Topics

Abstract

Objectives: To examine the epidemiological and clinical characteristics of SARS‐CoV‐2‐positive children in Australia during 2020.

Design, setting: Multicentre retrospective study in 16 hospitals of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network; eleven in Victoria, five in four other Australian states.

Participants: Children aged 0‒17 years who presented to hospital‐based COVID‐19 testing clinics, hospital wards, or emergency departments during 1 February ‒ 30 September 2020 and who were positive for SARS‐CoV‐2.

Main outcome measures: Epidemiological and clinical characteristics of children positive for SARS‐CoV‐2.

Results: A total of 393 SARS‐CoV‐2‐positive children (181 girls, 46%) presented to the participating hospitals (426 presentations, including 131 to emergency departments [31%]), the first on 3 February 2020. Thirty‐three children presented more than once (8%), including two who were transferred to participating tertiary centres (0.5%). The median age of the children was 5.3 years (IQR, 1.9‒12.0 years; range, 10 days to 17.9 years). Hospital admissions followed 51 of 426 presentations (12%; 44 children), including 17 patients who were managed remotely by hospital in the home. Only 16 of the 426 presentations led to hospital medical interventions (4%). Two children (0.5%) were diagnosed with the paediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2 (PIMS‐TS).

Conclusion: The clinical course for most SARS‐CoV‐2‐positive children who presented to Australian hospitals was mild, and did not require medical intervention.

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1 Murdoch Children’s Research Institute, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Western Health, Melbourne, VIC
4 Austin Hospital, Melbourne, VIC
5 Northern Hospital Epping, Melbourne, VIC
6 Monash Health, Melbourne, VIC
7 Monash University, Melbourne, VIC
8 Eastern Health, Melbourne, VIC
9 Box Hill Hospital, Melbourne, VIC
10 The Children’s Hospital at Westmead, Sydney, NSW
11 The University of Sydney, Sydney, NSW
12 John Hunter Hospital, Newcastle, NSW
13 Gold Coast University Hospital, Gold Coast, QLD
14 The University of Queensland Child Health Research Centre, Brisbane, QLD
15 Women’s and Children’s Hospital, Adelaide, SA
16 Perth Children’s Hospital, Perth, WA
17 Curtin University, Perth, WA
18 University Hospital Geelong, Geelong, VIC

Correspondence: Laila.Ibrahim@mcri.edu.au

Acknowledgements:

This study was unfunded, but was supported by a National Health and Medical Research Council (NHMRC) Centre of Research Excellence grant for paediatric emergency medicine (GNT1171228) and the Victorian Government Infrastructure Support Program. The participation of Franz Babl was partly funded by an NHMRC Practitioner Fellowship (GNT1124466) and by the Royal Children’s Hospital Foundation. Laila Ibrahim was supported by a Clinician‐Scientist Fellowship from the Murdoch Children’s Research Institute.

We acknowledge the staff who assisted with data retrieval: Visakan Krishnananthan and Caoimhe Basquille (emergency medicine, Eastern Health); Rebecca Gormley (Sunshine Hospital, Western Health); Gaby Nieva (Women’s and Children’s Hospital, Adelaide); and Rebecca Hughes (Royal Children’s Hospital Melbourne).

Competing interests:

No relevant disclosures.

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Editorials

COVID‐19 in children: time for a new strategy

Mary‐Louise McLaws

Med J Aust 2021; 215 (5): . || doi: 10.5694/mja2.51206
Published online: 16 August 2021

ARTICLE
AUTHORS
REFERENCES

Topics

Infectious diseases

Pediatric medicine

Environment and public health

Health services administration

We need to consider offering vaccination to adolescents and young adults

The generally mild course of coronavirus disease 2019 (COVID‐19) in children, as observed during the early phase of the pandemic, may not continue to be typical as the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) mutates. In this issue of the MJA, Ibrahim and colleagues1 describe the characteristics of children positive for SARS‐CoV‐2 who presented to 16 Australian hospitals during February – September 2020, when the Wuhan strain of the virus was circulating in Australia. Reassuringly, most of the 393 children did not need hospital care, and there were no deaths.1 However, 44 children were admitted to hospital (11%), including two who developed paediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2 (PIMS‐TS), and 17 were managed with hospital in the home care.1

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1 University of New South Wales, Sydney, NSW
2 WHO Health Emergencies Programme, Ad‐hoc COVID‐19 Infection Prevention and Control Guidance Development Group

Correspondence: m.mclaws@unsw.edu.au

Competing interests:

No relevant disclosures.

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Narrative review

Co‐occurring depression and insomnia in Australian primary care: recent scientific evidence

Alexander Sweetman, Leon Lack, Emer Van Ryswyk, Andrew Vakulin, Richard L Reed, Malcolm W Battersby, Nicole Lovato and Robert J Adams

Med J Aust 2021; 215 (5): . || doi: 10.5694/mja2.51200
Published online: 16 August 2021

ARTICLE
AUTHORS
REFERENCES

Topics

Nervous system diseases

Pharmaceutical preparations

Mental disorders

General medicine

Summary

Depression and insomnia commonly co‐occur, resulting in greater morbidity for patients, and difficult diagnostic and treatment decisions for clinicians.
When patients report symptoms of both depression and insomnia, it is common for medical practitioners to conceptualise the insomnia as a secondary symptom of depression. This implies that there is little purpose in treating insomnia directly, and that management of depression will improve both the depression and insomnia symptoms.
In this review, we present an overview of research investigating the comorbidity and treatment approaches for patients presenting with depression and insomnia in primary care.
Evidence shows that clinicians should avoid routinely conceptualising insomnia as a secondary symptom of depression. This is because insomnia symptoms: (i) often occur before mood decline and are independently associated with increased risk of future depression; (ii) commonly remain unchanged following depression treatment; and (iii) predict relapse of depression after treatment for depression only. Furthermore, compared with control, cognitive behaviour therapy for insomnia improves symptoms of both depression and insomnia.
It is critical that primary care clinicians dedicate specific diagnostic and treatment attention to the management of both depression (eg, psychotherapy, antidepressants) and insomnia (eg, cognitive behaviour therapy for insomnia administered by trained therapists or psychologists through a mental health treatment plan referral, by online programs, or by a general practitioner or nurse) when they co‐occur. These treatments may be offered concurrently or sequentially (eg, insomnia treatment followed by depression treatment, or vice versa), depending on presenting symptoms, history, lifestyle factors and other comorbidities.

1 Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA
2 National Centre for Sleep Health Services Research, Flinders University, Adelaide, SA
3 College of Medicine and Public Health, Flinders University, Adelaide, SA

Correspondence: alexander.sweetman@flinders.edu.au

Acknowledgements:

This work was supported by a National Health and Medical Research Council Centres of Research Excellence program of research, aiming to position primary care at the centre of sleep health management in Australia (GNT1134954).

Competing interests:

Leon Lack and Nicole Lovato have received research funding from Re‐Timer Pty Ltd.

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Editorials

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

ARTICLE
AUTHORS
REFERENCES

Topics

Statistics, epidemiology and research design

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

1 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
2 Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany

Correspondence: annelies.wilder-smith@uni-heidelberg.de

Competing interests:

No relevant disclosures.

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6. Ma Y, Li S, Wan Z, et al. Phylogenetic analyses of dengue virus serotypes imported to Shanghai, China. J Travel Med 2020; 27: taaa195.
7. Ritchie SA, Pyke AT, Hall‐Mendelin S, et al. An explosive epidemic of DENV‐3 in Cairns, Australia. PLoS One 2013; 8: e68137.
8. Masyeni S, Yohan B, Somia IKA, et al. Dengue infection in international travellers visiting Bali, Indonesia. J Travel Med 2018; 25: tay061.
9. Walker J, Pyke A, Florian P, et al. Re‐defining the dengue‐receptive area of Queensland after the 2019 dengue outbreak in Rockhampton. Med J Aust 2021; 215: 182.
10. Russell RC, Currie BJ, Lindsay MD, et al. Dengue and climate change in Australia: predictions for the future should incorporate knowledge from the past. Med J Aust 2009; 190: 265–268. https://www.mja.com.au/journal/2009/190/5/dengue-and-climate-change-australia-predictions-future-should-incorporate
11. Queensland Health. Queensland dengue management plan 2015‒2020. Sept 2015. https://www.health.qld.gov.au/__data/assets/pdf_file/0022/444433/dengue-mgt-plan.pdf (viewed July 2021).
12. Trewin BJ, Kay BH, Darbro JM, Hurst TP. Increased container‐breeding mosquito risk owing to drought‐induced changes in water harvesting and storage in Brisbane, Australia. Int Health 2013; 5: 251–258.
13. van den Hurk AF, Nicholson J, Beebe NW, et al. Ten years of the Tiger: Aedes albopictus presence in Australia since its discovery in the Torres Strait in 2005. One Health 2016; 2: 19–24.
14. Montgomery BL, Shivas MA, Hall‐Mendelin S, et al. Rapid Surveillance for Vector Presence (RSVP): development of a novel system for detecting Aedes aegypti and Aedes albopictus. PLoS Negl Trop Dis 2017; 11: e0005505.
15. Utarini A, Indriani C, Ahmad RA, et al; AWED Study Group. Efficacy of Wolbachia‐infected mosquito deployments for the control of dengue. N Engl J Med 2021; 384: 2177–2186.
16. Ritchie SA. Wolbachia and the near cessation of dengue outbreaks in Northern Australia despite continued dengue importations via travellers. J Travel Med 2018; 25: tay084.

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Editorials

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

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Rehabilitation

Gerontology

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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Perspectives

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

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Topics

Environment and public health

Pharmaceutical preparations

Infectious diseases

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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Perspectives

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

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REFERENCES

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Gerontology

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

Correspondence: paven.kaur@health.qld.gov.au

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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Research

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

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REFERENCES

Topics

Environment and public health

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 PM_2.5 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 PM_2.5 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 PM_2.5 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.

1. European Environment Agency. Air quality in Europe: 2020 report (EEA report no. 09/2020). Luxembourg: Publications Office of the European Union, 2020. https://www.eea.europa.eu/publications/air‐quality‐in‐europe‐2020‐report (viewed Apr 2021).
2. The Lancet. Ambient particulate matter pollution: Level 4 risk. In: Global Burden of Disease (GBD) cause and risk summaries (2019 data). Lancet 2020; 396: S228–S230. https://www.thelancet.com/pb‐assets/Lancet/gbd/summaries/risks/ambient‐particulate‐matter‐pollution.pdf (viewed Apr 2021)
3. The Lancet. Ambient ozone pollution: Level 3 risk. In: Global Burden of Disease (GBD) cause and risk summaries (2019 data). Lancet 2020; 396: S232–S233. https://www.thelancet.com/pb‐assets/Lancet/gbd/summaries/risks/ambient‐ozone‐pollution.pdf (viewed Apr 2021).
4. Broome RA, Powell J, Cope ME, Morgan GG. The mortality effect of PM2.5 sources in the Greater Metropolitan Region of Sydney, Australia. Environ Int 2020; 137: 105429.
5. Chang LTC, Scorgie Y, Duc HN, et al. Major source contributions to ambient PM2.5 and exposures within the New South Wales Greater Metropolitan Region. Atmosphere 2019; 10: 138.
6. Department of Planning, NSW Clean Air Strategy 2021–30. Draft for consultation. Mar 2021. https://www.environment.nsw.gov.au/topics/air/clean‐air‐strategy/draft‐nsw‐clean‐air‐strategy‐public‐consultation (viewed Apr 2021).
7. Borchers‐Arriagada N, Palmer AJ, Bowman DMJS, et al. Health impacts of ambient biomass smoke in Tasmania, Australia. Int J Environ Res Public Health 2020; 17: 3264.
8. Borchers Arriagada N, Palmer AJ, Bowman DMJS, et al. Unprecedented smoke‐related health burden associated with the 2019–20 bushfires in eastern Australia. Med J Aust 2020; 213: 282–283. https://www.mja.com.au/journal/2020/213/6/unprecedented‐smoke‐related‐health‐burden‐associated‐2019‐20‐bushfires‐eastern
9. Robinson DL. Accurate, low cost PM2.5 measurements demonstrate the large spatial variation in wood smoke pollution in regional Australia and improve modeling and estimates of health costs. Atmosphere 2020; 11: 856.
10. Office of Environment and Heritage (NSW). NSW annual air quality statement 2018. June 2019. https://www.environment.nsw.gov.au/research‐and‐publications/publications‐search/nsw‐annual‐air‐quality‐statement‐2018 (viewed Apr 2021).
11. Riley ML, Kirkwood J, Jiang N, et al. Air quality monitoring in NSW: from long term trend monitoring to integrated urban services. Air Quality and Climate Change 2020; 54: 44–51.
12. Burnett R, Chen H, Szyszkowicz M, et al. Global estimates of mortality associated with long‐term exposure to outdoor fine particulate matter. Proc Natl Acad Sci U S A 2018; 115: 9592–9597.
13. World Health Organization (Regional Office for Europe). Health risks of air pollution in Europe: HRAPIE project. Recommendations for concentration–response functions for cost–benefit analysis of particulate matter, ozone and nitrogen dioxide. Copenhagen: WHO, 2013. https://www.euro.who.int/__data/assets/pdf_file/0006/238956/Health_risks_air_pollution_HRAPIE_project.pdf (viewed Apr 2021).
14. Office of Best Practice Regulation (Australia). Best practice regulation guidance note. Value of statistical life. Aug 2019. https://www.pmc.gov.au/sites/default/files/publications/value‐of‐statistical‐life‐guidance‐note_0_0.pdf (viewed Apr 2021).
15. AECOM Australia. Economic appraisal of wood smoke control measures. Final report. Prepared for the Office of Environment and Heritage. June 2011. https://www.epa.nsw.gov.au/resources/air/WoodsmokeControlReport.pdf (viewed Apr 2021).
16. Wilton E. Review: particulate emissions from wood burners in New Zealand. Prepared for the National Institute of Water and Atmospheric Research. Dec 2012. https://niwa.co.nz/sites/niwa.co.nz/files/WoodburnerReportFinal.pdf (viewed Apr 2021).
17. Australian Air Quality Group – Woodsmoke. Comparison of real‐life and AS/NZS 4013 lab test results of 35 wood heaters in NZ. July 2021. http://woodsmoke.3sc.net/files/AS-NZS_4013_vs_real_life_in_NZ.pdf (viewed July 2021).
18. Meyer CP, Luhar A, Gillett R, Keywood M. Measurement of real‐world PM10 emission factors and emission profiles from woodheaters by in situ source monitoring and atmospheric verification methods. Final Report of Clean Air Research Project 16 for Australian Commonwealth Department of the Environment Water Heritage and the Arts. May 2008. Archived: https://web.archive.org/web/20130430161853/http://environment.gov.au/atmosphere/airquality/publications/pubs/emission‐factor.pdf (viewed Apr 2021).
19. Phair R. Wood heaters: the cosy killers. VicDoc (AMA Victoria) [online], Sept 2020. https://vicdoc.partica.online/vicdoc/vicdoc‐september‐2020/features/wood‐heaters‐the‐cosy‐killers (viewed Apr 2021).
20. Hope Z. AMA fires up over wood heater buy‐back scheme. The Age (Melbourne), 13 June 2020. https://www.theage.com.au/national/victoria/ama‐fires‐up‐over‐wood‐heater‐buy‐back‐scheme‐20200611‐p5528k.html (viewed Apr 2021).
21. Regulatory Impact Solutions. Variation to the waste management policy (solid fuel heating). Policy impact assessment. Prepared for the Environment Protection Authority, Victoria. Nov 2017. https://www.epa.vic.gov.au/‐/media/epa/files/about-epa/what-we-do/piawastemanagementpolicysolidfuelheating.pdf (viewed Apr 2021).
22. Paton‐Walsh C, Rayner P, Simmons J, et al. A clean air plan for Sydney: an overview of the special issue on air quality in New South Wales. Atmosphere 2019; 10: 774.
23. Asthma Australia. Public would support a “phase‐out” of woodfire heaters [media release]. 18 Mar 2021. https://asthma.org.au/about‐us/media/public‐would‐support‐a‐phase‐out‐of‐woodfire‐heaters (viewed Apr 2021).
24. Johnston FH, Hanigan IC, Henderson SB, Morgan GG. Evaluation of interventions to reduce air pollution from biomass smoke on mortality in Launceston, Australia: retrospective analysis of daily mortality, 1994–2007. Br Med J 2013; 346: e8446.
25. Thurston GD, Kipen H, Annesi‐Maesano I, et al. A joint ERS/ATS policy statement: what constitutes an adverse health effect of air pollution? An analytical framework. Eur Respir J 2017; 49: 1600419.
26. Bourdrel T, Annesi‐Maesano I, Alahmad B, et al. The impact of outdoor air pollution on COVID‐19: a review of evidence from in vitro, animal, and human studies. Eur Resp Rev 2021; 30: 200242.
27. Australian Government. Economic response to the coronavirus: Home Builder. https://treasury.gov.au/sites/default/files/2021‐04/homebuilderfactsheet2704.pdf (viewed Apr 2021).

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The characteristics of SARS‐CoV‐2‐positive children who presented to Australian hospitals during 2020: a PREDICT network study

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COVID‐19 in children: time for a new strategy

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Co‐occurring depression and insomnia in Australian primary care: recent scientific evidence

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The expanding geographic range of dengue in Australia

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The future of rehabilitation for older Australians

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Effectiveness of COVID‐19 vaccines: findings from real world studies

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The ABCD of the comprehensive geriatric assessment

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The effects on mortality and the associated financial costs of wood heater pollution in a regional Australian city

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Opioid prescribing in Australia: too much and not enough

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Update on voluntary assisted dying in Australia

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The characteristics of SARS‐CoV‐2‐positive children who presented to Australian hospitals during 2020: a PREDICT network study

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COVID‐19 in children: time for a new strategy

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Co‐occurring depression and insomnia in Australian primary care: recent scientific evidence

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The expanding geographic range of dengue in Australia

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The future of rehabilitation for older Australians

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Effectiveness of COVID‐19 vaccines: findings from real world studies

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The ABCD of the comprehensive geriatric assessment

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The effects on mortality and the associated financial costs of wood heater pollution in a regional Australian city

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Opioid prescribing in Australia: too much and not enough

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Update on voluntary assisted dying in Australia

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Pagination