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    Frailty in older adults: moving from measurement to management

    Emily H Gordon and Ruth E Hubbard
    Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50778
    Published online: 5 October 2020

    Incorporating routine assessment of frailty into health care would benefit both older people and the health system

    The past two decades have seen a tremendous research effort dedicated to defining, measuring and validating the frailty construct. Large cohort studies of older adults living in the community have consistently found that frail people are at risk of a range of adverse outcomes, including death, disability, and institutionalisation.1 More recently, there has been a move from population‐based cohort studies of frailty to analyses of data collected during routine clinical encounters. In this issue of the MJA, Khadka and colleagues2 contribute to this body of translational research with a large retrospective cohort study of community‐dwelling Australians undergoing Aged Care Assessment Program (ACAP) eligibility assessment.


    • 1 Centre for Health Services Research, University of Queensland, Brisbane, QLD
    • 2 The University of Queensland, Brisbane, QLD


    Correspondence: r.hubbard1@uq.edu.au
    Competing interests:

    No relevant disclosures.

    • 1. Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta‐analysis. Age Ageing 2018; 47: 193–200.
    • 2. Khadka J, Visvanathan R, Theou O, et al. Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Med J Aust 2020; 213: 321–326.
    • 3. Mitnitski A, Mogilner A, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323–336.
    • 4. Rockwood K, Mitnitski A. Limits to deficit accumulation in elderly people. Mech Ageing Dev 2006; 127: 494–496.
    • 5. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45: 353–360.
    • 6. Ludwig C, Busnel C. Derivation of a frailty index from the resident assessment instrument – home care adapted for Switzerland: a study based on retrospective data analysis. BMC Geriatr 2017; 17: 205.
    • 7. Burn R, Hubbard R, Scrase R, et al. A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission. BMC Geriatr 2018; 18: 319.
    • 8. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management (NICE guideline NG56). Sept 2016. https://www.nice.org.uk/guidance/ng56/resources/multimorbidity-clinical-assessment-and-management-pdf-1837516654789 (viewed Aug 2020).
    • 9. NHS England. Supporting routine frailty identification and frailty through the GP Contract 2017/2018. Apr 2017; updated June 2019. https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018 (viewed Aug 2020).
    • 10. Ellis G, Whitehead M, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta‐analysis of randomised controlled trials. BMJ 2011; 343: d6553.
    • 11. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post‐operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16: 157.
    • 12. Poudel A, Peel N, Nissen L, et al. Adverse outcomes in relation to polypharmacy in robust and frail older hospital patients. J Am Med Dir Assoc 2016; 17: 767.e9–767.e13.

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      Red‐flagging the prescribing of oral corticosteroids for people with asthma

      Christine F McDonald and Christopher J Worsnop
      Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50777
      Published online: 5 October 2020

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

      The isolation of compound E, later known as cortisone, from the adrenal gland in 1949 led to its use for treating many medical conditions; the first randomised controlled trial of its benefit for people with asthma was published in 1956.1 However, adverse effects are associated with cumulative corticosteroid doses, both with long term continuous use of low dose preparations and with repeated short courses of high dose preparations. The introduction in 1970 of inhaled corticosteroids (ICS) revolutionised asthma management, providing anti‐inflammatory benefits with a markedly reduced side effect profile. Yet many people with asthma are less adherent to ICS use as preventive treatment than their health care professionals would wish. As many as 80% of patients do not adhere to preventive therapy as prescribed,2 and both practical and perceptual barriers to adherence have been described.3


      • Austin Hospital, Melbournne, VIC


      Competing interests:

      Christine McDonald has received speaker’s fees (paid to her organisation) from Menarini and Astra Zeneca. Christopher Worsnop has received speaker’s fees from HealthEd, GlaxoSmithKline, AstraZeneca, Cipla, Boehringer Ingelheim, Mundipharma, and Menarini.

      • 1. Subcommittee on clinical trials in asthma. Controlled trial of effects of cortisone acetate in status asthmaticus: report to the Medical Research Council. Lancet 1956; 271: 803–806.
      • 2. Bårnes CB, Ulrik CS. Asthma and adherence to inhaled corticosteroids: current status and future perspectives. Respir Care 2015; 60: 455–468.
      • 3. Lindsay JT, Heaney LG. Nonadherence in difficult asthma: facts, myths, and a time to act. Patient Prefer Adherence 2013; 7: 329–336.
      • 4. Hew M, McDonald VM, Bardin PG, et al. Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia. Med J Aust 2020; 213: 316–320.
      • 5. Aaron SD, Vandemheen KL, FitzGerald JM, et al. Re‐evaluation of diagnosis in adults with physician‐diagnosed asthma. JAMA 2017; 317: 269–279.
      • 6. Bateman ED, Boushey HA, Bousquet J, et al. Can guideline‐defined asthma control be achieved? Am J Respir Crit Care Med 2004; 170: 836–844.
      • 7. Eger KAB, Amelink M, Hekking PP, Bel E. Overuse of oral corticosteroids in asthma‐modifiable factors and potential role of biologics. Eur Respir J 2019; 54 (Suppl 63): OA5334.

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        Female genital mutilation or cutting: an updated medico‐legal analysis

        Ben Mathews and Elizabeth Dallaston
        Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50768
        Published online: 5 October 2020

        A recent landmark High Court decision both directs and reassures medical and other practitioners in clinical and community settings that no parent or individual can compel this unlawful procedure

        Many people from countries where female genital mutilation or cutting (FGM/C) is customary have migrated to Australia and other nations. Legislation in many of these nations prohibits any person, including medical practitioners, from conducting FGM/C.1 Important questions exist about the nature of the prohibition, and lawful and ethical practice in dealing with requested FGM/C. Medical practitioners, community practitioners and religious leaders deserve sound guidance about legal responsibilities and optimal clinical practice.


        • 1 Queensland University of Technology, Brisbane, QLD
        • 2 Johns Hopkins University, Baltimore, MD, USA


        Correspondence: b.mathews@qut.edu.au
        Competing interests:

        No relevant disclosures.

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          Impact of antivaccination campaigns on health worldwide: lessons for Australia and the global community

          Helen Petousis‐Harris and Lisbeth Alley
          Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50779
          Published online: 5 October 2020

          The arrival of social media coincides with the point at which the antivaccination movement became globally coordinated

          The antivaccination movement has roots in the first vaccine, smallpox, although opposition to the practice of artificially inducing immunity reaches back to the practice of variolation. Despite over two centuries of vaccination practice and all the advances in medical science and societal changes that have occurred over this time, the objections still follow the same themes. These have been eloquently described as: vaccines cause idiopathic illness, unholy alliance for profit, vaccines as poisonous chemical cocktails, cover‐up, towards totalitarianism, vaccine immunity is temporary, vaccines are ineffective, and health lifestyle alternative.1 For over two centuries, antivaccination activities, distribution of literature, membership and scientific establishment responses remained unchanged.2


          • 1 University of Auckland, Auckland, New Zealand
          • 2 Immunisation Advisory Centre, University of Auckland, Auckland, New Zealand


          Competing interests:

          No relevant disclosures.

          • 1. Leask JA, Chapman S. An attempt to swindle nature: press anti‐immunisation reportage 1993–1997. Aust N Z J Public Health 1998; 22: 17–26.
          • 2. Wolfe RM, Sharp LK. Anti‐vaccinationists past and present. BMJ 2002; 325: 430–432.
          • 3. Ryan J. A history of the internet and the digital future. Reaktion Books 2013.
          • 4. Brügger N. A brief history of Facebook as a media text: the development of an empty structure. First Monday 2015; 20: https://doi.org/10.5210/fm.v20i5.5423.
          • 5. Markowitz LE, Tsu V, Deeks SL, et al. Human papillomavirus vaccine introduction — the first five years. Vaccine 2012; 30 (Suppl): F139–F148.
          • 6. Smith N, Graham T. Mapping the anti‐vaccination movement on Facebook. Inf Commun Soc 2019; 22: 1310–1327.
          • 7. Jamison AM, Broniatowski DA, Dredze M, et al. Vaccine‐related advertising in the Facebook Ad Archive. Vaccine 2020; 38: 512–520.
          • 8. Global Advisory Committee on Vaccine Safety. Global Advisory Committee on Vaccine Safety, 4–5 December 2019. Review of case studies of vaccine safety communications and lessons learnt. Wkly Epidemiol Rec 2020; 4: 25–36.
          • 9. Simms KT, Hanley SJB, Smith MA, et al. Impact of HPV vaccine hesitancy on cervical cancer in Japan: a modelling study. Lancet Public Health 2020; 5: e223–e234.
          • 10. Hansen PR, Schmidtblaicher M, Brewer NT. Resilience of HPV vaccine uptake in Denmark: decline and recovery. Vaccine 2020; 38: 1842–1848.
          • 11. World Health Organization. Ten threats to global health in 2019. Geneva: WHO, 2019. https://www.who.int/vietnam/news/feature-stories/detail/ten-threats-to-global-health-in-2019 (viewed Aug 2020).
          • 12. World Health Organization. Urgent health challenges for the next decade. Geneva: WHO, 2020. https://www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade (viewed Aug 2020).
          • 13. Lane S, MacDonald NE, Marti M, Dumolard L. Vaccine hesitancy around the globe: analysis of three years of WHO/UNICEF Joint Reporting Form data — 2015–2017. Vaccine 2018; 36: 3861–3867.
          • 14. Lo NC, Hotez PJ. Public health and economic consequences of vaccine hesitancy for measles in the United States. JAMA Pediatr 2017; 171: 887–892.
          • 15. Hanley SJ, Yoshioka E, Ito Y, Kishi R. HPV vaccination crisis in Japan. Lancet 2015; 385: 2571.
          • 16. World Health Organization; UNICEF. Samoa: WHO and UNICEF estimates of national immunization coverage: 2019 revision. https://www.who.int/immunization/monitoring_surveillance/data/wsm.pdf (viewed Aug 2020).
          • 17. Guarino Ben, Satija N, Sun LH. Deadly measles outbreak hits children in Samoa after anti‐vaccine fears. Washington Post 2019; 28: . Nov. https://www.washingtonpost.com/health/2019/11/26/deadly-measles-outbreak-hits-children-samoa-after-anti-vaccine-fears/ (viewed Aug 2020).
          • 18. Samoa arrests vaccination critic amid deadly measles crisis. BBC News 2019; 6 Dec. https://www.bbc.com/news/world-asia-50682881 (viewed Aug 2020).
          • 19. Duckor‐Jones A. Tragedy in paradise: how Samoa is faring after the measles epidemic. New Zealand Listener 2020; 5 Feb. https://www.noted.co.nz/currently/currently-world/samoa-measles-how-its-faring-after-the-epidemic (viewed Aug 2020).
          • 20. Greenberg J, Dubé E, Driedger M. Vaccine hesitancy: in search of the risk communication comfort zone. PLoS Curr 2017; 9: ecurrents.outbreaks.0561a011117a1d1f9596e24949e8690b.
          • 21. Corcoran B, Clarke A, Barrett T. Rapid response to HPV vaccination crisis in Ireland. Lancet 20186; 391: 2103.
          • 22. Berry NJ, Danchin M, Trevena L, et al. Sharing knowledge about immunisation (SKAI): an exploration of parents’ communication needs to inform development of a clinical communication support intervention. Vaccine 2018; 36: 6480–6490.
          • 23. Chung Y, Schamel J, Fisher A, Frew PM. Influences on immunization decision‐making among US parents of young children. Matern Child Health J 2017; 21: 2178–2187.
          • 24. Dubé E, Gagnon D, Vivion M. Best practices for addressing vaccine hesitancy. Can Commun Dis Rep 2020; 46: 48–51.
          • 25. Gesualdo F, Zamperini N, Tozzi AE. To talk better about vaccines, we should talk less about vaccines. Vaccine 2018; 36: 5107.
          • 26. Fagerlin A, Wang C, Ubel PA. Reducing the influence of anecdotal reasoning on people's health care decisions: is a picture worth a thousand statistics? Med Decis Making 2005; 25: 398–405.

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            Ethical issues in reproductive genetic carrier screening

            Lisa Dive and Ainsley J Newson
            Med J Aust 2021; 214 (4): . || doi: 10.5694/mja2.50789
            Published online: 28 September 2020

            Publicly funded reproductive carrier screening programs must weigh up a number of ethical considerations

            Reproductive genetic carrier screening (RCS) is undertaken by individuals or couples to determine their likelihood of having a child with particular autosomal recessive or X‐linked genetic conditions. It can be undertaken by anyone of reproductive age who wishes to have it, regardless of their family history or ancestry, and either before or during pregnancy.1 Some forms of RCS are currently available in Australia on a user‐pays basis, costing around $400–$500 per person. It is usually accessed via general practitioners but can also be accessed directly from testing companies.2 People who receive an increased chance result are offered genetic counselling to explore their reproductive options, which might include steps to avoid having a child with a genetic condition. Taking the test before pregnancy gives those with an increased chance result a wider range of reproductive options compared with prenatal testing.3

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            • University of Sydney, Sydney, NSW


            Acknowledgements: 

            The Australian Reproductive Genetic Carrier Screening Project (Mackenzie's Mission) is funded by the Australian Government Medical Research Future Fund as part of the Australian Genomics Health Futures Mission (GHFM73390 [MRFF‐G‐MM]). The funding source had no direct role in the planning, writing or publication of this article. The authors thank Alison Archibald, Edwin Kirk, Nigel Laing and Martin Delatycki, as well as members of the Mackenzie's Mission Research and Gene Selection Committees, for helpful discussions that informed the drafting of this article.

            Competing interests:

            Lisa Dive's position at the University of Sydney is funded by Mackenzie's Mission. Ainsley Newson is a Chief investigator with Mackenzie's Mission.

            • 1. Henneman L, Borry P, Chokoshvili D, et al. Responsible implementation of expanded carrier screening. Eur J Hum Genet 2016; 24: e1–e12.
            • 2. Delatycki MB, Alkuraya F, Archibald A, et al. International perspectives on the implementation of reproductive carrier screening. Prenat Diagn 2020; 40: 301–310.
            • 3. van der Hout S, Dondorp W, de Wert G. The aims of expanded universal carrier screening: autonomy, prevention, and responsible parenthood. Bioethics 2019; 33: 568–576.
            • 4. Mackenzie's Mission. https://www.mackenziesmission.org.au (viewed June 2020).
            • 5. Delatycki MB, Laing N, Kirk E. Expanded reproductive carrier screening — how can we do the most good and cause the least harm? Eur J Hum Genet 2019; 27: 669–670.
            • 6. De Wert GM, Dondorp WJ, Knoppers BM. Preconception care and genetic risk: ethical issues. J Community Genet 2012; 3: 221–228.
            • 7. Kater‐Kuipers A, De Beaufort ID, Galjaard R‐JH, et al. Ethics of routine: a critical analysis of the concept of ‘routinisation’ in prenatal screening. J Med Ethics 2018; 44: 626–631.
            • 8. Asch A. Prenatal diagnosis and selective abortion: a challenge to practice and policy. Am J Public Health 1999; 89: 1649–1657.
            • 9. Savell K, Karpin I. The meaning of “serious disability” in the legal regulation of prenatal and neonatal decision‐making. J Law Med 2008; 16: 233–245.
            • 10. Kirk EP, Ong R, Boggs K, et al. Gene selection for the Australian Reproductive Genetic Carrier Screening Project (“Mackenzie's Mission”). Eur J Hum Genet 2020; https://doi.org/10.1038/s41431-020-0685-x.
            • 11. Rowe CA, Wright CF. Expanded universal carrier screening and its implementation within a publicly funded healthcare service. J Commun Genet 2020; 11: 21–38.
            • 12. Newson AJ. Ethical aspects arising from non‐invasive fetal diagnosis. Semin Fetal Neonatal Med 2008; 13: 103–108.
            • 13. Schuurmans J, Birnie E, van den Heuvel LM, et al. Feasibility of couple‐based expanded carrier screening offered by general practitioners. Eur J Hum Genet 2019; 27: 691–700.
            • 14. Holtkamp KC, Mathijssen IB, Lakeman P, et al. Factors for successful implementation of population‐based expanded carrier screening: learning from existing initiatives. Eur J Public Health 2017; 27: 372–377.
            • 15. Newson AJ, Leonard SJ, Hall A, Gaff CL. Known unknowns: building an ethics of uncertainty into genomic medicine. BMC Med Genomics 2016; 9: 57.
            • 16. Plantinga M, Birnie E, Schuurmans J, et al. Expanded carrier screening for autosomal recessive conditions in health care: arguments for a couple‐based approach and examination of couples’ views. Prenat Diagn 2019; 39: 369–378.
            • 17. Haque IS, Lazarin GA, Kang HP, et al. Modeled fetal risk of genetic diseases identified by expanded carrier screening. JAMA 2016; 316: 734–742.
            • 18. Bennett R. Antenatal genetic testing and the right to remain in ignorance. Theor Med Bioeth 2001; 22: 461–471.
            • 19. Hildt E. Autonomy and freedom of choice in prenatal genetic diagnosis. Med Health Care Philos 2002; 5: 65–72.
            • 20. Ong R, Howting D, Rea A, et al. Measuring the impact of genetic knowledge on intentions and attitudes of the community towards expanded preconception carrier screening. J Med Genet 2018; 55: 744–752.

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              Addressing the oral health needs of Indigenous Australians through water fluoridation

              Andrew McAuliffe, Chris Bourke and Lisa M Jamieson
              Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50744
              Published online: 21 September 2020

              To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1

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              • 1 Australian Healthcare and Hospitals Association, Canberra, ACT
              • 2 University of Adelaide, Adelaide, SA


              Competing interests:

              No relevant disclosures.

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                Three‐dimensional printing in a pandemic: panacea or panic?

                Michael Wagels and Dietmar W Hutmacher
                Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50753
                Published online: 21 September 2020

                Patience and well designed studies are important for balancing opportunity and risk in uncertain times

                Even before they had to deal with the COVID‐19 pandemic, clinicians were negotiating the infiltration of three‐dimensional printing (3DP) into several aspects of medicine. This development probably began with the invention of stereolithography by Charles Hull in 1983.1 The technology has found broad application in engineering and manufacturing, particularly for computer‐aided design of machine parts. Its principles were also relevant to related aspects of clinical medicine, beginning with the production of reference biomodels from imaging data, and later in virtual surgical planning. It did not take long for the workflow that provided these services in the clinical environment to expand into other areas.

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                • 1 The Australian Centre for Complex Integrated Surgical Solutions, Princess Alexandra Hospital, Brisbane, QLD
                • 2 The University of Queensland, Brisbane, QLD
                • 3 ARC Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD


                Competing interests:

                No relevant disclosures.

                • 1. Jain A, Bansal KK, Tiwari A, et al. Role of polymers in 3D printing technology for drug delivery: an overview. Curr Pharm Des 2018; 24: 4979–4990.
                • 2. Ballard DH, Trace AP, Ali S, et al. Clinical applications of 3D printing: primer for radiologists. Acad Radiol 2018; 25: 52–65.
                • 3. Williams E, Bond K, Isles N, et al. Pandemic printing: a novel 3D‐printed swab for detecting SARS‐CoV-2. Med J Aust 2020; 213: 276–279.
                • 4. Vitali J, Cheng M, Wagels M. Utility and cost‐effectiveness of 3D‐printed materials for clinical use. Journal of 3D Printing in Medicine 2019; 3: 209–218.
                • 5. Langridge B, Momin S, Coumbe B, et al. Systematic review of the use of 3‐dimensional printing in surgical teaching and assessment. J Surg Educ 2018; 75: 209–221.
                • 6. Australian Department of Health, Therapeutic Goods Administration. Manufacturing medical devices and IVDs. Sept 2017. https://www.tga.gov.au/node/4425 (viewed July 2020).
                • 7. Bowling M. Catholic colleges printing thousands of face shields for frontline healthcare workers. The Catholic Leader (Brisbane), 8 Apr 2020. https://catholicleader.com.au/news/iona-college-plans-to-print-13000-face-shields-for-frontline-healthcare-workers (viewed July 2020).

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                  Beyond the womb: respiratory symptoms in children following acute in utero exposure to fire smoke

                  Julie M Marchant and Anne B Chang
                  Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50757
                  Published online: 21 September 2020

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

                  The impact of environmental pollutants from diverse sources on health and well‐being is widely recognised.1 However, much remains unknown, including the relative contributions of specific air pollutants, their size effects, the periods of maximum vulnerability, and the longer term effects of acute and prolonged exposure, particularly in children.2,3 The expected increases in the number and intensity of bushfires, as seen in Australia during the summer of 2019–20, require that the effects of such extreme events on public health be explored.


                  • 1 Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD
                  • 2 Queensland Children's Hospital, Brisbane, QLD
                  • 3 Menzies School of Health Research, Darwin, NT


                  Correspondence: anne.chang@menzies.edu.au
                  Acknowledgements: 

                  Anne Chang is supported by a National Health and Medical Research Council Practitioner Fellowship (APP1058213) and a top‐up fellowship from the Queensland Children's Hospital Foundation (grant 50286). Julie Marchant is supported by an Early Career Fellowship Grant from the Queensland Children's Hospital Foundation (RPC0772019).

                  Competing interests:

                  No relevant disclosures.

                  • 1. The Lancet Respiratory Medicine. Time to blow away the cobwebs. Lancet Respir Med 2018; 6: 231.
                  • 2. The Lancet Respiratory Medicine. Fuelling advances in paediatric lung health. Lancet Respir Med 2020; 8: 125.
                  • 3. Black C, Tesfaigzi Y, Bassein JA, Miller SA. Wildfire smoke exposure and human health: significant gaps in research for a growing public health issue. Environ Toxicol Pharmacol 2017; 55: 186–195.
                  • 4. Willis GA, Chappell K, Williams S, et al. Respiratory and atopic conditions in children two to four years after the 2014 Hazelwood coalmine fire. Med J Aust 2020; 213: 269–275.
                  • 5. Shao J, Zosky GR, Hall GL, et al. Early life exposure to coal mine fire smoke emissions and altered lung function in young children. Respirology 2020; 25: 198–205.
                  • 6. Melody SM, Ford J, Wills K, et al. Maternal exposure to fine particulate matter from a coal mine fire and birth outcomes in Victoria, Australia. Environ Int 2019; 127: 233–242.
                  • 7. Abdo M, Ward I, O'Dell K, et al. Impact of wildfire smoke on adverse pregnancy outcomes in Colorado, 2007–2015. Int J Environ Res Public Health 2019; 16: 3720.
                  • 8. Jayachandran S. Air quality and early‐life mortality: evidence from Indonesia's wildfires. J Human Resources 2009; 44: 916–954.
                  • 9. Reid CE, Brauer M, Johnston FH, et al. Critical review of health impacts of wildfire smoke exposure. Environ Health Perspect 2016; 124: 1334–1343.
                  • 10. Sun X, Luo X, Zhao C, et al. The associations between birth weight and exposure to fine particulate matter (PM2.5) and its chemical constituents during pregnancy: a meta‐analysis. Environ Pollut 2016; 211: 38–47.
                  • 11. Sapkota A, Chelikowsky AP, Nachman KE, et al. Exposure to particulate matter and adverse birth outcomes: a comprehensive review and meta‐analysis. Air Qual Atmos Health 2012; 5: 369–381.
                  • 12. Black C, Gerriets JE, Fontaine JH, et al. Early life wildfire smoke exposure is associated with immune dysregulation and lung function decrements in adolescence. Am J Respir Cell Mol Biol 2017; 56: 657–666.
                  • 13. Bui DS, Lodge CJ, Burgess JA, et al. Childhood predictors of lung function trajectories and future COPD risk: a prospective cohort study from the first to the sixth decade of life. Lancet Respir Med 2018; 6: 535–544.
                  • 14. Duong M, Islam S, Rangarajan S, et al. PURE investigators. Mortality and cardiovascular and respiratory morbidity in individuals with impaired FEV1 (PURE): an international, community‐based cohort study. Lancet Glob Health 2019; 7: e613–e623.

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                    Current COVID‐19 guidelines for respiratory protection of health care workers are inadequate

                    C Raina MacIntyre, Michelle Ananda‐Rajah, Mark Nicholls and Ashley L Quigley
                    Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50752
                    Published online: 21 September 2020

                    Guidelines need to reflect the mounting evidence for airborne transmission of SARS‐CoV‐2

                    The guidelines for protection of health care workers in Australia state that a medical mask is indicated for routine care of patients with coronavirus disease 2019 (COVID‐19), and a respirator only for aerosol‐generating procedures.1 These guidelines are not aligned with the growing body of scientific evidence regarding transmission and prevention of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection.

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                    • 1 The Kirby Institute, Sydney, NSW
                    • 2 Central Clinical School, Monash University, Melbourne, VIC
                    • 3 ANZICS, Melbourne, VIC
                    • 4 UNSW, Sydney, NSW


                    Correspondence: ashley.quigley@unsw.edu.au
                    Competing interests:

                    No relevant disclosures.

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                      Burning to reduce fuels: the benefits and risks of a public health protection strategy

                      Fay H Johnston
                      Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50751
                      Published online: 21 September 2020

                      We need to burn, but it is not a cure‐all and the side effects can be serious

                      Fire disasters are one of many serious and escalating environmental health problems that the world, and Australia in particular, is now facing.1 During the black summer of 2019–2020, population exposure to bushfire smoke was almost an order of magnitude greater than that documented for any of the fire seasons for at least the previous two decades, and it was estimated to be responsible for more than 400 premature deaths.2 The fires themselves, including firefighting‐related accidents and injuries, claimed a further 33 lives.3 Furthermore, the trauma experienced by communities affected by the fires, including serious risks to life, homes and livelihoods, will have ongoing psychological, physical health, social and economic impacts.4


                      • Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS


                      Correspondence: fay.johnston@utas.edu.au
                      Competing interests:

                      No relevant disclosures.

                      • 1. Whitmee S, Haines A, Beyrer C, et al. The Rockefeller Foundation–Lancet Commission on planetary health. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. Lancet 2015; 386(10007): 1973–2028.
                      • 2. Johnston FH, Borchers Arriagada N, Morgan GG, et al. Unprecedented health costs of smoke‐related PM2.5 from the 2019–20 Australian megafires. Nat Sustain 2020. In press.
                      • 3. Jalaludin B, Johnston F, Vardoulakis S, Morgan G. Reflections on the catastrophic 2019–2020 Australian bushfires. The Innovation 2020; 1: 100010.
                      • 4. Newnham EA, Titov N, McEvoy P. Preparing mental health systems for climate crisis. Lancet Planet Health 2020; 4: e89–e90.
                      • 5. Rutter H, Savona N, Glonti K, et al. The need for a complex systems model of evidence for public health. Lancet 2017; 390: 2602–2604.
                      • 6. Bowman DM, O'Brien JA, Goldammer JG. Pyrogeography and the global quest for sustainable fire management. Annu Rev Env Resour 2013; 38: 57–80.
                      • 7. Bowman DMJS, Balch J, Artaxo P, et al. The human dimension of fire regimes on Earth. J Biogeogr 2011; 38: 2223–2236.
                      • 8. Penman TD, Collins L, Duff TD, et al. Scientific evidence regarding the effectiveness of prescribed burning. In: Leavesley A, Wouters M, Thornton R; editors. Prescribed burning in Australasia: the science, practice and politics of burning the bush. Melbourne: Australasian Fire and Emergency Services Council, 2020; pp 99–110.
                      • 9. Scott RE, Neyland MG, McElwee DJ, Baker SC. Burning outcomes following aggregated retention harvesting in old‐growth wet eucalypt forests. Forest Ecol Manag 2012; 276: 165–173.
                      • 10. Meier EA, Thorburn PJ. Long term sugarcane crop residue retention offers limited potential to reduce nitrogen fertilizer rates in Australian wet tropical environments. Front Plant Sci 2016; 7: 1017.
                      • 11. Costello O. Fire has spirit. In: Leavesley A, Wouters M, Thornton R; editors. Prescribed burning in Australasia: the science, practice and politics of burning the bush. Melbourne: Australasian Fire and Emergency Services Council, 2020; pp 66–67.
                      • 12. Morgan G, Tolhurst K, Poynter M, et al. Prescribed burning in south‐eastern Australia: history and future directions. Aust For 2020; 83: 4–28.
                      • 13. Trauernicht C, Brook BW, Murphy BP, et al. Local and global pyrogeographic evidence that indigenous fire management creates pyrodiversity. Ecol Evol 2015; 5: 1908–1918.
                      • 14. McCaw WL. Managing forest fuels using prescribed fire–a perspective from southern Australia. For Ecol Manag 2013; 294: 217–224.
                      • 15. Schwilk DW, Keeley JE, Knapp EE, et al. The national Fire and Fire Surrogate study: effects of fuel reduction methods on forest vegetation structure and fuels. Ecol Appl 2009; 19: 285–304.
                      • 16. Johnson CN, Prior LD, Archibald S, et al. Can trophic rewilding reduce the impact of fire in a more flammable world? Philos T R Soc B 2018; 373: 20170443.
                      • 17. Curran TJ, Perry GL, Wyse SV, et al. Managing fire and biodiversity in the wildland‐urban interface: A role for green firebreaks. Fire 2018; 1: 3.
                      • 18. Bowman DM, Daniels LD, Johnston FH, et al. Can air quality management drive sustainable fuels management at the temperate wildland–urban interface? Fire 2018; 1: 27.
                      • 19. Australasian Fire and Emergency Services Authorities Council. National position on prescribed burning. Melbourne: AFAC, 2016. https://knowledge.aidr.org.au/media/4869/national-position-on-prescribed-burning.pdf (viewed Aug 2020).
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                      • 21. Dovers S. Prescribed burning as a public policy problem. In: Leavesley A, Wouters M, Thornton R; editors. Prescribed burning in Australasia: the science, practice and politics of burning the bush. Melbourne: Australasian Fire and Emergency Services Council, 2020; pp 15–17.
                      • 22. Australasian Fire and Emergency Service Authorities Council. Overview of prescribed burning in Australasia. Report for the National Burning Project, subproject 1. Melbourne: AFAC, 2015. https://knowledge.aidr.org.au/media/4893/overview-of-prescribed-burning-in-australasia.pdf (viewed Aug 2020).
                      • 23. Penman TD, Bradstock R, Price O. Reducing wildfire risk to urban developments: Simulation of cost‐effective fuel treatment solutions in south eastern Australia. Environ Modell Softw 2014; 52: 166–175.
                      • 24. Cirulis B, Clarke H, Boer M, et al. Quantification of inter‐regional differences in risk mitigation from prescribed burning across multiple management values. Int J Wildland Fire 2020; 29: 414–426.
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                      • 29. Cascio WE. Wildland fire smoke and human health. Sci Total Environ 2018; 624: 586–595.
                      • 30. Horsley JA, Broome RA, Johnston FH, et al. Health burden associated with fire smoke in Sydney, 2001–2013. Med J Aust 2018; 208: 309–310. https://www.mja.com.au/journal/2018/208/7/health-burden-associated-fire-smoke-sydney-2001-2013
                      • 31. Borchers Arriagada N, Palmer AJ, Bowman DM, et al. Exceedances of national air quality standards for particulate matter in Western Australia: sources and health‐related impacts. Med J Aust 2020; 213: 280–281.
                      • 32. Broome RA, Johnston FH, Horsley J, Morgan GG. A rapid assessment of the impact of hazard reduction burning around Sydney, May 2016. Med J Aust 2016; 205: 407–408. https://www.mja.com.au/journal/2016/205/9/rapid-assessment-impact-hazard-reduction-burning-around-sydney-may-2016
                      • 33. Williamson G, Bowman DMJS, Price O, et al. A transdisciplinary approach to understanding the health effects of wildfire and prescribed fire smoke regimes. Environ Res Lett 2016; 11: https://doi.org/10.1088/1748-9326/11/12/125009
                      • 34. Driscoll DA, Bode M, Bradstock RA, et al. Resolving future fire management conflicts using multicriteria decision making. Conserv Biol 2016; 30: 196–205.

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