Respiratory disease

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

Objective: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone‐equivalent). Design: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. Participants, setting: People aged 12 years or more treated for asthma during 2014–2018, according to dispensing of controller inhaled corticosteroids (ICS). Main outcome measures: Number of people dispensed OCS for managing asthma during 2014–2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone‐equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone‐equivalent during 2018, stratified by inhaler controller dose and use. Results: 124 011 people had been dispensed at least two prescriptions of ICS during 2014–2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone‐equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone‐equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone‐equivalent or more, for 2316 of whom (50%) controller use was inadequate. Conclusions: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one‐quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Mark Hew · Vanessa M McDonald · Phil G Bardin · Li Ping Chung · Claude S Farah · Amanda Barnard · Mark S Cooper · Peter G Gibson · John W Upham

Objective: To evaluate associations between exposure during early life to mine fire smoke and parent‐reported indicators of respiratory and atopic illness 2–4 years later. Design, setting: The Hazelwood coalmine fire exposed a regional Australian community to markedly increased air pollution during February – March 2014. During June 2016 – October 2018 we conducted a prospective cohort study of children from the Latrobe Valley. Participants: Seventy‐nine children exposed to smoke in utero, 81 exposed during early childhood (0–2 years of age), and 129 children conceived after the fire (ie, unexposed). Exposure: Individualised mean daily and peak 24‐hour fire‐attributable fine particulate matter (PM2.5) exposure during the fire period, based on modelled air quality and time‐activity data. Main outcome measures: Parent‐reported symptoms, medications use, and contacts with medical professionals, collected in monthly online diaries for 29 months, 2–4 years after the fire. Results: In the in utero exposure analysis (2678 monthly diaries for 160 children exposed in utero or unexposed), each 10 μg/m3 increase in mean daily PM2.5 exposure was associated with increased reports of runny nose/cough (relative risk [RR], 1.09; 95% CI, 1.02–1.17), wheeze (RR, 1.56; 95% CI, 1.18–2.07), seeking health professional advice (RR, 1.17; 95% CI 1.06–1.29), and doctor diagnoses of upper respiratory tract infections, cold or flu (RR, 1.35; 95% CI, 1.14–1.60). Associations with peak 24‐hour PM2.5 exposure were similar. In the early childhood exposure analysis (3290 diaries for 210 children exposed during early childhood, or unexposed), each 100 μg/m3 increase in peak 24‐hour PM2.5 exposure was associated with increased use of asthma inhalers (RR, 1.26; 95% CI, 1.01–1.58). Conclusions: Exposure to mine fire smoke in utero was associated with increased reports by parents of respiratory infections and wheeze in their children 2–4 years later.

Gabriela A Willis · Kate Chappell · Stephanie Williams · Shannon M Melody · Amanda Wheeler · Marita Dalton · Shyamali C Dharmage · Graeme R Zosky · Fay H Johnston

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

Irani Thevarajan · Kirsty L Buising · Benjamin C Cowie

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

Gemma Carey

Tetrahydrocannabinol‐containing (THC) products with vitamin E additives are implicated in the pathogenesis of EVALI Electronic cigarettes, or e‐cigarettes, are battery‐powered devices that heat liquids containing nicotine and other chemicals in order to produce vapour.1 “Vaping” is the act of inhaling the vapour produced by an e‐cigarette.1 First marketed in 2005, e‐cigarette use is viewed by many as less harmful than traditional cigarette smoking, and championed as a strategy for smoking cessation.1,2,3 A detailed discussion of e‐cigarette use in smoking cessation is available in the United States Surgeon General's 2020 report, and is beyond the scope of this article; however, the report states that “there is presently inadequate evidence to conclude that e‐cigarettes, in general, increase smoking cessation”.2 Thus far, no e‐cigarette product for the therapeutic purpose of smoking cessation has been submitted to Australia's Therapeutic Goods Administration for safety evaluation or approval. Vaping in the US was initially associated with nicotine‐containing solutions. However, it is important to note that nicotine or nicotine salts may no longer be the only active ingredient in vaping solutions.1,4,5 In particular, unregulated vaping solutions or “home‐brew” products that contain tetrahydrocannabinol (THC) oil, or cannabinoids, can be obtained in the US.4,6 Vaping solutions come in a wide range of flavours, many designed to appeal to adolescents.1,2 Indeed, e‐cigarette manufacturers have used celebrity endorsements and social media‐based marketing campaigns to target adolescents, and these strategies appear to have been highly successful.1,2 There has been significant uptake of vaping among tobacco‐naive high school students, particularly in the US, where it is estimated that one in four high school students are current e‐cigarette users;7 moreover, in 2019, 14% of year 12 students reported vaping cannabis in the preceding 30 days.8 Between 2011 and 2018, e‐cigarette use increased among US high school students from 1.5% to 20.8%, even when traditional cigarette use declined from 15.8% to 8.1%.9 Consequently, from 2017 to 2018, overall use of tobacco products (traditional and e‐cigarettes combined) increased from 19.6% to 27.1%.9 In contrast, e‐cigarettes use among adults in the US has remained largely stable at 8.1 million e‐cigarette users (3.2%).10 It is possible that for young non‐smokers, e‐cigarettes may normalise smoking and serve as a gateway to nicotine dependency and traditional cigarette smoking, although this is strongly debated.1,9 In 2016, the Australian National Drug Strategy Household Survey reported that e‐cigarette use within the 12–17 and 18–29 years age brackets was about 7.1% and 16% respectively.11,12,13 The 2017 Australian secondary students’ alcohol and drug survey found that 13% of students had used an e‐cigarette at least once.14 Of the 2410 students who used an e‐cigarette, 48% reported that they had never smoked a traditional tobacco cigarette before using an e‐cigarette.14 E‐cigarettes may be perceived by young people as “a cool new gadget” and “safer than smoking”.1 Unfortunately, it has become abundantly clear that the use of illicitly sourced e‐cigarettes can be dangerous.10 In 2019, disturbing reports emerged of an acute and, for some, deadly outcome from vaping.15 Across the US, e‐cigarette users began to be admitted to hospitals with acute respiratory failure. In August 2019, the first fatality was documented in Illinois, while 200 other cases across 22 states were under investigation by the Centers for Disease Control and Prevention (CDC).15 This epidemic has spread very rapidly. There have been over 2800 hospitalised cases reported from every US state and territory and a total of 68 deaths.16 Patients were predominantly male (66%) and under 35 years of age (76%).6 [Correction added on 2 July 2020 after first online publication: Information has been updated on the second last sentence.] The CDC has termed this new disease “e‐cigarette or vaping product use‐associated lung injury” (EVALI)17 and has proposed four obligatory criteria for its diagnosis: use of an e‐cigarette (“vaping”) in the 90 days before symptom onset;18 pulmonary infiltrates or ground glass opacities on x‐ray or computed tomography scan; absence of pulmonary infection (defined by negative respiratory viral panel, negative influenza polymerase chain reaction, negative urinary pneumococcal antigen and sputum culture including Legionella, and bronchoalveolar lavage [BAL] culture); and no evidence of an alternative plausible diagnosis such as a cardiac disease or a neoplastic process.17,18 Patients with EVALI typically present with both respiratory (dyspnoea, cough, fever) and gastrointestinal (nausea, vomiting, diarrhoea, abdominal pain) symptoms.15,19 Usually, there is no prior history of respiratory disease. Diagnosis may be challenging, as EVALI can mimic infective pneumonia and gastrointestinal symptoms may sometimes precede respiratory symptoms.15 Respiratory failure may be severe enough to require invasive ventilation and intensive care support.15,19 Imaging findings include ground glass opacities on chest imaging,20 suggesting diffuse lung injury with bronchiolitis obliterans and cryptogenic organising pneumonia.19 Pathologically, limited lung biopsies have shown acute lung injury, acute fibrinous pneumonitis and diffuse alveolar damage.21 “Foamy” or lipid‐laden macrophages are often seen, suggestive of lipoid pneumonia.15 Aetiology and pathophysiology of EVALI: reasons for its recent emergence Careful epidemiological investigation has revealed two key findings explaining the recent emergence of EVALI after more than a decade of e‐cigarette use. Firstly, 80% of hospitalised patients with EVALI have admitted to using THC vaping products.6 Eighty‐four per cent of the reported THC products were acquired via informal channels and were probably manufactured outside of regulated facilities.15 The CDC identified “Dank Vapes” — a group of largely counterfeit THC‐containing products — as the most commonly reported THC brand across the US and used by 56% of patients with EVALI admitted to hospital.6 In contrast, only 13% of hospitalised patients with EVALI reported exclusive use of nicotine‐containing products; however, traces of THC were found in BAL samples.6,19 There may be unreliable self‐reporting and it is possible that the nicotine e‐cigarettes may have been contaminated by black‐market THC additives. Most patients reported using combination products containing either THC, cannabidiol or nicotine.6 Secondly, there is mounting evidence that a specific additive to vaping solutions — vitamin E acetate — played a major role in the 2019 EVALI outbreak.19,20 It is hypothesised that vaping the vitamin E acetate oil causes direct lung injury and lipoid pneumonia.21 Supporting this, BAL fluid from 51 patients from 16 states diagnosed with EVALI yielded vitamin E acetate in 94% (48/51) of the BAL samples.19 In an analysis of the THC‐containing e‐cigarette products used by 12 patients, vitamin E acetate was found in products from 11 patients.19 It is likely that this substance was added as a diluent or filler, and this practice appears to be a very recent development.19 The same chemical analysis performed on THC e‐cigarette products seized in 2018 did not find vitamin E acetate.19 Current evidence shows that THC‐containing products with vitamin E acetate additives are implicated in the pathogenesis of EVALI.21 Given the outbreak has only manifested in the past 18 months, it is likely that the addition of these substances into e‐cigarette solutions is a very recent occurrence. The CDC outlines three broad tenets for treating suspected EVALI: cover possible infective agents with empiric broad‐spectrum antibiotics; administer systemic steroids (optimal dose unknown); and provide best supportive care with oxygen therapy and close monitoring.15,17,20 In mild to moderate cases, the decision to start steroids can be delayed until culture results exclude or identify potential infectious pathogens.17 In severe cases, systemic corticosteroids should be given early due to the potential life‐threatening nature of EVALI.20 There have been reports of progressive ventilatory failure despite administration of high dose steroids (methylprednisolone 1 mg/kg), with patients requiring extracorporeal membrane oxygenation.20 So far, there are no confirmed reports of EVALI in Australia. Unlike in the US, nicotine‐containing liquids are illegal in Australia and can only be obtained on medical prescription for personal use.11 The sale of e‐cigarettes to people aged under 18 years is also illegal.11 In practice, however, a 2015 survey of Australian e‐cigarette use found that 90% of users purchased e‐cigarettes and liquids from unregulated online stores.11 Even legal nicotine‐free liquids sold in Australia have been found to contain traces of nicotine and other toxic substances, with no regulation of products.22 Most Australian e‐cigarette users are therefore vulnerable to the possibility of potentially dangerous substances being added to solutions, as has occurred in the US. Conclusion Vaping THC oil contaminated with vitamin E acetate is linked with severe lung injury and death. With more than 2800 cases of EVALI reported and 68 deaths, e‐cigarettes are definitely not risk‐free. Australian clinicians should maintain vigilance and ask every patient about e‐cigarette use. Adults using nicotine‐containing e‐cigarettes as an alternative to cigarette smoking should not revert to tobacco smoking.2 A reasonable and precautionary strategy is to advise patients that little is known about the long term effects of e‐cigarettes, and also to inform users that severe lung disease and death have occurred mainly with unregulated solutions. We recommend further research and ongoing field monitoring of e‐cigarette usage patterns in Australia.

Maitri Munsif · Mark Hew · Eli Dabscheck