Infectious diseases

The prevalence of SARS-CoV-2 antibodies in children and adolescents in early 2021 was very low

the PAEDS Serosurvey Group

A 70-year-old man presented to the emergency department with abdominal pain, vomiting, diarrhoea and shortness of breath on the background of a one-week history of fevers, dysuria and headaches

Ajinkya Bhonsle · Mithun Nambiar · Michael Swan · Ralph Junckerstorff

The overall cancer detection rate increased and colonoscopy detection indicators were maintained during the 2020 lockdowns

Daniel Schneider · Michael Swan · Simon Hew

Neglected tropical diseases represent a threat to the health, wellbeing and economic prosperity of billions of people worldwide, often causing serious disease or death

Johanna Kurcheid · Catherine A Gordon · Naomi E Clarke · Kinley Wangdi · Matthew Kelly · Aparna Lal · Polydor N Mutombo · Dongxu Wang · Mary L Mationg · Archie CA Clements · Stephen Muhi · Richard S Bradbury · Beverley‐Ann Biggs · Wendy Page · Gail Williams · Donald P McManus · Darren Gray

Very high influenza vaccination rates among health and aged care staff will be crucial if influenza activity increases this winter

Lyn‐li Lim · Noleen J Bennett · Sheena G Sullivan · Ann L Bull · Leon J Worth

A previously well 4-month-old boy was admitted to a tertiary Victorian paediatric hospital in February 2022 following a febrile convulsion

Andrea Zhu · Nikki Petrakis · Mohamed Gaber · Daniel Mason · Vanessa Clifford · Julian Kelly

About two in three of participating urban Aboriginal infants had mild or moderate hearing loss at twelve months of age

Tamara Veselinović · Sharon A Weeks · Valerie M Swift · Deborah Lehmann · Christopher G Brennan‐Jones

The continuation of chronic disease management in primary care remains essential during the COVID-19 pandemic

Anne Parkinson · Sethunya Matenge · Jane Desborough · Sally Hall Dykgraaf · Lauren Ball · Michael Wright · Elizabeth A Sturgiss · Michael Kidd

An81-year-old man presented to his GP with a shallow, red ulcer on the dorsum of his left index finger over the distal interphalangeal joint, progressive over the previous 3 weeks

Rachel W Xu · Timothy P Stinear · Paul DR Johnson · Daniel P O’Brien

To the Editor: Fraile Navarro and colleagues1 recently published 20 recommendations for the treatment of coronavirus disease 2019 (COVID‐19) in children and adolescents from the National COVID‐19 Clinical Evidence Taskforce. For the paediatric inflammatory multisystem syndrome (PIMS‐TS) recommendations, the Taskforce convened an expert advisory group.1 In the absence of clinical trials, the panel considered peer‐reviewed guidelines and cohort studies to formulate consensus recommendations.1 However, they deferred providing any guidance to help clinicians prevent thromboembolism. We suggest the Taskforce consider the same approach for paediatric anticoagulation guidance. COVID‐19 is associated with marked coagulation activation and hypercoagulability in children.2,3 Life‐threatening pulmonary embolus requiring thrombolysis has been encountered in Australian adolescents hospitalised with COVID‐19. A retrospective cohort study published in 2021 found that 2.1% of children hospitalised with symptomatic COVID‐19 infection and 6.5% of those with PIMS‐TS developed thrombosis.4 Thrombosis occurred more frequently in children aged 12years and over who had central lines, PIMS‐TS, or an underlying oncological diagnosis. A D‐dimer of more than five times the upper limit of normal was significantly associated with thrombosis.4 The authors refer to “paediatric guidelines published in the US”, which are published on behalf of the Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee of the International Society of Thrombosis and Haemostasis; these adapt current consensus prophylaxis guidelines to include COVID‐19‐specific features.5 In deferring making specific recommendations, the authors suggested using existing local thromboprophylaxis guidelines. The Royal Children’s Hospital, Melbourne and the Sydney Children’s Hospital, Randwick have both independently developed COVID‐19‐specific thromboprophylaxis guidelines (that are very closely aligned),6,7 as have many other centres globally because previous local thromboprophylaxis guidelines are inadequate for COVID‐19‐associated thrombotic coagulopathy. The Melbourne/Sydney guidelines advise baseline coagulation testing in hospitalised children with COVID‐19, incorporating D‐dimer to assist risk assessment, twice‐daily enoxaparin and anti‐Xa monitoring/dose titration.6,7 These could be provided as supplemental material in these living guidelines. The COVID‐19 anticoagulation in Children–Thromboprophylaxis (COVAC‐TP) trial — a phase 2 single‐arm study looking at 40 children who will receive monitored, low dose, twice‐daily enoxaparin (ClinicalTrials.gov Identifier NCT04354155) — will not change the level of evidence, so waiting for completion of this trial does not seem appropriate.

Gemma L Crighton · Anthea Greenway · Susan Russell

To the editor: Clinicians are faced with requests for mask exemptions but guidance remains limited. In keeping with the Australasian College of Dermatologists’ guidelines,1 we believe skin problems are rarely severe enough to warrant exemption. The Department of Health and Human Services states people with “a serious skin condition of the face” are eligible for mask exemption,2 but this statement is open to interpretation. Mask exemptions for skin conditions are provided by numerous clinicians and not limited to dermatologists. Regardless of immunisation status, cases that may warrant exemption include severe dermatitis with crusting or weeping; severe infections such as impetigo or eczema herpeticum; bullous dermatoses, ectodermal dysplasias and other rare conditions featuring facial skin fragility; and post‐surgical procedures involving grafts or flaps where masks may impede healing. In addition, treatments for actinic damage such as 5‐fluorouracil, imiquimod or photodynamic therapy may cause severe inflammation.3 We suggest if exemptions are warranted, duration should be minimised, which may be before resolution of the dermatoses (eg, 2weeks followed by a review). This is essential given masks have been key in reducing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission.4 The development of an assessment pathway for facial dermatoses impeding mask use may be beneficial and should differentiate between health care workers, who wear fit‐tested masks, and the general public, guiding prompt treatment and follow‐up to facilitate a return to mask use. From our experience, facial masks may irritate the skin from pressure, sweating and humidity, and commonly aggravate underlying dermatoses, such as seborrheic dermatitis, acne or rosacea. Facial masks may rarely cause allergic contact dermatitis,5 and these cases should involve a contact dermatitis expert. Education regarding skin care is vital, in particular regular cleansing and reducing the number of products used which may aggravate acne. When utilising reusable masks, it is important to opt for an appropriate material such as light‐coloured cotton and maintain mask hygiene, which includes daily mask changes, regular washing, not sharing masks, and taking regular breaks from mask wearing. In summary, clinicians should remain vigilant when writing mask exemptions, aiming to minimise the duration by treating underlying skin problems and providing patient education.

Kajal Patel · Rosemary L Nixon

To the Editor: We recently reviewed the first studies of the real‐world effectiveness of coronavirus disease 2019 (COVID‐19) vaccines.1 We found evidence of protection against serious illness and death but noted the difficulties in performing such studies in Australia. This was because of the (then) low national case numbers and lack of ready access to the necessary linked health data. Since then, the literature on vaccine effectiveness has expanded dramatically. By February 2022 the Johns Hopkins Bloomberg School of Public Health and partners had generated a database of 181 studies conducted in 26 countries.2 The most studied vaccines were Pfizer (117 studies), Moderna (47), AstraZeneca (43), Janssen (17) and Sinovac (8). Twenty‐three studies investigated booster doses, and seven studies mentioned analysis of the Omicron variant. Study outcomes included infections (117 studies), hospitalisations (69), deaths (30), and viral transmission (5). Study designs varied, with 32 mentioning cohort analysis and 16 mentioning test negative analysis in their titles. Most studies were performed in the United States (56 studies), followed by Israel (32), the United Kingdom (29), Qatar (9), Canada (8), Brazil (6) and Denmark (4). Not one of the listed studies was conducted in Australia. We should be asking why. Australia no longer lacks the case numbers to make estimates of vaccine effectiveness. We collect good data on vaccination status, infections (including viral variants), hospitalisations and deaths, plus the information needed to adjust for confounding of the associations between vaccine exposure and outcomes. However, authorities have not linked these datasets at individual level and made them available for detailed analysis. This situation should not continue. There are well established principles for protecting the privacy of individuals who are included in routinely collected data.3 The Commonwealth and state governments and relevant agencies seem unable or unwilling to link and properly analyse these data. Consequently, they should ensure that regularly updated comprehensively linked de‐identified datasets can be accessed by qualified researchers. Stephen Duckett has recently called for an Australian review of lessons from the COVID‐19 pandemic using a systems rather than a punitive lens.4 We agree. Better linkage, access and analysis of our health system data should be high on the list.

David A Henry · Mark A Jones · Paulina Stehlik · Paul P Glasziou

A 35-year-old South Asian man with mild asthma had SARS-CoV-2 infection in August 2021

Jamma Li · Kathryn Sutton · Lawrence Ong · Oliver Flower · Jonathan J Gatward · Helena Jang · Nicholas Wood · Bernard Hudson · Sanaz Tehrani · Suran L Fernando

Nations need to come together to plan and execute urgent actions to break through the obstacles to sharing essential intellectual property

Martin Hensher · Sithara Wanni Arachchige Dona

Information from trusted influential messengers that is clear and consistent might be successful in addressing patients’ beliefs in health-related conspiracy theories

Mathew D Marques · Karen M Douglas · Daniel Jolley

Supporting people with COVID-19 should look beyond medical management and take into account their social and economic situation

Joanne Flavel · Fran Baum

A 63-year-old man presented with headache, fever and decreased conscious state

Claudine Banal · Steve Lau · Sonalmeet Nagra · David AK Watters

A 7-year-old girl presented to the emergency department with fever and right forearm redness

Yu‐Lin Tai · Chien‐Yu Lin

Global pandemics are inevitable, but their effects can be ameliorated by better health systems, education, and being prepared

Robert Booy · Gary Grohmann

About 80% of participants could be adequately supported by primary care and community organisations

Seok Ming Lim · Nicole L Allard · Janelle Devereux · Benjamin C Cowie · Michelle Tydeman · Alistair Miller · Khanh Ho · Brigitte Cleveland · Liz Singleton · Karen Aarons · Paul Eleftheriou · Thomas Chan · George Braitberg · Andrea Maier

Recommendations are based on evidence-based knowledge of safety, immunogenicity and efficacy of the vaccines in the general population, plus emerging data regarding COVID-19 vaccination in immunocompromised individuals

Eliska Furlong · Rishi S Kotecha · Rachel Conyers · Tracey A O'Brien · Jordan R Hansford · Leanne Super · Peter Downie · David D Eisenstat · Gabrielle Haeusler · Brendan McMullan · Marianne B Phillips · Bhavna Padhye · Luciano Dalla‐Pozza · Frank Alvaro · Christopher J Fraser · Wayne Nicholls · Julia E Clark · Matthew O'Connor · Benjamin R Saxon · Heather Tapp · John Heath · Sarah E Hunter · Karen Tsui · Mark Winstanley · Amanda Lyver · Emma J Best · Ushma Wadia · Daniel Yeoh · Christopher C Blyth · Nicholas G Gottardo

To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18). The first 100 consecutive patients were all born overseas (Box). Melbourne’s only public sexual health clinic referred 65 patients. Almost all patients were male, all patients had sex with men and reported a median of three sexual partners in 3 months at baseline; 76 patients inconsistently used condoms for anal sex. Fifty‐eight patients reported previous sexually transmissible infections (STIs); STIs were diagnosed in 12/100 patients at baseline, a rate similar to that found in Medicare‐eligible PrEP users.2 Thirty‐four patients had previously accessed HIV post‐exposure prophylaxis (PEP), and 49 patients had previously unsuccessfully attempted to obtain PrEP. The reported barriers to access mainly included costs of medical appointments and pathology, and difficulties navigating Australia’s health care system. All patients received a non‐PBS PrEP prescription. At 3‐month follow‐up, 87 patients had commenced PrEP. Local pharmacies supplied PrEP at cost price (A$40–55 per month) or free to patients with financial hardship; other patients purchased PrEP online (US$20–30 per month) or obtained free PrEP online using assistance coupons (www.pan.org.au; Box). Most patients who ordered PrEP online experienced delivery delays of 4–6 weeks, leaving them at risk of HIV infection. We report that Medicare‐ineligible gay and bisexual men and transgender women were at high risk of HIV infection, yet faced significant financial barriers to accessing PrEP. PrEP uptake has been associated with significant population‐level declines in incident HIV infection in Australia.3 Australia’s Eighth National HIV Strategy aims for virtual elimination of HIV transmissions by 2022,4 and to achieve this goal, Australia must provide universally subsidised PrEP medication and clinical services, irrespective of Medicare status.5 Medicare‐ineligible gay and bisexual men often already attend publicly funded sexual health clinics for free HIV/STI testing and treatment, as reported here. In a high income country like Australia, the additional cost of providing universally subsidised PrEP care would likely be lower than treating preventable new HIV infections, with an estimated lifetime cost of more than US$350 000 per HIV infection diagnosis.6 Box – Demographic characteristics, immunodeficiency virus (HIV) acquisition risk, and prior efforts to obtain pre‐exposure prophylaxis (PrEP) in the first 100 consecutive patients to attend the PrEPMe HIV prevention clinic at the Alfred Hospital in Melbourne, Australia* Values Total number of patients 100 Demographic characteristics Region of birth Asia 47 Latin America 31 Europe 14 Other 8 Age, years, median (IQR) 28 (26–31) Gender Cisgender male 96 Transgender female 4 Visa status Student visa 62 Working visa 34 Other 4 Referral sources Melbourne Sexual Health Centre 65 Word of mouth 16 Other† 13 Unknown 6 HIV risk at initial clinical assessment Sexual partners (3 months), median (IQR) 3 (1–5) Condom use for anal sex (3 months) Always 24 Mostly or sometimes 60 Never 13 Not applicable 1 Unknown 2 Previous STIs (ever) Yes 58 No 42 Previous STIs (ever, specific STIs) Gonorrhoea 35 Chlamydia 21 Syphilis 21 Other‡ 5 STIs diagnosed at baseline Chlamydia only 6 Other§ 6 Previous attempts at HIV risk reduction Previous use of PEP Yes 34 No 57 Unknown 9 Previous unsuccessful attempts to obtain PrEP Yes 49 No 46 Unknown 5 PrEP commencement by 3‐month follow‐up Commenced PrEP 87 Local pharmacy 65 Online 19 Online order did not arrive, then purchased at pharmacy 3 PrEP not commenced 6 Online order did not arrive 3 Other¶ 3 Lost to follow‐up 7 COVID‐19 = coronavirus disease 2019; IQR = interquartile range; PEP = post‐exposure prophylaxis; STIs = sexually transmissible infections. * Enrolment dates: 1 June 2020 to 26 October 2020. † Includes general practices, internet search, “PrEP Access Now” Facebook page, Alfred Hospital PEP program. ‡ Includes herpes simplex virus, Mycoplasma genitalium, hepatitis B virus. § Includes syphilis, hepatitis B virus, both chlamydia and gonorrhoea. ¶ Includes lost prescription, no sex due to COVID‐19.

Vincent J Cornelisse · Jude Armishaw · Mike Catton · Dean Murphy · Edwina J Wright

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1 The management of large numbers of COVID‐19 inpatients with diabetes has been challenging. People with diabetes are a vulnerable population who are at risk of adverse outcomes from COVID‐19, with a two‐ to threefold likelihood of death compared with people without diabetes.2 Hyperglycaemia is associated with higher risk;3 hence, good glucose management is desirable. Exacerbation of diabetes by dexamethasone therapy, used to treat patients with COVID‐19, and the development of steroid‐induced hyperglycaemia in non‐diabetic patients present further challenges. Traditional models of care relying on referrals from parent teams to an endocrinologist (or registrar), who then reviews the patient daily to chart insulin, are inefficient and impractical for this situation. We have developed a virtual inpatient diabetes management service (vIDMS) as a means for a small diabetes team to manage COVID‐19 inpatients with diabetes. The success of this model has revolved around an electronic medical record, electronic inpatient prescribing, a diabetes dashboard, and videoconferencing communications. The recording of all glucose measurements (including point of care) within the electronic medical record has enabled the systematic capture and display of hospital‐wide glucose data on a diabetes dashboard (Box). This also allows viewing and filtering by any variable in the electronic medical record, such as ward, age, biochemistry (including formal laboratory glucose and glycated haemoglobin), development of hypoglycaemia, prescribed medications (including corticosteroids), and COVID‐19 status. Therefore, COVID‐19 patients with diabetes or hyperglycaemia are easily identified. The vIDMS, comprising of a consultant, a registrar and a diabetes educator, reviewed patients with COVID‐19 and hyperglycaemia on a daily basis, using the dashboard and electronic medical record, by sharing a screen on a videoconferencing platform. Remote management was undertaken through the electronic medical record, including medication and insulin dose adjustments. Communication with ward staff and patients with COVID‐19 through the electronic medical record, or by telephone or video, was undertaken when needed, including for diabetes education. Entry into the COVID‐19 wards and usage of personal protective equipment was not required. In the 6 weeks to 5 September 2021, 112 COVID‐19 patients with diabetes were thus managed in Westmead Hospital (median age, 62 years; range, 23–91 years), with up to 40 patients reviewed per day. Necessitated by COVID‐19, the future of inpatient diabetes management is now here. With one‐quarter of patients in metropolitan hospitals having self‐reported diabetes4 but insufficient specialised diabetes staff to provide individual management, the vIDMS will become a significant part of the wider model of diabetes care for large hospitals.5 While initial and intermittent face‐to‐face contact remains valuable to build a relationship and discuss relevant issues, and careful review of medical records is necessary to understand perturbations in glucose levels (eg, fasting, missed medication), the vIDMS enables daily specialist care for large numbers of patients with diabetes by a small team. The health system needs to facilitate its wider application for the management of both COVID‐19 and non‐COVID‐19 patients with diabetes in hospital. Box – Diabetes dashboard showing hospital‐wide glucose data for patients with coronavirus disease 2019 (COVID‐19)

N Wah Cheung · Amanda Hor · Tien‐Ming Hng

A combination of targeted vaccinations and COVID-19 public health measures has led to reduced rates of invasive meningococcal disease and influenza

CR Robert George · Robert Booy · Michael D Nissen · Monica M Lahra