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    The expanding geographic range of dengue in Australia

    Annelies Wilder‐Smith
    Med J Aust 2021; 215 (4): . || doi: 10.5694/mja2.51185
    Published online: 16 August 2021

    If suitable mosquito vectors are present in a region, returning infected travellers can initiate local transmission

    Dengue outbreaks outside their usual geographic distribution — the subtropics and tropics of Asia, Africa, and Latin America — always attract media attention. The first major autochthonous dengue outbreaks in Europe were in Madeira (Portugal) in 2012;1 smaller clusters have been reported in France, Croatia,2 and Italy.3 Despite suitable mosquito vectors, the seasonal window for the establishment of dengue in Europe is short and the risk of its propagation, even in southern Europe, is low.4 It could, however, increase with global warming;5 for example, importation of dengue into more temperate climate zones in China has resulted in local outbreaks in cities such as Shanghai.6

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      The future of rehabilitation for older Australians

      Ian D Cameron, Maria Crotty and Susan E Kurrle
      Med J Aust 2021; 215 (4): . || doi: 10.5694/mja2.51184
      Published online: 16 August 2021

      We urgently need a national strategy to reduce overreliance on hospital services for functional recovery treatments

      In this issue of the Journal, Soh and colleagues report their study of the outcomes of inpatient rehabilitation for older people.1 Their findings can be interpreted in a variety of ways. Most participants (396 of 618, 60%) recovered pre‐admission levels of functional performance (as measured with the Activities of Daily Living [ADL] scale), but cognitive impairment (64% of participants) and frailty (the median Clinical Frailty Score at admission was 6 = “moderately frail”) were confirmed as negative prognostic factors. Within three months of discharge from inpatient rehabilitation, 160 of the 618 had been newly institutionalised (26%) and 75 of the 693 initially included patients had died (11%). Recovery of ADL function was, as expected, more frequent than recovery of the more complex functioning assessed by the Instrumental Activities of Daily Living scale (35%). But 110 of the 192 people living at home prior to admission who made no functional gains on the ADL during rehabilitation (57%) were still at home at the three‐month follow‐up and had probably received some benefit from the coordinated rehabilitation program. While the investigation by Soh and colleagues was a single centre study, their findings are broadly similar to those of an older Australian multicentre study.2


      • 1 John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, NSW
      • 2 Flinders University, Adelaide, SA
      • 3 Hornsby Ku‐ring-gai Hospital, Sydney, NSW


      Correspondence: ian.cameron@sydney.edu.au
      Competing interests:

      Susan Kurrle is the Clinical Director, Rehabilitation and Aged Care Network, in the Northern Sydney Local Health District (NSLHD). Ian Cameron is employed by the NSLHD. Maria Crotty is the Unit Head of Rehabilitation in the Southern Adelaide Local Health Network (SAHLN). The opinions expressed in this editorial do not reflect the policy of NSLHD or SAHLN.

      • 1. Soh CH, Reijnierse EM, Tuttle C, et al. Trajectories of functional performance recovery after inpatient geriatric rehabilitation: an observational study. Med J Aust 2021; 215: 173–179.
      • 2. Cameron ID, Schaafsma FG, Wilson S, et al. Outcomes of rehabilitation in older people–functioning and cognition are the most important predictors: an inception cohort study. J Rehabil Med 2012; 44: 24–30.
      • 3. Mitchell R, Harvey L, Brodaty H, et al. Hip fracture and the influence of dementia on health outcomes and access to hospital‐based rehabilitation for older individuals. Disabil Rehabil 2016; 38: 2286–2295.
      • 4. Killington M, Davies O, Crotty M, et al. People living in nursing care facilities who are ambulant and fracture their hips: description of usual care and an alternative rehabilitation pathway. BMC Geriatr 2020; 20: 128.
      • 5. Cameron ID, Kurrle SE. Frailty and rehabilitation. Interdiscip Top Gerontol Geriatr 2015; 41: 137–150.
      • 6. World Health Organization. Rehabilitation 2030: a call for action. https://www.who.int/initiatives/rehabilitation-2030 (viewed June 2021).
      • 7. Cameron ID, Fairhall N, Langron C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med 2013; 11: 65.
      • 8. Dyer SM, Standfield LB, Fairhall N, et al. Supporting community‐dwelling older people with cognitive impairment to stay at home: a modelled cost analysis. Australas J Ageing 2020; 39: e506–e514.
      • 9. Australian Institute of Health and Welfare. Trends in hospitalised injury due to falls in older people 2007–08 to 2016–17 (AIHW cat. no. INJCAT 206). Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/injury/trends-in-hospitalised-injury-due-to-falls (viewed June 2021).
      • 10. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2018; 7: CD012221.
      • 11. NSW Health. NSW rehabilitation model of care. Jan 2015. https://aci.health.nsw.gov.au/resources/rehabilitation/rehabilitation-model-of-care/rehabilitation-moc (viewed June 2021).
      • 12. Australian Department of Health. Transition care programme. Updated July 2021. https://www.health.gov.au/initiatives-and-programs/transition-care-programme (viewed July 2021).
      • 13. Australian Department of Health. Short Term Restorative Care (STRC) Programme. Updated July 2021. https://www.health.gov.au/initiatives-and-programs/short-term-restorative-care-strc-programme (viewed July 2021).
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        Effectiveness of COVID‐19 vaccines: findings from real world studies

        David A Henry, Mark A Jones, Paulina Stehlik and Paul P Glasziou
        Med J Aust 2021; 215 (4): . || doi: 10.5694/mja2.51182
        Published online: 16 August 2021

        Community‐based studies in five countries show consistent strong benefits from early rollouts of COVID‐19 vaccines

        By the beginning of June 2021, almost 11% of the world’s population had received at least one dose of a coronavirus disease 2019 (COVID‐19) vaccine.1 This represents an extraordinary scientific and logistic achievement — in 18 months, researchers, manufacturers and governments collaborated to produce and distribute vaccines that appear effective and acceptably safe in preventing COVID‐19 and its complications.2,3

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        • 1 Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD
        • 2 Gold Coast University Hospital and Health Service, Gold Coast, QLD
        • 3 University of Queensland, Brisbane, QLD


        Correspondence: dhenry@bond.edu.au
        Competing interests:

        No relevant disclosures.

        • 1. Our World in Data. Coronavirus (COVID-19) vaccinations. https://ourworldindata.org/covid-vaccinations (viewed May 2021).
        • 2. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med 2020; 383: 2603–2615.
        • 3. Voysey M, Clemens SA, Madhi SA, et al. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four randomised trials. Lancet 2021; 397: 881–891.
        • 4. Bell KJL, Glasziou P, Stanaway F, et al. Equity and evidence during vaccine rollout: stepped wedge cluster randomised trials could help. BMJ 2021; 372: n435.
        • 5. Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N Engl J Med 2021; 384: 1412–1423.
        • 6. Vasileiou E, Simpson CR, Shi T, et al. Interim findings from first-dose mass COVID-19 vaccination roll-out and COVID-19 hospital admissions in Scotland: a national prospective cohort study. Lancet 2021; 397: 1646–1657.
        • 7. Bernal JL, Andrews N, Gower C, et al. Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on covid-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study. BMJ 2021; 373: n1088.
        • 8. Pawlowski C, Lenehan P, Puranik A, et al. FDA-authorized COVID-19 vaccines are effective per real-world evidence synthesized across a multi-state health system [preprint]. medRxiv 2021; 27 Feb. https://www.medrxiv.org/content/10.1101/2021.02.15.21251623v3 (viewed May 2021).
        • 9. Bjork J, Inghammar M, Moghaddassi M, et al. Effectiveness of the BNT162b2 vaccine in preventing COVID-19 in the working age population — first results from a cohort study in Southern Sweden. medRxiv 2021; 21 Apr. https://www.medrxiv.org/content/10.1101/2021.04.20.21254636v1 (viewed May 2021).
        • 10. Hernán MA, Robins JM. Using big data to emulate a target trial when a randomized trial is not available. Am J Epidemiol 2016; 183: 758–764.
        • 11. Menni C, Klaser K, May A, et al. Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. Lancet Infect Dis 2021; 21: 939–949.
        • 12. Hall VJ, Foulkes S, Saei A, et al. Effectiveness of BNT162b2 mRNA vaccine against infection and COVID-19 vaccine coverage in healthcare workers in England, multicentre prospective cohort study (the SIREN Study) [preprint]. Preprints with The Lancet 2021; 22 Feb. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3790399 (viewed May 2021).
        • 13. Amit S, Regev-Yochay G, Afek A, et al. Early rate reductions of SARS-CoV-2 infection and COVID-19 in BNT162b2 vaccine recipients. Lancet 2021; 397: 875–857.
        • 14. Thompson MG, Burgess JL, Naleway AL, et al. Interim estimates of vaccine effectiveness of BNT162b2 and mRNA-1273 COVID-19 vaccines in preventing SARS-CoV-2 infection among health care personnel, first responders, and other essential and frontline workers — eight US locations, December 2020–March 2021. MMWR Morb Mortal Wkly Rep 2021; 70: 495–500.
        • 15. Shah AS, Gribben C, Bishop J, et al. Effect of vaccination on transmission of COVID-19: an observational study in healthcare workers and their households [preprint]. medRxiv 2021; 21 Mar. https://www.medrxiv.org/content/10.1101/2021.03.11.21253275v1 (viewed May 2021).
        • 16. Sheikh A, McMenamin J, Taylor B, Robertson C. SARS-CoV-2 Delta VOC in Scotland: demographics, risk of hospital admission, and vaccine effectiveness. Lancet 2021; 397: 2461–2462.
        • 17. Stowe J, Andrews N, Gower C, et al. Effectiveness of COVID-19 vaccines against hospital admission with the Delta (B.1.617.2) variant [preprint]. London: Public Health England, 2021. https://media.tghn.org/articles/Effectiveness_of_COVID-19_vaccines_against_hospital_admission_with_the_Delta_B._G6gnnqJ.pdf (viewed July 2021).
        • 18. Henry D, Stehlik P, Camacho X, Pearson SA. Access to routinely collected data for population health research: experiences in Canada and Australia. Aust N Z J Public Health 2018; 42: 430–433.
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          The ABCD of the comprehensive geriatric assessment

          Paven Kaur, Jeffrey Rowland and Elizabeth Whiting
          Med J Aust 2021; 215 (5): . || doi: 10.5694/mja2.51203
          Published online: 9 August 2021

          The concept of the “ABCD of CGA” would result in varying assessments depending on the environment and needs of the patient

          The comprehensive geriatric assessment (CGA) is considered the gold standard assessment tool for evaluating and providing care to at‐risk and frail older patients. The key elements of the CGA include a multidimensional approach with a coordinated multidisciplinary assessment to identify medical, psychosocial, environmental and functional concerns. The information gathered is used to inform and formulate a detailed and individualised care plan with identified goals focusing on restoring or maintaining function with clear follow‐up.1,2,3


          • Prince Charles Hospital, Brisbane, QLD


          Competing interests:

          No relevant disclosures.

          • 1. Rubenstein LZ, Rubenstein LV. Chapter 35: multidimensional geriatric assessment. In: Fillit HM, Rockwood K, Woodhouse K, editors. Brocklehurst’s textbook of geriatric medicine and gerontology; 7th ed. Philadelphia: Saunders Elsevier, 2010; pp 211–217.
          • 2. Pilotto A, Panza F. Section 2 — key concepts in care of older adults: comprehensive geriatric assessment: evidence. In: Michel JP, Beattie BL, Martin FC, Walston JD, editors. Oxford textbook of geriatric medicine. Oxford University Press, 2018; pp 117–127.
          • 3. Parker SG, McCue P, Phelps K, et al. What is comprehensive geriatric assessment (CGA)? An umbrella review. Age Ageing 2018; 47: 149–155.
          • 4. St John PD, Hogan DB. The relevance of Marjory Warren’s writings today. Gerontologist 2014; 54: 21–29.
          • 5. Pilotto A, Cella A, Pilotto A, et al. Three decades of comprehensive geriatric assessment: evidence coming from different healthcare settings and specific clinical conditions. J Am Med Dir Assoc 2017; 18: 192.
          • 6. Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: a meta-analysis of randomised controlled trials. BMJ 2011; 343: d6553.
          • 7. Stuck AE, Siu AL, Wieland GD, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032–1036.
          • 8. Baztán JJ, Suárez-García FM, López-Arrieta J, et al. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ 2009; 338: b50.
          • 9. Conroy SP, Ansari K, Williams M, et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the “emergency frailty unit”. Age Ageing 2014; 43: 109–114.
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            The effects on mortality and the associated financial costs of wood heater pollution in a regional Australian city

            Dorothy L Robinson, Joshua A Horsley, Fay H. Johnston and Geoffrey G Morgan
            Med J Aust 2021; 215 (6): . || doi: 10.5694/mja2.51199
            Published online: 9 August 2021

            Abstract

            Objectives: To estimate the annual burden of mortality and the associated health costs attributable to air pollution from wood heaters in Armidale.

            Design: Health impact assessment (excess annual mortality and financial costs) based upon atmospheric PM2.5 measurements.

            Setting: Armidale, a regional Australian city (population, 24 504) with high levels of air pollution in winter caused by domestic wood heaters, 1 May 2018 – 30 April 2019.

            Main outcome measures: Estimated population exposure to PM2.5 from wood heaters; estimated numbers of premature deaths and years of life lost.

            Results: Fourteen premature deaths (95% CI, 12–17 deaths) per year, corresponding to 210 (95% CI, 172–249) years of life lost, are attributable to long term exposure to wood heater PM2.5 pollution in Armidale. The estimated financial cost is $32.8 million (95% CI, $27.0–38.5 million), or $10 930 (95% CI, $9004–12 822) per wood heater per year.

            Conclusions: The substantial mortality and financial cost attributable to wood heating in Armidale indicates that effective policies are needed to reduce wood heater pollution, including public education about the effects of wood smoke on health, subsidies that encourage residents to switch to less polluting home heating (perhaps as part of an economic recovery package), assistance for those affected by wood smoke from other people, and regulations that reduce wood heater use (eg, by not permitting new wood heaters and requiring existing units to be removed when houses are sold).

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            • 1 University of New England, Armidale, NSW
            • 2 Sydney Medical School, University of Sydney, Sydney, NSW
            • 3 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
            • 4 University Centre for Rural Health, Lismore, NSW


            Correspondence: drobin27@une.edu.au
            Acknowledgements: 

            We thank the NSW Office of Environment and Heritage for installing an air pollution monitoring station in Armidale and assisting with the installation of PurpleAir units (for checking and calibration) on the roof of the monitoring station, and the Armidale Regional Council for purchasing and installing further PurpleAir units.

            Competing interests:

            No relevant disclosures.

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              Opioid prescribing in Australia: too much and not enough

              Adrian J Dunlop, Buddhima Lokuge and Nicholas Lintzeris
              Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51180
              Published online: 2 August 2021

              A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

              Opioid prescribing in Australia has increased steadily over the past three decades.1,2 Each time a new opioid formulation becomes available, it is enthusiastically prescribed. Ten opioids are currently approved by the Therapeutic Goods Administration for pain management, and there are more than 126 different formulations.3

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              • 1 Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW
              • 2 University of Newcastle, Newcastle, NSW
              • 3 University of Sydney, Sydney, NSW
              • 4 Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW


              Acknowledgements: 

              Buddhima Lokuge holds a Hunter New England Local Health District/University of Newcastle General Research Fellowship.

              Competing interests:

              Nicholas Lintzeris has served on the advisory boards for GW Pharmaceuticals, Indivior, and Mundipharma, received speaker’s honoraria from Chiesi Pharmaceuticals and Mundipharma, and received research‐related funding from Braeburn Pharmaceuticals/Camurus.

              Adrian Dunlop has served (in an honorary capacity) on the advisory board for Mundipharma; his organisation has received research‐related funding from Braeburn Pharmaceuticals/Camurus (manufacturers of buprenorphine), and he served as an honorary investigator in an Indivior‐funded study of buprenorphine‒naloxone products.

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                Update on voluntary assisted dying in Australia

                Cameron J McLaren and Greg Mewett
                Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51152
                Published online: 2 August 2021

                More research is needed to ensure safe and unimpeded access for eligible applicants and to inform practice

                We now have two years’ experience in providing voluntary assisted dying to terminally ill patients in Victoria. Western Australian legislation will come into force on 1 July 2021; Tasmanian legislation has received Royal assent, and the early stages of implementation are underway. The South Australian Voluntary Assisted Dying Bill has been passed by both Houses and may have been sent for Royal assent by the time this article is published. The Queensland Law Reform Commission report and draft bill1 were tabled in parliament on 18 May 2021; a bill is expected to be tabled in the New South Wales parliament in late 2021. There have been calls for the Commonwealth to repeal the Euthanasia Laws Act 1997 to reinstate Australian territories’ rights to debate voluntary assisted dying legislation.


                • 1 Monash University, Melbourne, VIC
                • 2 Monash Health, Melbourne, VIC
                • 3 Ballarat Health Services, Ballarat, VIC


                Correspondence: cameron.mclaren@monash.edu
                Competing interests:

                No relevant disclosures.

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                  Diabetes care for hospital patients in Australia needs repair

                  Jeffrey D Zajac and Sofianos Andrikopoulos
                  Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51160
                  Published online: 2 August 2021

                  Annual audits of practice, national guidelines, specialist diabetes care teams, and increased patient participation are all needed

                  Diabetes inpatient care is broken and, given the disease burden, it requires urgent attention. The Queensland Impatient Diabetes Survey reported by Donovan and colleagues in this issue of the Journal1 found that care for hospital patients with diabetes is suboptimal. The authors report that rates of medication error and hospital‐acquired diabetic ketoacidosis are high and that peri‐operative planning is inadequate. This is a major problem, as many hospital inpatients have diabetes.


                  • 1 Austin Hospital, Melbourne, VIC
                  • 2 The University of Melbourne, Melbourne, VIC


                  Correspondence: j.zajac@unimelb.edu.au
                  Competing interests:

                  No relevant disclosures.

                  • 1. Donovan P, Eccles‐Smith J, Hinton N, et al. The Queensland Inpatient Diabetes Survey (QuIDS) 2019: the bedside audit of practice. Med J Aust 2021; 215: 119–124.
                  • 2. National Diabetes Services Scheme. Diabetes data snapshots. Updated Mar 2021. https://www.ndss.com.au/about-the-ndss/diabetes-facts-and-figures/diabetes-data-snapshots (viewed June 2021).
                  • 3. Australian Institute of Health and Welfare. Diabetes. Updated June 2020. https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/diabetes/overview (viewed June 2021).
                  • 4. Andrikopoulos S, Johnson G. The Australian response to the COVID‐19 pandemic and diabetes: lessons learned. Diabetes Res Clin Pract 2020; 165: 108246.
                  • 5. Nanayakkara N, Nguyen H, Churilov L, et al. Inpatient HbA1c testing: a prospective observational study. BMJ Open Diabetes Res Care 2015; 3: e000113.
                  • 6. Yong PH, Weinberg L, Torkamani N, et al. The presence of diabetes and higher HbA1c are independently associated with adverse outcomes after surgery. Diabetes Care 2018; 41: 1172–1179.
                  • 7. Kyi M, Wang J, Fourlanos S. Increased hyperglycemia and hospital‐acquired infections following withdrawal of the RAPIDS early intervention model of diabetes care in medical and surgical inpatients. Diabetes Care 2021; 44: e25–e26.
                  • 8. Australian Diabetes Society. Guidelines for routine glucose control in hospital. 2012. https://diabetessociety.com.au/documents/ADSGuidelinesforRoutineGlucoseControlinHospitalFinal2012.pdf (viewed June 2021).
                  • 9. Bach LA, Ekinci EI, Engler D, et al. The high burden of inpatient diabetes mellitus: the Melbourne Public Hospitals Diabetes Inpatient Audit. Med J Aust 2014; 201: 334–338. https://www.mja.com.au/journal/2014/201/6/high-burden-inpatient-diabetes-mellitus-melbourne-public-hospitals-diabetes
                  • 10. American Diabetes Association. Diabetes care in the hospital: Standards of Medical Care in Diabetes, 2019. Diabetes Care 2019; 42 (Suppl 1): S173–S181.
                  • 11. Kyi M, Gorelik A, Reid J, et al. Clinical prediction tool to identify adults with type 2 diabetes at risk for persistent adverse glycemia in hospital. Can J Diabetes 2021; 45: 114–121.e3.
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                    The impact of the COVID‐19 pandemic on routine vaccinations in Victoria

                    Brynley P Hull, Alexandra J Hendry, Aditi Dey, Kerin Bryant, Catherine Radkowski, Stephen Pellissier, Kristine Macartney and Frank H Beard
                    Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51145
                    Published online: 19 July 2021

                    The coronavirus disease 2019 (COVID‐19) pandemic reduced routine vaccination activity in many countries.1,2,3 Strict physical distancing and movement restrictions (stage 3 lockdown measures) were implemented in Australia from 23 March 2020, with many health care providers moving to telehealth‐based models of care. Earlier analyses found the first pandemic wave did not affect childhood vaccination activity at the national or state/territory levels to July 2020.4 But vaccination activity has not been assessed during the more stringent stage 4 lockdowns during the second epidemic wave in Victoria (early August ‒ late October 2020). Further, the effects of the shift to remote learning on the vaccination of adolescents, usually delivered in schools, have not been assessed, nor the impact of the epidemic on vaccinations for older adults. We therefore compared vaccination activity in Victoria in 2019 and 2020 by analysing de‐identified Australian Immunisation Register (AIR) surveillance data (status: 28 February 2021). The Sydney Children’s Hospitals Network Human Research Ethics Committee exempted our analysis of AIR data, approved by the Australian Department of Health, from formal ethics approval.

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                    • 1 National Centre for Immunisation Research and Surveillance (NCIRS), Children’s Hospital Westmead, Sydney, NSW
                    • 2 University of Sydney, Sydney, NSW
                    • 3 Victorian Department of Health and Human Services, Melbourne, VIC


                    Competing interests:

                    No relevant disclosures.

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                      Non‐alcoholic fatty liver disease: raising awareness of a looming public health problem

                      Lucy Gracen and Elizabeth E Powell
                      Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51109
                      Published online: 19 July 2021

                      In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

                      Despite being the most frequent cause of chronic liver disease in Australia, the prevalence and clinical consequences of non‐alcoholic fatty liver disease (NAFLD) remain uncertain.1 Accurate population‐based data on the burden of NAFLD are crucial for guiding public health strategies and directing health care resources to reducing the incidence of NAFLD and associated metabolic conditions.


                      • 1 Centre for Liver Disease Research, Translational Research Institute Australia, Brisbane, QLD
                      • 2 Princess Alexandra Hospital, Brisbane, QLD


                      Correspondence: e.powell@uq.edu.au
                      Acknowledgements: 

                      Lucy Gracen is supported by a PA Research Foundation research award (2021).

                      Competing interests:

                      Elizabeth Powell has received an unrestricted grant from Siemens Healthineers.

                      • 1. Mahady SE, Adams LA. Burden of non‐alcoholic fatty liver disease in Australia. J Gastroenterol Hepatol 2018; 33 (Suppl 1): 1–11.
                      • 2. Roberts SK, Majeed A, Glenister K, et al. High prevalence of non‐alcoholic fatty liver disease in regional Victoria: a prospective population‐based study. Med J Aust 2021; 215: 77–82.
                      • 3. Younossi Z, Anstee QM, Marietti M, et al. Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol 2018; 15: 11–20.
                      • 4. European Association for the Study of the Liver; European Association for the Study of Diabetes; European Association for the Study of Obesity. EASL‐EASD-EASO clinical practice guidelines for the management of non‐alcoholic fatty liver disease. J Hepatol 2016; 64: 1388–1402.
                      • 5. Cuthbertson DJ, Weickert MO, Lythgoe D, et al. External validation of the fatty liver index and lipid accumulation product indices, using 1H‐magnetic resonance spectroscopy, to identify hepatic steatosis in healthy controls and obese, insulin‐resistant individuals. Eur J Endocrinol 2014; 171: 561–569.
                      • 6. Younossi ZM, Koenig AB, Abdelatif D, et al. Global epidemiology of nonalcoholic fatty liver disease: meta‐analytic assessment of prevalence, incidence, and outcomes. Hepatology 2016; 64: 73–84.
                      • 7. Angulo P, Kleiner DE, Dam‐Larsen S, et al. Liver fibrosis, but no other histologic features, is associated with long‐term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology 2015; 149: 389–397.e10.
                      • 8. Anstee QM, Lawitz EJ, Alkhouri N, et al. Noninvasive tests accurately identify advanced fibrosis due to NASH: baseline data from the STELLAR trials. Hepatology 2019; 70: 1521–1530.
                      • 9. Eddowes PJ, Sasso M, Allison M, et al. Accuracy of FibroScan controlled attenuation parameter and liver stiffness measurement in assessing steatosis and fibrosis in patients with nonalcoholic fatty liver disease. Gastroenterology 2019; 156: 1717–1730.
                      • 10. Eslam M, Sarin SK, Wong VWS, et al. The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease. Hepatol Int 2020; 14: 889–919.
                      • 11. McPherson S, Stewart SF, Henderson E, et al. Simple non‐invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non‐alcoholic fatty liver disease. Gut 2010; 59: 1265–1269.
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