene Ng · Benjamin Kave · Fiona Begg · Charles R Bodas · Reny Segal · Daryl Williams