Respiratory disease

The Care of Older People and Palliative Care Panel developed two clinical flow charts with practice points providing guidance on the delivery of quality geriatric and palliative care during the COVID-19 pandemic

for the National COVID‐19 Clinical Evidence Taskforce

COPD is the fifth greatest contributor to burden of disease and fifth overall cause of death among Australians

Alan M Carew · Jonathan P Williamson · Claude S Farah · Tajalli Saghaie · Martin Phillips · Alvin Ing

Our current approaches to limiting transmission of respiratory viruses, including SARS-CoV-2, are inadequate

Peter AB Wark · C Raina MacIntyre · Scott Bell · Brian Oliver · Guy B Marks

A 56-year-old man presented with cough, dyspnoea and urinary symptoms

Michael A Cilento · Christopher M Hocking

New measures are designed to improve health outcomes for workers in the coal mining, artificial stone and other dust‐generating industries In Australia, there has recently been a worrying resurgence of dust‐related lung diseases (pneumoconioses) previously assumed to be obsolete. Pneumoconioses are chronic fibrotic lung diseases produced by inhaling mineral dust or dusts (pneumon = lung; konis = dust [Greek]). Conditions include coal workers’ pneumoconiosis (black lung disease) and silicosis.1,2,3,4 Many cases of these diseases have been described in Australia for the first time in over 40 years, including a new type of accelerated silicosis caused by cutting and polishing engineered (artificial) stone seen in kitchen and bathroom benchtop workers.5,6 The latter has occurred in men, often at the height of their working lives, producing much disability and distress and resulting in completely preventable deaths. Artificial stone silicosis differs from other types of silicosis in that it progresses more rapidly and is also associated with a higher rate of development of autoimmunity than classical silicosis. Pneumoconiosis has recurred primarily due to a widespread failure of regulatory controls in a situation where the medical evidence for efficacy of surveillance and prevention is very well established.7,8,9 This has included deficiencies in dust monitoring and control, even in industries where lung health is notoriously at risk (eg, mining), as well as potential changes in dust exposure due to increases in length of shifts and changes in mining technologies.9,10,11 New technologies may have altered the types and characteristics of respirable dust particles as well as the total dust levels.4,12 In some industries, new products like artificial stone have been introduced without adequate awareness of likely hazards, alongside lack of labelling, inadequate respiratory protection, and widespread complacency about dust control measures.13 Dry cutting of stone is notoriously dangerous,7,8 yet was occurring frequently and is still not banned throughout Australia. Many employers (often in small businesses without access to any occupational medical advice) did not appreciate the potential hazards of products they were using, and were not warned by the regulators. Thus, they failed to assess the type or levels of respirable dusts, implement any health surveillance, or use even basic dust control measures.7,8 Because symptoms occur only very late in these diseases, workers were often unaware of any adverse effects. Many workplaces were non‐unionised and workers came from non‐English speaking backgrounds, and did not have access to information about dust hazards and ways to find help. Workers were reluctant to be identified because of job insecurity and financial concerns. Even after a respiratory abnormality had been identified, there was sometimes a failure to identify the disease as occupational in origin.10,11 It was only after cases of severe disease were described by the medical profession, and after several cases had been referred for lung transplantation, that the resurgence of pneumoconiosis was identified.3,4,5 These events are a stark reminder that occupational lung diseases are still a real issue in Australia and that we as health professionals need to maintain vigilance to prevent them in the future. As health professionals, we also need to be aware of the full range of health effects resulting from dust exposures. Inhaled dusts have been shown to cause a broader range of disorders than was originally understood.7,8,14 Pneumoconiosis is only one of several lung disorders which can arise from dust inhalation. In general, high dust levels are needed to produce lung fibrosis; however, other diseases have different, often lower, dose–response profiles. There is now convincing evidence that coal and silica/silicate dust inhalation also produces chronic bronchitis, emphysema and diffuse dust‐related pulmonary fibrosis,7,8,14 and that these effects are additive and not only attributable to tobacco smoking. It is also underappreciated that lung cancer and tuberculosis risk rises in a dose‐related manner after silica exposure, and particularly with silicosis itself.7,14,15 Dust exposure is a factor related to several systemic connective tissue diseases,16,17 including Sjögren’s syndrome, rheumatoid arthritis and mixed connective tissue disorder,18 and renal dysfunction has also been described.7,8 Positive auto‐antibodies are particularly common after artificial stone exposure.16 Clinicians must therefore be aware that inhaled dust produces a broader spectrum of disease than just pneumoconiosis. The primary management of pneumoconiosis has always been to reduce or stop dust exposure. This slows the rate of progression of disease and increases time from exposure to development of symptoms (or disease latency).7,8,19 This has been the rationale for respiratory surveillance programs, which involve regular assessment of a worker’s respiratory health in the workplace every few years, and usually include a questionnaire, spirometry and chest x‐ray, with reduction or removal from exposure once a threshold for early disease diagnosis has been reached. These programs have been the cornerstone of the reductions in incidence of pneumoconiosis worldwide19,20 and are compulsory for workers exposed to several dusts in most Australian states and territories. General practitioners often become involved in these programs either as examining doctors or after an abnormal result has been detected, and are key players in ensuring disease recognition, implementing appropriate work plans, and referring for support. It was because of serious concerns about disease resurgence that members of the Thoracic Society of Australia and New Zealand (TSANZ), Australia’s primary organisation representing respiratory health, developed recommendations in June 2016 aimed at controlling coal mine lung dust diseases.3 The TSANZ suggested standardisation of coal mine dust exposure limits throughout Australia, and alignment to international standards (which were generally lower levels than those in Australia). It also suggested a standardised national surveillance program for at‐risk workers and highlighted the need for better education regarding occupational hazards.3 Following media interest and political support, the federal government established a National Dust Disease Taskforce21 to establish a national approach to the prevention, early identification, control and management of occupational dust diseases. It supported establishing a National Dust Disease Register and provided some funds for new research.21 To assist with the forthcoming recommendations of this Taskforce, the TSANZ has reviewed the evidence and developed a position statement22 in light of advances in knowledge and new techniques available for diagnosing respiratory disease. Respiratory surveillance programs for pneumoconioses22 have been mainly based on the World Health Organization recommendations from the late 1970s,19 but respiratory medicine has advanced since those times, enabling detection of much earlier disease. Modern computed tomography scans provide excellent visualisation of lung anatomy at much lower radiation doses than before, and global initiatives have standardised lung function measurement and reporting.23 The gathering, storage and analysis of data have been revolutionised. In its position statement, the TSANZ recommends enhanced methods for respiratory surveillance of dust‐exposed workers using contemporary methods22 (Box 1). Despite legislated reductions in exposure limits,24,25,26,27 dust levels may not always achieve these limits, and workplace exposure data need to be collected and made available in a central repository to enable improved assessment of a worker’s likelihood of developing disease. This would also significantly improve existing understanding of dose–response relationships, especially with artificial stone. Periodic assessments of respiratory health need to involve a standardised format and high quality, standardised imaging and full lung function assessments. Workers with early abnormalities need to be optimally clinically assessed, treated where possible, and protected by suitable legislation from loss or downgrading of employment.22 Implementing such recommendations will inevitably involve detection of other lung disorders, including those which are non‐occupational in origin, and workers will be referred back to their GP for advice. It is therefore important that GPs understand the possible spectrum of diseases induced by dusts and other toxins, and obtain adequate and ongoing training in occupational lung disorders, including local support systems and when to refer for specialist advice (Box 2). The Royal Australian College of General Practitioners has a training resource for GPs which is a useful tool.28 Ultimately, such a system should prove beneficial to the health of both the individual and the community. However, it will require support and careful implementation in its initial stages. Early disease is difficult to distinguish in clinical practice from other lung pathologies, but difficulties in diagnosis can be overcome using modern techniques. International standards for diagnosis are available and new treatments are under evaluation. Multidisciplinary team meetings in hospitals have been established for respiratory disease diagnosis for many years and are now embedded nationally, and a similar system for occupational lung diseases would be a valuable addition to improving the diagnostic process. An occupational multidisciplinary team in each jurisdiction would bring together a wide range of specialties (primary care, occupational and respiratory medicine, occupational hygiene, radiology, pathology and allied health) and could assist hugely in improving diagnostic standards, improving expertise and disseminating information. This would be best advanced using new virtual technologies, which would also enhance involvement by community and rural physicians. The TSANZ recommendations represent best practice on the basis of existing information and need to evolve with new evidence. The TSANZ has also recommended careful evaluation of the efficacy of new measures using prospective studies, and updating in the light of new research. Changing the system would inevitably require increased resources. However, long term costs are likely to eventually decrease for health services and the economy, given the chronic debilitating nature of these preventable diseases. The TSANZ recommendations are a start in the process of re‐engaging industry and regulator, workers, doctors and politicians; hopefully, they will lead Australia towards a future where preventable death and disablement from occupational lung diseases does not occur. [Corrections added on 22 June 2021 after first online publication: the article title was amended and a footnote was added to Box 1.] Box 1 – Thoracic Society of Australia and New Zealand (TSANZ) proposed improvements to periodic health surveillance in the coal mining and artificial stone industries22 Regular training of staff in accordance with international standards of respiratory surveillance (including quality control and assurance). Plain chest radiographs to be performed using International Labour Organization recommended techniques, technically acceptable, with classification only by qualified thoracic radiologists, and compared with previous images. Individual spirometry to be performed according to American Thoracic Society/European Respiratory Society standards; results to be interpreted using reference values of the Global Lung Initiative. Serial data to be compared with longitudinal predicted values using the lower limit of normal to define lung function abnormality, and spirometry longitudinal data analysis software (SPIROLA). Dust monitoring to be performed under typical working conditions (≥ 75% capacity) and recorded using an accredited facility, with individualised data available for periodic surveillance. Extending surveillance methods for artificial stone exposure to potentially include low dose CT. Careful evaluation of the role of ultra low dose CT for coal miners and artificial stone workers in longitudinal prospective studies. Extending surveillance methods for all workers to include lung diffusing capacity (DLCO) at intervals of 3years or less; careful evaluation of such surveillance within longitudinal prospective studies. A flexible, individualised approach to the timing of surveillance of coal mine dust workers, including annual spirometry and DLCO if results are abnormal but do not yet fulfil diagnostic criteria for disease. Active case finding for artificial stone workers previously exposed to high respirable crystalline silica levels using conventional high resolution CT/spirometry/DLCO performed at accredited respiratory laboratories and radiological facilities using recommended protocols; follow‐up by expert treating specialists/teams, preferably at occupational respiratory disorder multidisciplinary team meetings. For artificial stone workers, pre‐employment plain chest radiographs to exclude major abnormalities. For artificial stone workers undergoing active case finding without abnormal chest x‐ray or high resolution CT, annual spirometry/DLCO and imaging 3‐yearly or more often depending on individual factors and test results. Chest x‐ray imaging to be complemented with high resolution CT scans in high risk groups (eg, borderline fibrosis found on plain chest radiographs and/or discrepancy with lung function findings). Improving existing medical databases to allow capacity to compare serial lung function data, occupational exposure history, imaging findings and dust measurements over time. Early evaluation of the diagnostic utility of best available tests (low dose CT, ultra low dose CT and DLCO) using data collected prospectively with consent from workers, ideally in a research setting. CT = computed tomography; DLCO = diffusing capacity of the lung for carbon monoxide. Adapted from: Perret et al. Respiratory surveillance for coal mine dust and artificial stone exposed workers in Australia and New Zealand: a position statement from the Thoracic Society of Australia and New Zealand. https://doi.org/10.1111/resp.13952. Licence at http://creativecommons.org/licenses/by/4.0. Box 2 – How to manage a case of possible pneumoconiosis in primary care: first steps Be aware that many dusts, fumes and vapours can cause lung diseases. The time between exposure and disease occurrence (latency period) can be very long, usually years. Take time to go through a patient’s full occupational history in detail, from leaving school to retirement. A chronological table of jobs may help (www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf). If the patient uses technical descriptions of a particular job, make sure you know exactly what they mean. Ask them to describe exactly what was done. Ask about conditions in the job, including dust controls like ventilation, use of personal protective equipment, dust measurements and any workplace respiratory health surveillance. Ask about shifts, including length of time worked and any improvements in symptoms when away from work (especially on holidays). Ask whether any other workers were affected. Ask if the patient has access to any safety data sheets. These are information sheets which are meant to be made available from the employer if a worker is exposed to a potentially hazardous exposure (www.safeworkaustralia.gov.au/sds). If unavailable, search the internet for the suspected agent of concern, or contact the Australasian Faculty of Occupational and Environmental Medicine to find a suitable occupational physician and obtain advice (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine). Make contact with an occupational health practitioner if possible (an occupational physician and/or occupational health nurse and/or occupational hygienist). Small employers may not employ such specialists, but a local occupational health practitioner may be a local GP. Be careful not to contact a patient’s employer without obtaining permission first! Your local WorkSafe or similar government agency may be helpful in identifying a potential hazard and can often provide anonymous advice (ACT: www.worksafe.act.gov.au; New South Wales: www.icare.nsw.gov.au; Northern Territory: worksafe.nt.gov.au; Queensland: www.business.qld.gov.au/industries/mining-energy-water/resources/safety-health/mining; South Australia: www.safework.sa.gov.au; Tasmania: worksafe.tas.gov.au; Victoria: www.worksafe.vic.gov.au; Western Australia: www.workcover.wa.gov.au). Keep careful records of all the above. Negative information is also useful. Ensure that a complete history of the patient’s other risk factors (eg, tobacco use, other inhaled substance usage) is recorded. Obtain relevant investigations performed to recommended standards (spirometry, chest x‐ray, computed tomography scan if indicated). If there is reasonable suspicion of an occupational disease, refer to an occupational physician and/or a respiratory physician with occupational lung expertise (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine; www.thoracic.org.au). Costs of care may be covered by WorkCover if a link with employment is established, but this may take time to confirm. Standards for accepting an occupational disease vary in different jurisdictions and do not always accord with medical diagnoses. Other support is available to workers via their local SafeWork or similar government agency.

Deborah H Yates · Jennifer L Perret · Margaret Davidson · Susan E Miles · AW Musk

Characterising the care requirements of patients with coronavirus disease 2019 (COVID‐19) is essential for resource allocation.1 Knowledge of care needs is based predominantly on experience in regions where health care capacity has been strained, and may not reflect ideal practice.2,3 We therefore examined COVID‐19 testing data for South Australia, the care requirements of patients with confirmed COVID‐19, and the disposition of people with potential COVID‐19 who presented to the designated COVID‐19 hospital for SA, the Royal Adelaide Hospital (RAH), during a period of low COVID‐19 prevalence and limited community transmission (30 January – 26 April 2020). We analysed SA Pathology data on tests for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and other respiratory pathogens, and clinical data from hospital electronic health records (further details: online Supporting Information). The Central Adelaide Local Health Network Human Research Ethics Committee approved the study, and waived the requirement for patient consent (reference, 13091). Of 52 883 people tested in SA for SARS‐CoV‐2, 438 had polymerase chain reaction (PCR)‐confirmed infections (0.8%); their median age was 54 years (interquartile range [IQR], 31–64 years; range, 1–94 years), and 211 were female (48%). The median age of screened people with negative results was 43 years (IQR, 28–60 years; range, 0–104 years), of whom 30 380 were female (58%). Seventeen people with confirmed COVID‐19 (3.9%) and 7588 of those without COVID‐19 (14%) were also positive for another respiratory pathogen (Supporting Information, table 1). There were no cases of COVID‐19 among people in high care nursing facilities or prisons, nor among homeless people; one infection of a health care worker caring for people with COVID‐19 was recorded in Adelaide. The number of patients admitted to the RAH with COVID‐19 broadly paralleled that of new cases in SA, but intensive care unit (ICU) occupancy peaked (6/7 April) and the number of people screened in the RAH emergency department for COVID‐19 declined (from 17 April) after the peak in new cases (21 March) (Box 1). The median time from diagnosis to viral clearance (according to national guidelines4) was 15 days (IQR, 12–19 days); it was lower for people managed in the community (14 days; IQR, 11–17 days) than for those admitted to hospital (17 days; IQR, 13–22 days), and there were no sex‐ or age‐related differences (data not shown). A total of 285 people with confirmed COVID‐19 (227 aged 18–65 years; 58 over 65 years) were managed entirely in the community (Box 2); their age and sex distributions were similar to those of all SARS‐CoV‐2‐positive people (data not shown). Of 18 228 patients who presented to the RAH emergency department, 2327 (12.8%) met screening criteria for potential COVID‐19, of whom 120 (5.2%) proved to be SARS‐CoV‐2‐positive (new diagnoses in 19 people) (Supporting Information, figure). Among people who met the criteria for potential COVID‐19, a larger proportion of people with positive results than of those with negative results arrived by private vehicle (59 [49%] v 797 [36%]), and smaller proportions required resuscitation (one [0.8%] v 72 [3%]) or had conditions deemed imminently life‐threatening (14 [12%]) v 706 [32%]); among people over 65 years, two of 37 SARS‐CoV‐2‐positive people (5%) and 406 of 939 SARS‐CoV‐2‐negative people (43%) required resuscitation or emergency review. Most people with confirmed infections were admitted to the inpatient COVID‐19 unit (90 [75%] v 419 with negative results [19%]), while three SARS‐CoV‐2‐positive (2%) and 79 SARS‐CoV‐2‐negative people (4%) were admitted from the emergency department to the ICU (Supporting Information, table 2). One of 18 228 people who presented to the ED did not meet screening criteria for potential COVID‐19 but subsequently tested positive (screening failure rate, 0.005%). A total of 536 patients were admitted to the inpatient COVID‐19 unit, including 117 who were SARS‐CoV‐2‐positive (22%). The proportion of SARS‐CoV‐2‐positive patients aged 18–65 years was larger than for other patients in the COVID‐19 unit (84 [72%] v 188 patients [45%]); the proportions of women were similar (53 [45%] v 186 patients [44%]). Median length of stay was longer for SARS‐CoV‐2‐positive than for SARS‐CoV‐2‐negative patients over 65 years of age (182 h; IQR, 87–285 h v 96 h; IQR, 48–158 h), but was similar for all patients aged 18–65 years. Six SARS‐CoV‐2‐positive (18%) and five SARS‐CoV‐2‐negative patients over 65 (2%) were transferred from the COVID‐19 unit to the ICU (Supporting Information, table 3). Seventeen patients hospitalised with COVID‐19 (14%) were admitted to the ICU. The median time from hospital to ICU admission was 2.4 days (IQR, 1.8–3.4 days) for the eight patients over 65, and 5.2 days (IQR, 1.0–6.1 days) for the nine aged 18–65 years; the median ICU stay was 17.3 days (IQR, 3.0–29.3 days) for those over 65, and 2.2 days (IQR, 1.6–4.4 days) for those aged 18–65 years. Four patients died (24%), the only COVID‐19‐related deaths in South Australia (overall case fatality, 0.9%; 18–65 years, 0.3%; over 65 years, 3.2%) (Supporting Information, table 4). Over the past 14 years, 15% of RAH patients with viral pneumonia in intensive care died, with a medium length of stay of 6.2 days (18–65 years, 7.4 days; over 65 years, 4.8 days) (unpublished data). More modest, but persistent, prevalence of COVID‐19 is expected to follow the major pandemic wave of 2020. Our data, gathered in an environment of low community transmission and a health care system with considerably greater capacity than demand, reflects the COVID‐19‐related resource burden that might be anticipated as we prepare for living with COVID‐19. Box 1 – New confirmed cases of COVID‐19 in South Australia, numbers of inpatients with COVID‐19 in the Royal Adelaide Hospital, and numbers of people presenting with potential COVID‐19 infection to the Royal Adelaide Hospital emergency department, 30 January – 26 April 2020 COVID‐19 = coronavirus disease 2019. Box 2 – Care requirements of people with confirmed COVID‐19 admitted to the Royal Adelaide Hospital, 30 January – 26 April 2020 COVID‐19 = coronavirus disease 2019; SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. * Includes one patient initially admitted under a non‐COVID‐19 inpatient team. † Fourteen SARS‐CoV‐2‐positive patients admitted under the COVID‐19 inpatient team required transfer to the intensive care unit, 11 of whom returned to the COVID‐19 inpatient team, as did two of three patients admitted to the intensive care unit from the emergency department. These patients are counted in both intensive care unit and COVID‐19 inpatient team numbers. ‡ includes three intensive care unit patients admitted directly from the emergency department then transferred to the inpatient team, and one patient who was still an inpatient at the end of the study.

Daniel Haustead · Dylan J Toh · Benjamin Reddi · Emily Kirkpatrick · Emily Rowe · Pamela Outhwaite · Elizabett Harnack · Michael Cusack · Megan Brooks

To the Editor: We thank the MJA for highlighting the fit testing of N95 or P2 respirators in Australian health care workers. Regli and colleagues1 make a compelling case that mandatory fit testing should be implemented in Australian hospitals for frontline staff, in line with South Australian guidelines.2 We note that NSW Health has recently implemented mandatory fit testing in high risk areas.3 We commend these efforts, but they may have important implications that would need planning and consideration in implementation. First, it is clear that anatomical variation of the nasal and malar regions means that some health care workers will only pass the fit tests with particular N95 or P2 respirators.4 This means that along with the implementation of a fit testing program, inventory management systems are also required to facilitate hospital tracking of stocks of particular respirator types and to ensure that sufficient stock is available in high risk areas for individual health care workers. At the Southern Adelaide Local Health Network, we have implemented such a system, which tracks stock levels of all available respirators within the hospital so that key workers who can use only specific types of N95 or P2 respirators will have access to the right type of mask when needed. Second, the coronavirus disease 2019 (COVID‐19) pandemic has disrupted global supply chains, affecting the availability of N95 and P2 respirators. Moreover, fit testing is not a one‐off process, but must be conducted as a rolling program to ensure that all workers have access to appropriately fitting N95 or P2 respirators. Finally, even with an efficient fit testing program, due to anatomical variations, there will always be a proportion of health care workers for whom no masks will be suitable. Along with fit testing, health departments should prioritise health care worker redeployment policies and the development of new technologies to address the needs of the proportion of the workforce with ongoing fit test failure.

Anand Ganesan · Jane Parker · Darius Chapman

To the Editor: In a recent letter published in the MJA, Muhi and colleagues1 reviewed the source of acquisition by 11 health care workers with coronavirus disease 2019 (COVID‐19) who presented for symptomatic screening at a single clinic. Travel and transmission outside the workplace were considered the likely source of infection for most of them. Data on COVID‐19 cases collected for public health purposes in Western Australia up to 1 June 2020 were reviewed to inform local public health strategies to protect health care workers. Fifty‐seven cases of COVID‐19 among health care workers or workers in health care settings with direct patient contact were identified. Fifty‐six cases were confirmed by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) polymerase chain reaction (PCR) test, and one case had positive SARS‐CoV‐2 IgG serology indicating past infection. Thirty‐one health care workers acquired their infection from a cruise ship or overseas, and 26 health care workers acquired COVID‐19 within Australia. The likely source of the 26 locally acquired cases is shown in the Box. Ten health care workers acquired the infection in the workplace. A further eight had no known contact with a COVID‐19 case but worked during their incubation period. These health care workers may have acquired the infection from an unidentified patient with COVID‐19, from another health care worker, or via fomite transmission at work. Extensive contact tracing did not reveal an alternate source in a setting of limited community transmission. Where possible, whole genome sequencing was used to substantiate epidemiological findings. Transmission of COVID‐19 occurred between health care workers, emphasising the need for staff to recognise not only the risk from patients but also from colleagues, where use of personal protective equipment and physical distancing may be relaxed. There were no cases among staff in COVID‐19 clinics, suggesting that the use of personal protective equipment does mitigate risk. Workplace fomite transmission was the putative source on three occasions, which reinforces the importance of regular environmental cleaning, rigorous cleaning of shared equipment, and good cough etiquette and hand hygiene practices within health care facilities. Our review describes a larger cohort of COVID‐19 cases among health care workers, encompassing metropolitan and regional settings. With international travel restrictions, an increasing proportion of locally acquired infections among health care workers may be expected. From this analysis and others,2 colleagues and fomites should be recognised as potential workplace sources of infection, in addition to direct patient contact. Box – Likely source of coronavirus disease 2019 (COVID‐19) infection for locally acquired cases by Western Australian health care workers (HCWs) Source of infection Cases Direct HCW to HCW transmission 7 Likely fomite transmission 3 Unknown, but worked during incubation period* 8 From a close contact outside of work 5 Contact not identified, but interstate travel 3 Total 26 * No alternate source of infection identified in the context of limited community transmission.

Rebecca J Hogan · Suzanne McEvoy

Many patients had persistent symptoms two months after diagnosis, including fatigue, chest pain, and breathlessness

David R Darley · Gregory J Dore · Lucette Cysique · Kay A Wilhelm · David Andresen · Katrina Tonga · Emily Stone · Anthony Byrne · Marshall Plit · Jeffrey Masters · Helen Tang · Bruce Brew · Philip Cunningham · Anthony Kelleher · Gail V Matthews

CHRIS supported the Victorian ICU response during the COVID‐19 pandemic The coronavirus disease 2019 (COVID‐19) pandemic put an unprecedented strain on intensive care resources throughout the world. Initially in Wuhan (China)1 and then in Lombardy (Italy),2 London (United Kingdom) and New York (United States),3 demand exceeded capacity, with 10–15% of the patients admitted to hospital developing critical illness. Australia has 191 adult and paediatric intensive care units (ICUs), with over 2300 ICU beds.4 This is equivalent to 8.9 ICU beds per 100 000 population, more than the UK but fewer than Italy and the US.5,6 In late March 2020, rising numbers of COVID‐19‐related admissions to ICUs were observed throughout Australia.7 The Australian and New Zealand Intensive Care Society (ANZICS) and the Australian Government Department of Health recognised that ICU demand was unlikely to be uniform, that capacity might be exceeded in one region but not in another, and that matching ICU resources to areas of greatest need might be required. A single sentence encapsulated the approach: “Why would we let a patient die in Western Australia if we can see a spare ventilator in Sydney?” A nationwide system to monitor ICU demand and capacity in Australia A nationwide dashboard of ICU activity, the Critical Health Resources Information System (CHRIS), was rapidly developed as a collaboration between Telstra Purple, Ambulance Victoria, ANZICS and the Australian Government Department of Health. All adult and paediatric ICUs (public and private) in Australia were instructed to enter data twice daily. This manual data entry typically took 5 minutes. Each ICU was immediately able to see patient numbers and resources available within every ICU in their region and also see an aggregate summary of all ICUs in Australia. CHRIS was available to all state and territory health departments, to all patient transport and retrieval agencies, and also to ICUs in New Zealand. The system went live on 1 May 2020, after 26 days of development. Three weeks later, 184 out of 188 eligible ICUs (98%) in Australia were contributing data. The ICU response to the second wave of COVID‐19 in Victoria After a decline in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections throughout Australia, notifications rose again in Melbourne at the end of June 2020.8 In response, ICU directors from the lead hospitals of the nine designated Victorian health care clusters commenced a daily morning meeting with representatives from Ambulance Victoria, Safer Care Victoria and the Victorian Department of Health and Human Services. The group committed to maintaining standards of care expected under normal (non‐pandemic) conditions and to achieving this by proactively transferring patients (with or without COVID‐19) to another ICU if delivery of care was compromised by high local demand. Decisions to transfer patients were informed by data from CHRIS. Pre‐existing critical care transfer systems run by Ambulance Victoria were used. From the beginning of July to the end of September 2020, there were 237 ICU admissions with COVID‐19 pneumonitis, of which 210 (88%) occurred in July and August. Admissions were predominantly to public hospitals in north‐western Melbourne.9 The rapid and localised nature of presentations meant that it was faster to transfer patients to ICUs with vacant capacity than to open and staff additional beds, despite physical ICU bed spaces being available. Transfers from the emergency department or ICU at the four north‐western metropolitan hospitals alone accounted for 35% (46/133) of all critical care transfers in Victoria during July and August. Spare ventilators were available at all sites on all days. On six occasions in August, there were more than 140 ventilated patients (with or without COVID‐19) in Victoria. On each of these days, there were more than 500 spare ICU ventilators available (Box 1 and Supporting Information, graphic 1 in the video). Despite individual hospitals indicating transient increases in ICU bed numbers, there was no overall increase in open staffed ICU beds. As COVID‐19 cases rose, so too did numbers of critical care staff unavailable due to COVID‐19 exposure or illness, with 15 consecutive days when there were more than 60 staff unavailable (Box 2). Lessons learned CHRIS provided real‐time data on ICU activity and capacity. In addition to facilitating the transfer of critically ill patients, CHRIS also enabled early diversion of ambulance presentations to emergency departments at hospitals where ICUs had capacity. These approaches were integral to ensuring standards of care were maintained by clinicians, retrieval agencies and the Victorian health department. At the same time, there was visibility to the Australian Government Department of Health, which would, if required, coordinate a national response to overwhelmed ICU services. Although several individual ICUs came under strain, retrieval and critical care systems in metropolitan Melbourne were not overwhelmed. Strategies to redistribute critical care demand are likely to have contributed to high survival rates for ventilated patients with COVID‐19 in Victoria.9 Timely transfers to ICUs with open available beds could be facilitated. Availability of staff was more important in determining capacity to deliver care than availability of ventilators. The role for CHRIS in the future The local application of a national tool (CHRIS) for real‐time display of ICU activity and resources was a key component of the response to the COVID‐19 pandemic in Victoria. CHRIS has the potential to augment existing ICU monitoring systems. The tool may also assist in the response to local and national public health emergencies, such as mass casualty events, bushfires10 or thunderstorm asthma.11 Automated linkage of CHRIS to existing state‐based and national systems should be investigated. In addition, it may have potential use in monitoring health policy impacts more broadly. Box 1 – Snapshot of the Critical Health Resources Information System (CHRIS) summary page for Victoria during August 2020 ACT = Australian Capital Territory; COVID‐19 = coronavirus disease 2019; ECMO = extracorporeal membrane oxygenation; HDU = high dependency unit; ICU = intensive care unit; NSW = New South Wales; NT = Northern Territory; NZ = New Zealand; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Box 2 – Number of ventilated (dark blue) and non‐ventilated (light blue) patients in Victorian intensive care units and the number of critical care staff unavailable to work due to coronavirus disease 2019 (COVID‐19) exposure or illness (green dots), listed each morning in the Critical Health Resources Information System (CHRIS) LOWESS = locally weighted scatterplot smoothing.

David Pilcher · Nicholas R Coatsworth · Melissa Rosenow · Jason McClure

An emergency imaging pathway based on local and international guidance tailored to the Australian health care setting Imaging in coronavirus disease 2019 (COVID‐19) is primarily helpful in diagnosing COVID‐19‐related complications and identifying alternative diagnoses that may explain a patient’s presentation. It can also be useful in the risk stratification of patients by identifying the presence and severity of comorbidities.1,2 Imaging is of limited use in screening for COVID‐19 in asymptomatic individuals, and in many cases where COVID‐19 symptoms are mild.1,3 Indiscriminate use of imaging in patients with confirmed or suspected COVID‐19 not only exposes the patient to unnecessary radiation but also represents an unnecessary infection risk and logistic demand for medical imaging departments. Existing international COVID‐19 imaging pathways have been derived in clinical environments significantly different from Australia, often where there is high COVID‐19 prevalence and constrained resource availability. Some centres preferentially use chest x‐ray, whereas others perform various types of computed tomography (CT) imaging of the chest. There is also inconsistency in the reporting of imaging studies in suspected or confirmed COVID‐19, with some reports following traditional didactic format, and others using synoptic template reports as recommended by a variety of medical bodies.4,5 Here we describe an imaging pathway developed at the Royal Adelaide Hospital, the designated COVID‐19 hospital in South Australia. This pathway aims to outline the imaging indications, technique and reporting of chest imaging in an emergency setting, at a time of low COVID‐19 prevalence. We incorporate current available international pathways and best practice guidelines for emergency imaging of COVID‐19 patients into a simple pathway relevant to Australian practice. Imaging pathway development We reviewed consensus and position statements from the Royal Australian and New Zealand College of Radiologists, the Australian and New Zealand Society of Thoracic Radiology, the Fleischner Society and the British Society of Thoracic Imaging. Recommendations pertaining to high COVID‐19 prevalence environments and resource‐constrained environments were modified to suit a scenario of low prevalence. When local guidelines conflicted with international organisations, priority was given to local recommendations on the basis of relevance. Recommendations were subsequently integrated into a clinical imaging pathway in consultation with local specialists in radiology, emergency medicine, general medicine, respiratory medicine and infectious diseases (Box). Reporting terminology The pathway incorporates standardised reporting terminology for patients with COVID‐19 as recommended by the Australian and New Zealand Society of Thoracic Radiology.5 Categorisation of study findings as “normal,” “indeterminate,” “typical” or “other diagnosis favoured” improves report clarity and creates actionable imaging outcomes. Appropriate use of CT The main role of CT in this pathway is to exclude complications and alternative diagnoses in patients with confirmed or suspected COVID‐19. The pathway prompts clinicians to consider CT for patients who are hypoxic (or have an oxygen requirement) and who have a chest x‐ray that is either “normal” or “indeterminate for COVID‐19”. In this instance there is a clinicoradiological discrepancy, and either a complication (such as a pulmonary embolus) or an alternative diagnosis is suspected. In keeping with British Society of Thoracic Imaging guidance, a low‐dose unenhanced CT of the chest is the CT scan of choice, with strong consideration given to an additional CT pulmonary angiogram.4 There is accumulating evidence that patients with COVID‐19 are abnormally prothrombotic, and conventional clinical decision rules and blood tests (especially D‐dimer) may not be applicable.3 Clinicians should have a lower threshold than usual for performing a CT pulmonary angiogram. The unenhanced CT functions primarily as a baseline, as the presence of intravenous contrast can artifactually simulate ground glass. Whenever possible, the non‐contrast CT scan and the CT pulmonary angiogram should be performed on the same occasion to minimise infection control risk and operational demands on medical imaging departments. Baseline imaging for patients at risk of deterioration Patients with comorbidities are recognised as being at higher risk of deterioration. Defined risk factors vary between institutions but include older patients, requirement for oxygen supplementation, significant comorbidities (especially cardiac or respiratory) and immunosuppression. The consensus statement from the Fleischner Society supports imaging in patients who have a positive test result for COVID‐19 and risk factors for disease progression, regardless of their clinical status. The use of imaging in this situation is to establish a baseline for future comparison and determine the extent of comorbidities. Imaging may also inform the intensity of follow‐up monitoring, either in the community or an inpatient setting.1 Incidental findings suspicious for COVID‐19 Although there are no radiological findings pathognomonic for COVID‐19, there are radiological findings commonly associated with infection.5 When imaging findings typical for COVID‐19 are seen in a patient who is not suspected of having infection, the pathway prompts the radiologist to discuss the findings with the referring emergency physician. Patient isolation and COVID‐19 testing may be required. This is intended as a safety net for patients who may not be identified by current clinical screening processes, acknowledging that patients with COVID‐19 may be asymptomatic, may present with atypical symptoms and do not necessarily have knowledge of close contact with an infected individual. Ultrasound There is some evidence that point‐of‐care ultrasound can be used in the imaging of patients with COVID‐19; however, given variability in specialist expertise and availability, this has not been incorporated in this pathway.1 Conclusion Chest imaging in suspected or confirmed COVID‐19 in a low prevalence environment is best used to detect complications and rule out alternative diagnoses. The pathway described here aims to clarify imaging indications, technique and reporting of studies performed on patients with suspected or confirmed COVID‐19 in an acute care setting. Box – COVID‐19 emergency imaging guidelines AP = anteroposterior; ANZSTR = Australian and New Zealand Society of Thoracic Radiology; COVID‐19 and COVID = coronavirus disease 2019; CT = computed tomography; CTPA = computed tomography pulmonary angiogram; CXR = chest x‐ray; ED = emergency department.

David Ngan · Suzanne McKeen · Meegan Gun · Daniel Haustead · Andrew Low · Brett Lorraine · James Bewes

A 58-year-old man presented with shortness of breath on exertion and cough.

Mike M Nguyen · Melissa M Moore

To the Editor: Pandemic responses across the world have been highly reactive. However, there remain only three strategic options to managing coronavirus disease 2019 (COVID‐19): mitigation, suppression and elimination (Box).2 With the promise of efficacious new vaccines, mitigation is appropriately not considered as part of Australia’s national strategy. However, our stated goal of achieving “no community transmission” remains poorly defined and risks missing important distinctions between elimination and suppression.3 Effective elimination is dependent both on getting to zero local cases and then staying there, with any new transmission chains immediately halted. All jurisdictions of Australia have now achieved elimination over significant periods, even without articulating this as their strategy. By comparison to suppression, greater relaxation of restrictions may well be allowable under an elimination approach if vigilance is maintained, as New Zealand has demonstrated.4 Although the challenges of ensuring quarantine of returning travellers are well recognised, this is an essential aspect of maintaining elimination and increases in importance as distancing restrictions are eased. Australia’s current strategy appears to imply suppression, with some virus circulating but with case numbers at manageable levels. Whether suppression has been achieved can be monitored by maintaining an effective reproduction number of no greater than one, or equivalently by ensuring the epidemic curve of new community cases is not upsloping. Importantly, the reproduction number and the rate of new cases at any point in time are unrelated — we could have effective suppression and a reproduction number of one with daily case rates of five, ten or 50. Our definition of no community transmission appears to imply complete identification of transmission chains with no “mystery cases”, regardless of the number of new cases. These considerations are important in determining whether we have full visibility of the epidemic and effective contact tracing but do not determine the reproduction number. The rapid spread of the virus necessitates a public health strategy that is clear, robust and agile. Improved control combined with the increasingly clear seasonality of the virus5 suggest that control can be maintained throughout the summer. However, if vaccination has not been widely distributed before winter 2021 and we do not make clear choices, further major outbreaks remain likely. Box – Characteristics of coronavirus disease 2019 (COVID‐19) epidemic response strategies (Trauer et al) Elimination Suppression Mitigation Our definition No cases or transmission, except in quarantined arrivals Very low community case rates; limited transmission Higher case rates, but within health service capacity Key metric of success No locally acquired cases Effective reproduction number not exceeding one,* or a horizontal sloping epidemic curve of locally acquired cases Hospital and ICU occupancy within (expanded) capacity Accrual of significant population‐level immunity No No1 Yes, likely to take many months, with considerable morbidity and mortality Need for mobility restrictions and hygiene measures Mobility may return to near normal while cases and transmission remain at zero; vigilance essential; likely need for episodic restrictions if quarantine escape occurs Continuous need for high levels of restrictions; strong possibility of disruptive lockdowns given that community transmission persists Unpredictable Need for restrictions on international arrivals Extremely high, and increases as distancing restrictions are eased Moderate Less important Current appropriateness for Australian jurisdictions† Reasonable Reasonable Not under consideration ICU = intensive care unit. * The effective reproduction number becomes more difficult to quantify precisely as numbers fall. † Given an effective vaccine appears likely.

James M Trauer · Ben J Marais · Romain Ragonnet · Julian Savulescu · Emma S McBryde

The prognosis may not be as poor as overseas, but the intensive care resource burden may be greater

Aidan JC Burrell · Breanna Pellegrini · Farhad Salimi · Husna Begum · Tessa Broadley · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Arul Earnest · Simon J Erickson · Craig J French · John M Kaldor · Edward Litton · Srinivas Murthy · Richard E McAllister · Alistair D Nichol · Annamaria Palermo · Mark P Plummer · Mahesh Ramanan · Benjamin AJ Reddi · Claire Reynolds · Tony Trapani · Steve A Webb · Andrew A Udy

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

Katherine E Triplett · Luke W Collett

In reply

David J Brewster · Christopher J Groombridge · Jonathan J Gatward

The pleural space is one of the most slippery mysteries of the body

John Massie

The MJA–Lancet Countdown on health and climate change was established in 2017, and produced its first Australian national assessment in 2018 and its first annual update in 2019. It examines indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In the wake of the unprecedented and catastrophic 2019–20 Australian bushfire season, in this special report we present the 2020 update, with a focus on the relationship between health, climate change and bushfires, highlighting indicators that explore these linkages. In an environment of continuing increases in summer maximum temperatures and heatwave intensity, substantial increases in both fire risk and population exposure to bushfires are having an impact on Australia’s health and economy. As a result of the “Black Summer” bushfires, the monthly airborne particulate matter less than 2.5 μm in diameter (PM2.5) concentrations in New South Wales and the Australian Capital Territory in December 2019 were the highest of any month in any state or territory over the period 2000–2019 at 26.0 μg/m3 and 71.6 μg/m3 respectively, and insured economic losses were $2.2 billion. We also found growing awareness of and engagement with the links between health and climate change, with a 50% increase in scientific publications and a doubling of newspaper articles on the topic in Australia in 2019 compared with 2018. However, despite clear and present need, Australia still lacks a nationwide adaptation plan for health. As Australia recovers from the compounded effects of the bushfires and the coronavirus disease 2019 (COVID‐19) pandemic, the health profession has a pivotal role to play. It is uniquely suited to integrate the response to these short term threats with the longer term public health implications of climate change, and to argue for the economic recovery from COVID‐19 to align with and strengthen Australia’s commitments under the Paris Agreement.

Ying Zhang · Paul J Beggs · Alice McGushin · Hilary Bambrick · Stefan Trueck · Ivan C Hanigan · Geoffrey G Morgan · Helen L Berry · Martina K Linnenluecke · Fay H Johnston · Anthony G Capon · Nick Watts

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

Kaitlyn Lam · Sarah McClelland · Michael J Dallo

An 83-year-old male non- smoker presented with chronic purulent cough

Adrián López Alba · Agustín Blanco Echevarría

To the Editor: Infectious diseases physicians and microbiologists are pivotal in guiding the response to the coronavirus disease 2019 (COVID‐19) pandemic. Their involvement ranges from managing cases and coordinating local responses to establishing timely and accurate diagnostic testing.1,2 We conducted a survey of infectious diseases physicians and microbiologists in Australia and New Zealand in early March 2020 to assess the impact on workload and the perspectives of infectious diseases physicians in the pre‐pandemic period. Responses were received from 214/600 infectious diseases physicians (35.6%) and 55/310 practising microbiologists (17.7%). During February 2020, infectious diseases physicians spent a median of 27 hours (interquartile range [IQR], 17–50 h) on COVID‐19‐related activities. Microbiologists worked a median of 8 hours (IQR, 2.5–8 h) overtime per week, and nearly one‐third of infectious diseases physicians (70/214) worked late hours at least 3 days a week on COVID‐19‐related activities. While many doctors have been less busy than usual lately,3 infectious diseases physicians and microbiologists have been busier than ever. At the time of the survey, only 45% (95/212) of infectious diseases physicians agreed that the government's response was well coordinated. Similarly, only 25% (11/42) of microbiologists felt that advice from laboratory regulatory bodies was of assistance. This feedback highlights the confusion and lack of clarity that many clinicians experienced at the beginning of the pandemic. To improve coordination and response, we advocate for the establishment of a national Centre for Disease Prevention and Control.4 This Centre would need to be supported politically and financially by the federal government and all jurisdictions to be effective. Reflecting the current lack of clear data about therapeutic options for patients with COVID‐19, over three‐quarters (169, 79%) of infectious diseases physicians felt they had equipoise for a clinical trial of specific antiretroviral. We advocate for investigational agents for COVID‐19 to only be used in the context of a clinical trial.5 At this time of great challenge to the Australian and New Zealand health care systems, infectious diseases physicians and microbiologists stand with all health care professionals and members of the community. The unedited version of this article was published as a preprint on mja.com.au on 20 August 2020.

On behalf of the Australasian Society for Infectious Diseases Clinical Research Network

Fit testing of respirators is recommended to ensure proper fit for individual health care workers and is required to comply with respirator standards

Adrian Regli · Britta S Ungern‐Sternberg

High cumulative doses are often unnecessary and can have major adverse effects

Christine F McDonald · Christopher J Worsnop

Modelling suggests that elimination could have been achieved if Victoria had gone into stage 4 lockdown immediately from 9 July Victoria is the unlucky state in a lucky country. Australian states and territories, other than New South Wales, have achieved elimination of community transmission of the sudden acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2): 28 days of no locally acquired cases where the source is unknown; twice the maximum incubation period. The situation in NSW is mixed. On one hand, NSW had ongoing case notifications of 10–20 per day in the month to mid‐August 2020, arising largely from imported cases from Victoria. On the other hand, on 16 July there had only been three locally acquired cases of SARS‐CoV‐2 infection with no known source in the preceding 28 days, suggesting NSW was on the cusp of elimination.1 If NSW successfully contains the current outbreak, it may resume its prior trajectory towards the elimination of local transmission, leaving Victoria isolated as the only state with community transmission. As of late August, Queensland is also experiencing community transmission — possibly ending its elimination status (28 days of no locally acquired cases where the source is unknown), subject to investigation of the new cases. It seems unlikely that states and territories that have eliminated local transmission will relinquish their status by freely opening borders and engaging with Victoria (and NSW if community transmission remains). Indeed, on 17 August the Queensland Premier stated: “Let me make it very clear, we will always put Queenslanders first and … we do not have any intentions of opening any borders while there is community transmission active in Victoria and in New South Wales”.2 Australia proceeding with two separate systems (six or seven states and territories having eliminated the virus, one or two not) is a significant concern. There are three general strategic policy responses to the challenge of coronavirus disease 2019 (COVID‐19): elimination, suppression, and mitigation (or herd immunity). No response is free of economic, social and health harms; rather, it is about minimising harm. Society has largely rejected a mitigation response because of concerns about the likely high morbidity and mortality arising from such a response. On 24 July, the Australian Health Protection Principal Committee recommended “that the goal for Australia is to have no community transmission of COVID‐19”,3 and on the same day Prime Minister Scott Morrison accepted and affirmed this recommendation, stating “The goal of that is obviously, and has always been no community transmission”.4 Unfortunately, this first clear statement that Australia's goal is to eliminate community transmission was late in coming, as the Victorian outbreak was already in full swing, with case numbers peaking at a 5‐day average of about 500 per day from 29 July to 5 August, resulting in a stage 4 lockdown in metropolitan Melbourne from 6 pm on 2 August. Elimination strategy We know from New Zealand (population, 5.0 million)5 and Taiwan (23.8 million)6 that elimination of community transmission is achievable in island jurisdictions, with NZ having no community transmission for 102 days until 11 August. The advantage of elimination is that despite international border closures or strict quarantine, citizens can go about life with a near‐normal functioning of their society and economy. Elimination presents challenges. First, there is the extra effort to achieve it, and the fact that aiming to achieve elimination does not guarantee success. Second, having achieved elimination, there is the constant risk of the virus re‐entering due to quarantine breaches (eg, the current outbreak in NZ). How frequently a COVID‐19‐free jurisdiction with tight border controls will retain elimination status is unclear, although we know that NZ lasted 102 days with no community transmission and that Western Australia, Northern Territory, South Australia, Australian Capital Territory, Queensland and Tasmania achieved over 100 days without a locally acquired case with no known source (although the status of Queensland is unclear as of early September). Was elimination achievable with a 6‐week stage 3 lockdown as implemented in Victoria from 9 July, or a more stringent lockdown? Lockdowns are effective for COVID‐19 pandemic control.7,8 Our case for an explicit elimination strategy in Victoria at lockdown commencement in early July was that given Victoria was going into a lockdown for 6 weeks, there was probably only a marginal extra cost of “going hard” with a rigorous public health response that increased the probability of achieving elimination. But was elimination achievable within 6 weeks? We examined four policy scenarios using an agent‐based model, a type of microsimulation of individuals. The model accurately reflects the prior experience of both NZ and Australia ( https://github.com/JTHooker/COVIDModel), and here we adapted it to Victoria (including the case counts up to 14 July; see Supporting Information for details). The four policy approaches, all simulated from 9 July 2020, were: Standard: reflecting the first Australian stage 3 lockdown (calibrated to case numbers as described at https://github.com/JTHooker/COVIDModel), with key parameters including 85% of people observing physical distancing; those observing physical distancing doing so 85% of the time; 30% of adult workers being essential workers; 93% of people asked to isolate doing so; 20% uptake of the COVIDSafe app; but no closure of schools and no mask wearing. Standard with masks at 50%: Standard, plus 50% of people wearing masks in crowded indoor environments. Stringent with masks at 50%: Standard with masks at 50%, plus schools closed and essential workers restricted to 20% of workers. Stringent with masks at 90%: Stringent, with mask use increased to 90% (ie, close to stage 4, which was implemented in Melbourne from 6 pm on 2 August after the 5‐day moving average case numbers increased from 300 to 500 in the first 3 weeks of stage 3). Box 1 shows the percentage likelihood of elimination in Victoria, defined as the date of clearance of infection by the last case, and the date of last acquisition of infection. The model is omniscient about infectious status; in the real world, based on a definition of 28 days of no cases, elimination would occur about 2 weeks after the clearance dates shown in Box 1, A. Under the “standard” policy approach (ie, equivalent to stage 3 without masks), there was no chance that all infected people would have cleared their SARS‐CoV‐2 infection by 19 August (6 weeks after lockdown commenced; Box 1, A). The probabilities for the other three policy approaches achieving elimination 6 weeks after implementation (Box 1, A) were 0% for “standard with masks at 50%”; about 4% for “stringent with masks at 50%”; and 30% for “stringent with masks at 90%”. The probabilities of the last actual infection occurring by 19 August were more encouraging at 0%, 1%, 45% and 90%, respectively (Box 1, B). Of particular note, given that the stage 3 lockdown imposed on 9 July failed because caseloads increased to an average of 500 per day, in our simulations 48% of the 1000 iterations of the “standard” scenario (stage 3, no masks) and 22% of the 1000 iterations for “standard with masks at 50%” had peaks in the first 3 weeks in excess of 400 per day. This is consistent with what eventuated, and further speaks (in hindsight) to the desirability of entering a stage 4 lockdown on 9 July; the “stringent with masks at 90%” scenario had no instances of peak cases greater than 400 per day in the first 3 weeks. Undertaking simulation modelling of SARS‐CoV‐2 policy options is challenging and the uncertainties are still considerable even when using the best estimates available. Nevertheless, our results lend weight to the proposition that elimination was achievable if Victoria had gone into stage 4 lockdown with mandatory wearing of masks immediately from 9 July. A ten‐point plan to maximise the chance of elimination in Victoria Box 2 lists enhancements to the stay‐at‐home orders of the 9 July lockdown. The first and critical point was leadership. As above, we did get a clear statement of an elimination goal from the Chief Health Officers (who comprise the Australian Health Protection Principal Committee membership) and Prime Minister Scott Morrison on 24 July, but with the benefit of hindsight it was perhaps too late. Target‐setting is still not occurring (eg, a target number of cases per day could be set for when we step out of stage 4 under both elimination and suppression strategy options). Moreover, an expert advisory group on elimination was not convened, limiting the capacity for an optimal evidence‐informed policy response. Nevertheless, since the 9 July lockdown, progress with other aspects of the ten‐point plan has been made with the closure of schools, mandatory mask wearing, and commitments to improve contact tracing capacity. Conclusion We argued in the preprint version of this article on 17 July that Melbourne and Victoria should not waste the opportunity that the (then) 6‐week lockdown presented and go hard and early. By learning from the lessons on social and preventive measures to lower SARS‐CoV‐2 transmissibility,7,8,12,14 and specifically the lessons from NZ,3 Taiwan and the six Australian jurisdictions that have achieved elimination, Victoria could have increased its chances of also eliminating community transmission. Our work and that of others who have independently considered the alternatives consistently demonstrates that elimination was possible, and if achieved would have been optimal for health and for the economy in the long term.15,16,17 In this article, we modelled the situation as at mid‐July — we are now updating modelling under the current situation. Authors’ note: This Perspective was submitted to the MJA on 16 July 2020 and published as a preprint on 17 July.9 The revised version, submitted on 23 August, retains the simulation modelling of the original but the uncertainty of inputs was updated to include uncertainty other than stochastic uncertainty. Our aim was rapid modelling to estimate the probability of virus elimination during the planned 6‐week stage 3 lockdown that Victoria had just commenced. The revised version was also published as a preprint on mja.com.au on 4 September, following full peer review and prior to typesetting, pagination and proofreading. Box 1 – Percentage likelihood of elimination of community transmission of SARS‐CoV‐2 infection in Victoria, by date of clearance of last active infection (A) and date of acquisition of last infection (B)* * Across 1000 Monte Carlo simulations in an agent‐based SEIR (susceptible, exposed, infectious, recovered) model. The vertical dashed line is the date 6 weeks after implementation of the lockdown policies. Compared with modelling published in the preprint version of this article,9 the only change here is the inclusion of additional parameter uncertainty in addition to stochastic uncertainty (see Supporting Information), resulting in increased sloping in the curves due to a wider range of potential parameter values (ie, the time distribution to elimination is wider). Box 2 – A ten‐point plan to maximise the chance of successful elimination of community transmission of SARS‐CoV‐2 in Victoria, based on the planned 6‐week lockdown from 9 July 2020 (as published on 17 July 2020)9 Strong and decisive leadership with strategic clarity. An explicit goal of elimination should be articulated, learning from the New Zealand experience (Prime Minister Jacinda Ardern, government ministers and senior officials).10 A clear set of targets for loosening of policies needs to be articulated, so citizens know what is likely to happen and when. Convene an advisory group of experts in the elimination strategy and SARS‐CoV‐2 public health response, reporting weekly to the Victorian Chief Health Officer, with the agenda, papers and minutes made publicly available. Close all schools. Although children do not usually suffer severe illness from SARS‐CoV‐2 infection, the virus still transmits between children and staff in schools.11 Accordingly, schools need to close until such time as the daily rate of SARS‐CoV‐2 infection without a known source falls beneath a target set by the Chief Health Officer. Tighten the definition of essential shops to remain open. Supermarkets and chemists need to remain open. However, department stores and hardware stores should be closed. A staged re‐opening based on set target levels of daily numbers of SARS‐CoV‐2 infection without a known source should then be implemented, so long as mask wearing by both staff and patrons is mandatory, along with hand sanitiser use on entry and exit from stores. Require mask wearing by Melbourne residents in indoor environments where 1.5 m physical distancing cannot be ensured, such as supermarkets and (especially) public transport. While no panacea, the wearing of masks reduces the chance of infected people spreading the virus.12 Tighten the definition of essential workers and work. There is currently a loose definition of who is an essential worker and what is essential work. This needs urgent tightening; for example, as per the NZ definitions used in their level 4 lockdown.13 Require mask wearing by essential workers whenever they are in close contact with people other than those in their immediate household. Ensure financial and other supports to businesses, community and other groups most affected by more stringent stay‐at-home and lockdown requirements, and provide enhancements, targeted where warranted, to programs such as JobKeeper and JobSeeker. Further strengthen contact tracing to ensure the majority of notifications (and their close contacts) are interviewed within 24 hours of the index case notification and placed in isolation if necessary. The use of smart phone and digital adjuncts needs to be improved, be that for initial contact tracing (eg, the COVIDSafe app, or a South Korean‐style use of telecommunications data) or monitoring of adequacy of isolation (eg, text message follow‐up, GPS monitoring, or electronic bracelets). Extend suspension of international arrivals into Victorian quarantine and divert resources. To allow a stronger focus on elimination within Victoria, extend the suspension of international arrivals to Victoria. Quarantine capacity can be redeployed for isolation of Melbourne residents infected with SARS‐CoV‐2 (and potentially high risk close contacts) if they do not have satisfactory home environments for self‐isolation.

Tony Blakely · Jason Thompson · Natalie Carvalho · Laxman Bablani · Nick Wilson · Mark Stevenson

Air pollution poses global health, equity, and environmental problems with short and long term consequences

Julie M Marchant · Anne B Chang