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We thank Katie Quail for assistance with indicator 1.2 Indigenous health and climate change. We thank Robert Fawcett, John Nairn (retired), Elizabeth Ebert and Bronwyn Brown (all from the Australian Bureau of Meteorology) for indicators 1.3 Health effects of heatwaves and 2.4 Climate information services for health. We thank Nathan Morris for assistance with the analysis for indicator 1.4 Heat impact on physical and sporting activities. We thank Tord Kjellstrom and Matthias Otto for providing the results for indicator 1.5 Change in labour capacity. The Bushfires indicator was generated with support from NASA Applied Sciences Program (grant no. 80NSSC21K0507) and we thank Yang Liu, Bryan Vu and Liuhua Shi (all from Emory University) for the Australian data used for this indicator (1.7), and Nicolas Borchers Arriagada (Menzies Institute for Medical Research, University of Tasmania) for assistance with analysis. Shouro Dasgupta conducted the sea level rise‐related data analysis for indicator 1.9 Migration, displacement, and environmental change. He is an author on the Lancet Countdown global report, and contributor to the sea level rise indicator. The global version of this indicator was developed in collaboration also with Ilan Kelman and Sonja Ayeb‐Karlsson. We thank Kerry Nice (University of Melbourne) who worked on indicator 2.6 Urban green space. The assistance of Zahra Borghei Ghomi (Macquarie University) in compiling the data for indicators 3.1 Carbon intensity of the energy system, 3.2 Coal phase‐out, 3.3 Zero carbon emission electricity, and 3.4 Clean household energy is acknowledged. We thank Marco Springman from the Lancet Countdown for providing the results for indicator 3.9 Diet and health co‐benefits. We thank Maddie Heenan for searching and data compilation for indicator 5.3 Government engagement in health and climate change in Australia. We thank the NHMRC for providing the data for indicator 5.4 Health and climate change research funding.
No relevant disclosures.
Powerful new automated tools are being developed to identify the women most likely to have an existing or future cancer
The article by Noguchi and colleagues in this issue of the MJA1 is timely and motivated by an important aim: to improve breast screening for both women and its funders. The authors conducted a comprehensive analysis of routinely collected data for all screening mammograms by BreastScreen WA over the ten years from July 2007. Although they studied screening episodes rather than individual women, they found evidence that key performance indicators — screen‐detected and interval cancer rates — differed by age, family history, hormone replacement therapy use, benign breast disease, and breast density. Importantly, the strengths of the relationships between some factors and performance varied by age group.1
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We acknowledge the generous support for our work in this area over many years from the National Breast Cancer Foundation, the Cancer Council Victoria, Cancer Australia, the National Health and Medical Research Council, and the National Institutes of Health (USA).
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Identifying inequity of access and assessing the effectiveness of interventions is difficult without systematic abortion data collection
The past two decades have seen major changes in both abortion law and abortion provision across Australia. Safe legal abortion is now available to all Australian women, and is accessible to many. Decriminalisation in all states and territories and legislated safety zones around abortion services have led to wider discussion of abortion in Australian society and softening of the attached stigma.1
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Self‐collection will facilitate new community‐led, co‐designed delivery models that could greatly increase the acceptability and uptake of screening
In December 2017, the Australian National Cervical Screening Program (NCSP) underwent a major renewal, transitioning from two‐yearly cytology screening for people with a cervix (“women”) aged 18‒20 to 69 years, to five‐yearly primary human papillomavirus (HPV) screening for women aged 25‒74 years. The NCSP renewal was driven by accumulated international evidence for the very high effectiveness of primary HPV screening for predicting current and future risk of pre‐cancerous lesions and invasive cancer.1 It was also prompted by the Australian HPV vaccination program that commenced in 2007, which has resulted in rapid population‐level reductions in the incidence of pre‐cancerous lesions in young women.2
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Karen Canfell receives salary support from the National Health and Medical Research Council (NHMRC; APP1194679). Megan Smith receives salary support from the NHMRC (APP1159491) and the Cancer Institute NSW (ECF181561).
Karen Canfell is co‐principal investigator in an unrelated investigator‐initiated trial of cervical screening in Australia (Compass; ACTRN12613001207707 and NCT02328872), conducted and funded by the VCS Foundation, a Victorian government‐funded health promotion charity. The VCS Foundation has received equipment and a funding contribution from Roche Molecular Systems USA. Neither Karen Canfell nor her institution on her behalf (Cancer Council NSW) receives direct funding from industry for this trial or any other project.
Scaling up the treatment of alcohol problems will lead to considerable health benefit across the nation
Alcohol is Australia’s most widely used drug, consumed by nearly 80% of the adult population.1 We lack recent prevalence data for alcohol use disorder in Australia but previous estimates vary from about 800 0002 to over a million.3 With such large numbers, it is quite a paradox that we are not better equipped to manage those who develop problems related to its use.
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Paul Haber has been funded by the Lambert Initiative for Cannabinoid Therapeutics at the University of Sydney to undertake clinical trials of cannabinoid treatment for alcohol withdrawal syndrome; has served on industry advisory boards for Indivior, AbbVie and Gilead; and has been an investigator on clinical trials supported by Camurus. He has also served on international and Australian advisory boards for Lundbeck in relation to nalmefene (2013–2015 and 2014, respectively).
What Australia can learn from overseas guidelines
Depression is a common sequela of stroke, with about 30% of stroke survivors developing depression.1 The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‐5) recognises post‐stroke depression within the category “Depressive disorder due to another medical condition”.2 Post‐stroke depression significantly hinders patients’ ability to participate in rehabilitation and is associated with poor health outcomes. Despite its high prevalence and negative impact, post‐stroke depression is vastly underdiagnosed.3 One estimate suggested that only 5% of stroke survivors are diagnosed with and treated for depression in routine clinical practice.4 Diagnosis of depression can be challenging in stroke survivors, especially in those who have residual communication and cognitive impairments.
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Katherine Sewell is the recipient of a La Trobe University postgraduate scholarship for undertaking a PhD, which supported her during the writing of this article.
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The health reform imperative is clear; it now requires national courage and leadership to implement it
While Australia has traditionally delivered some of the best health care outcomes in the world,1 there are increasing signs that our strained health care system is pushing the stress performance curve into the red. Benchmarks of hospital activity demonstrate ongoing difficulty;2 Local Hospital Networks scramble to meet demand despite annual federal government funding increases of 6.5%; and the grey literature attests to the unfolding human impact behind the figures.3 Patients deteriorate waiting for specialist assessment,4 and junior doctors find themselves trapped in increasingly overstretched, dysfunctional work environments. The much‐reviewed experience of Yumiko Kadota is not an isolated incident, with similar experiences documented regularly by doctors‐in‐training nationwide.5
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Objective: To compare the concordance and acceptability of saliva testing with standard‐of‐care oropharyngeal and bilateral deep nasal swab testing for severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) in children and in general practice.
Design: Prospective multicentre diagnostic validation study.
Setting: Royal Children’s Hospital, and two general practices (cohealth, West Melbourne; Cirqit Health, Altona North) in Melbourne, July–October 2020.
Participants: 1050 people who provided paired saliva and oropharyngeal‐nasal swabs for SARS‐CoV‐2 testing.
Main outcome measures: Numbers of cases in which SARS‐CoV‐2 was detected in either specimen type by real‐time polymerase chain reaction; concordance of results for paired specimens; positive percent agreement (PPA) for virus detection, by specimen type.
Results: SARS‐CoV‐2 was detected in 54 of 1050 people with assessable specimens (5%), including 19 cases (35%) in which both specimens were positive. The overall PPA was 72% (95% CI, 58–84%) for saliva and 63% (95% CI, 49–76%) for oropharyngeal‐nasal swabs. For the 35 positive specimens from people aged 10 years or more, PPA was 86% (95% CI, 70–95%) for saliva and 63% (95% CI, 45–79%) for oropharyngeal‐nasal swabs. Adding saliva testing to standard‐of‐care oropharyngeal‐nasal swab testing increased overall case detection by 59% (95% CI, 29–95%). Providing saliva was preferred to an oropharyngeal‐nasal swab by most participants (75%), including 141 of 153 children under 10 years of age (92%).
Conclusion: In children over 10 years of age and adults, saliva testing alone may be suitable for SARS‐CoV‐2 detection, while for children under 10, saliva testing may be suitable as an adjunct to oropharyngeal‐nasal swab testing for increasing case detection.
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Our study was supported by a donation from the Isabel and John Gilbertson Charitable Trust. We acknowledge all participants, and the clinical, administrative and laboratory staff who assisted our study at the Royal Children’s Hospital Melbourne, cohealth, Cirqit Health, the Microbiological Diagnostic Unit Public Health Laboratory, Golden Messenger, the Royal Melbourne Hospital, and the University of Melbourne.
No relevant disclosures.
Collaboration and education are critical to understanding and managing this mounting public health problem
Drug‐induced liver injury (DILI) is a major cause of acute liver failure, leading to liver transplantation and death,1 and it is one of the most frequent safety‐related causes of drug marketing withdrawals.2 DILI poses a growing challenge for clinicians, researchers, and regulatory bodies, with a vast array of new medications and herbal and dietary supplements constantly becoming available. Despite decades of experience with drug hepatotoxicity and the relatively recent development of clinical guidelines, registries, and other collaborative resources, much is still to be learned in this important field of medicine.
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We thank the patient and his wife for their insights and help in preparing this article. Their fortitude and commitment throughout his illness were remarkable. We also acknowledge the many other clinicians involved in the patient's care, without whose contributions the outcome might have been quite different.
No relevant disclosures.