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Standing Committee on Health, Aged Care and Sport
Impacts of long COVID and repeated COVID infections

IRVING, Associate Professor Louis, Respiratory Physician, Post-Covid Clinic, Royal Melbourne Hospital [by video link]

McCONNELL, Ms Carly, ReCOV Team Leader, Royal Melbourne Hospital [by video link]

Committee met at 0 9 :00

CHAIR ( Dr Freelander ): I declare open this public hearing of the House of Representatives Standing Committee on Health, Aged Care and Sport for the inquiry into long COVID and repeated COVID infections. In accordance with the committee's resolution of 4 August 2022, this hearing will be broadcast on the parliament's website, and the proof and official transcripts of the proceedings will also be published on the parliament's website. I'd like to thank our witnesses for appearing and taking time out of their very busy schedules. This hearing is a legal proceeding of the parliament, and the giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. I invite our witnesses from Royal Melbourne Hospital to make a short opening statement of no more than five minutes, before we proceed to discussion.

Prof. Irving : My colleague, Ms McConnell, will give a five-minute description of what we've been doing, but I'd like to describe a clinic that we set up just over two years ago in response to a couple of startling patients whom we didn't fully understand. I should say that everything I'm going to pass on is our experience, and we've learned from our patients; we've kept an open mind. We haven't been entirely certain of what we're dealing with, but, after two years, I think we now have a better understanding of the breadth of symptoms that occur after COVID infection.

In a nutshell, when we set up this clinic, we had three or four respiratory physicians see each patient. Then, at the end of the clinic, we had a multidisciplinary discussion. This was a model suggested to us by liaison psychiatry and by a couple of GPs who were associated with Royal Melbourne. The multidisciplinary meeting included liaison psychiatry, general practice, psychology, physiotherapy, exercise physiology and other people as needed.

The clinic was a combination of assessment and a model of care that we developed over a period of time. The principles of the model of care—and we learnt this from our GP colleagues—were, firstly, to validate the symptoms. These were very real symptoms, but we couldn't always explain the pathophysiological cause of the symptoms. The usual symptoms were dependent on the background of the case, and I'll just describe the three groups, because it's a heterogeneous group of patients, and there might be more than three.

The first group were people who'd been in hospital with acute COVID and who were often desperately ill but had survived, and they had ongoing lung inflammation and fibrosis—resolving into acute lung injury, ARDS. They were no different from other causes of ARDS, but their symptoms were reflected by the severity of lung function abnormality and by their CTs. The patients were often deconditioned because they had spent a significant amount of time in hospital—acutely. All of these patients improved over time with the standard support of cardiopulmonary rehabilitation, of nutritional support and of supplemental oxygen when required, as well as the support of any other issues, including the trauma of having been desperately ill. They make up about a third of our patients.

There's a second group, who were a small number of people presenting with a nuance of breathlessness or palpitations. When we did some screening tests, we discovered that they actually had underlying asthma or potentially PEs or potentially myocarditis. They're a small group; but they're important, because they're eminently treatable, providing they're accurately diagnosed. So it's important to have careful assessment when people present with persisting symptoms after COVID.

The majority of patients—we call this group type 2—are people who had mild initial COVID and didn't require hospitalisation but, several weeks later, developed progressive fatigue, breathlessness, palpitations and sometimes brain fog. If a solution wasn't provided for their symptoms, they became increasingly frustrated, anxious, hypervigilant and depressed. Over time, we've learnt to not over-investigate and to just do some focused tests depending on their symptoms. We tend to use a six-minute walk for people who say they can't walk or that they're too breathless to move. Interestingly, the six-minute walk is usually a minimum. If a patient has a lot of palpitations, we might do an echo or a Holter monitor, but we don't use a wide battery of tests on everyone. Instead, we validate their symptoms and we refer them to a program that Carly will describe, called ReCov.

The last point I'd make is that a lot of patients get better over time, and our most severe patient—in fact, she was the stimulus for setting up this clinic—a young mother working as a medical scientist and leading an incredibly busy life and who was wheelchair- and bed-bound when we first saw her, is completely back to normal after two years. But it has been a long road, and it's required very careful ongoing treatment. Being able to reassure people that they're not going to be permanently damaged is part of the management. I'll hand over to Carly, and then we can expand on some of the issues.

Ms McConnell : I'm a physiotherapist by background, and I'm currently leading the Royal Melbourne Hospital's allied health long-COVID clinic. It runs in conjunction with Lou's respiratory service. We started seeing patients in May 2022. While Lou's service focuses a lot on the assessment and reassurance side of things, we focus more on the therapy. We have a 12-week multidisciplinary program that we run for patients that is very much tailored to the unique needs of the individual patients. We have a physiotherapist, an exercise physiologist, a clinical psychologist, a neuropsychologist, a social worker and so on. So we have quite a large array, and patients are referred to the disciplines that they need to best treat their symptoms.

This service is really designed to bridge that gap between initial hospital care and community therapy services, which we found were being quite inundated with referrals and were perhaps not able to provide the care that was needed by this unique population of patients. Anecdotally, [inaudible] we've discharged 40 patients and got another 60 actively enrolled. We've seen 270 referrals, and we are finding, as Lou mentioned, that patients do get better. Twelve weeks is an arbitrary number. Not all patients, of course, will make a significant or a full recovery in that time, but we certainly find that it's enough time to be able to embed some self-management strategies and get people started on a return to work, starting to increase their hours, and starting to return to some exercise or just their activities of daily living by employing strategies around their mood and their cognitive complaints, and things like that.

We are hoping to have more robust data in the coming months. We do a battery of validated outcome measures with patients on admission and on discharge. We look at quality life, mental health, symptom severity, and understanding and control of their illness. We hope to have that data soon; we don't quite have it yet. Clinically, though, we are seeing an improvement.

CHAIR: Good. Have you finished?

Ms McConnell : Yes, thank you.

CHAIR: Thank you so much for that. We might open up to questions now. I will start with Mrs McIntosh, the member for Lindsay.

Mrs McINTOSH: Professor, you talked about the reassurances that you give people that they won't be permanently damaged. Have we got enough data at this stage to be confident that the damage isn't permanent, and how does that apply to things like autoimmune diseases or other conditions that have been triggered by COVID?

Prof. Irving : If we're talking about that larger group with the mild initial illness and then very severe, unexplained symptoms that occur, you are quite right: I can't be 100 per cent certain that there isn't some form of ongoing issue. Interestingly, we keep an eye on the research, and I should mention there is a very good group down here called VPCC, who are led by Professor David Watters. We have a monthly meeting of all researchers into COVID in Victoria, and we're keeping an eye on the literature. As you are probably aware, nothing has been found so far that can explain the severity of symptoms. There is no pathophysiology. This is excluding the people who had severe lung damage and who are in the recovery phase of ARDS.

How can I be sure when I reassure the patients? I'm actually just using my experience from the clinic. Luckily—and she won't mind me mentioning her first name—Giovanna, who was our first catastrophic case, is showing the way; she has got better. She's now working full time, caring for two young children and going to the gym. If we look back in 20 years time, is it going to be another example of encephalitis lethargica—that strange condition that occurred in 1918 and was never fully explained and has never occurred again? Maybe. But it doesn't apply to the large majority of people that we see. Reassurance is incredibly important because, by the time they get to see us, the patients are just paralysed with hypervigilance. I'll give an example: a subgroup have got very significant brain fog. They're often young people, and we've been doing neurocognitive testing on that group. We've done between 20 and 40 studies. The neuropsychologists have not found an abnormality apart from the fact that the patients are all hypervigilant. So they're aware of the minor mistakes that we all make in daily life, but they're blowing those mistakes out and becoming paralysed by their occurrence.

Mrs McINTOSH: So you are saying that the psychological impact of this is quite a strong part of the symptoms?

Prof. Irving : The secondary frustration of not improving, of anxiety and of depression is very common, and it's really important that we have a liaison psychiatrist in the group. He's been with us from the beginning and he's really thought about the interaction between the mind and the body. We're certainly not saying it's all psychological, but we're saying there can be roadblocks to getting better that need to be managed. One of those roadblocks is anxiety and frustration. A second roadblock, which leads on to Carly, is that we've found a subgroup of people who are high-achieving people—and I suspect some members of the committee might be in this group as well! They're very active and they validate their wellness by running 20 kays, cycling or staying up and working hard at night. They solve problems by putting energy into the problem. Long COVID doesn't get solved by putting more energy into it; you've actually got to learn to rest. The group are greatly helped by Carly's program, which helps and guides them to slow down for the first time in their lives. A balance between work and activity outside of work—a graded return to work and a graded return to usual activity—is incredibly important. Carly, do you want to comment on that? The start of rehab is to crack a whip and get people moving, but this is very interesting. This is actually about slowing a subgroup of these people down.

Ms McConnell : Yes, thank you, Lou. We've found that when patients that have been referred to our service complete their triage questionnaires—that's what we base the referral to different disciplines on—around 80 per cent have responded in a way that would indicate that they would benefit from clinical psychology and another 80 per cent have responded in a way that would indicate that they would benefit from occupational therapy. Our occupational therapist works a lot around pacing, reducing fatigue and being able to return to work and activities of daily living. I would certainly second what Lou is saying and I would also add that the median age of patients accessing our service is 43. So they are very young, of working age and, as Lou says, probably leading quite busy lives. Often, for many people in our service, it's the first time they've been significantly unwell and limited in what they can do in their lives. We do certainly find that the psychological impact is significant, and it's a bit of a self-perpetuating cycle; they become anxious and that can lead to palpitations and those kinds of physiological symptoms that are also linked with long COVID. It's a difficult cycle to break.

Mrs McINTOSH: Thank you, Chair.

CHAIR: Thanks. We might move on to Ms Stanley.

Ms STANLEY: Hi and thank you both for joining us today. Do you have any sense of the number of patients who experience long COVID compared to the number of people who get COVID? In some of the literature that I've been reading it seems long COVID is more prevalent with the earlier strains, but there seems to be a bit of a debate about whether that is because of vaccinations or whatever. What percentage of people do you think are going to get it, and is it specifically those people who overwork themselves, so their immune systems are a bit hypervigilant anyway; is that the sort of scenario?

Prof. Irving : The early studies suggest high-frequency symptoms are for COVID, but more recent controlled studies, where they have data before the individual got COVID, indicate that some symptoms at around 12 weeks would be normal. It occurs in around 15 per cent, and severe symptoms are probably in the order of six per cent of people who get COVID. On your question as to whether it's less now with vaccination than it was at the beginning of the pandemic: there is certainly some suggestion that that might be true, although my experience with all the COVID-related publications is that you need to see it a second and a third time before you believe it. There are a lot of early reports that turned out not to be true.

[Inaudible] larger samples in a case study that was published in the Lancet recently, and it showed that risk factors or having persistent symptoms—and this was in a group of people who didn't have severe lung disease, so it's that top two that I am describing. The risk factors were people with pre-existing physical or mental health issues and older people. They didn't describe the same group that I described—the high-achieving people—but I think that's because our clinic has been up to 40 per cent health care workers. We unfortunately had a large [inaudible] outbreak of COVID with the second wave, and 250 of our own staff were infected. Some of them have got persistent symptoms.

Healthcare workers are particularly at risk, in my experience. The comment about staged return to work is incredibly important. One of the things that in our clinic we've been able to achieve is liaising with hospital administration about short and staggered shifts. Usually, we advise our staff to return to work no more than four hours in a shift no more than three times a week to start with and to do only day work, not night work. This is an example of how prescriptive you need to be, particularly with that subgroup of people who are high achieving, very active and don't know how to slow down. You need to give them very clear instructions.

CHAIR: Thanks very much.

Ms STANLEY: Can I ask one supplementary question? If the incidents you're referring to are substantially health workers, is that because they may well be exposed but subclinical, where their immune response is heightened, or are you not up to that sort of conclusion?

Prof. Irving : Yes, I don't think we're up to that conclusion. We [inaudible] might have a little bit of psoriasis or a history of rheumatoid [inaudible], and part of it can certainly bring out a [inaudible] autoimmune tendencies, but [inaudible] people with a background of chronic fatigue or post-traumatic stress, and COVID can actually reactivate that. I see asthmatics who reactivated by COVID. How much of this is new disease and how much of it is activation of a background tendency is unclear. There certainly isn't a single disease called long COVID, nor is there a test, nor is there a unifying physiology.

Ms STANLEY: Thank you very much.

Ms McConnell : I was just going to add that I think both of our services are quite open to selection bias, being that we're located within the hospital. I would comment, from our perspective, we see around one-third of our patients being staff, but we're advertised within the hospital. When we look at our population as a whole, only two per cent require an interpreter. Clearly, the messaging is getting out to our staff and our English-speaking, educated, health-literate population but potentially not to our non-English speaking population. So I think we're quite heavily biased in that regard as well.

CHAIR: We'll go to Dr Michelle Ananda-Rajah, the member for Higgins, for her questions.

Dr ANANDA-RAJAH: Hello, everyone. Thank you for your presentations; it's really fantastic to hear about this work going on at the Royal Melbourne. You've got a really excellent multidisciplinary team, but you are a centre of excellence as well. How do we scale up a model like this? We have to, given the numbers that we think are below the waterline.

Ms McConnell : There are some other services that exist in Victoria. I've been liaising quite heavily with them. The Austin Hospital have a very similar model of care to ours, as do the Alfred. We do try and work together to make sure that we're doing similar models of care and we've got similar outcome measures and things that we're using. Lou and I have met with the Department of Health regularly; as Lou said, we're members of the VPCC research committee. So we're certainly trying, we're certainly keen, and we're finding that the demand is outstripping our capacity at the moment. We'd be very keen to upscale. Public education comes into it quite significantly so that, as I mentioned, those non-English-speaking and different populations can start to access our services, too.

Dr ANANDA-RAJAH: There are models overseas that are used to scale up this sort of care. Project ECHO is one—it's a hub-and-spoke model. Have you considered that, where you start training up other clinicians around the country, particularly in regional and remote areas where access to care is very difficult?

Ms McConnell : When any service has reached out, we've been very quick to engage with them and to do that. We've met with a number of different health services in Australia, and in New Zealand as well, recently. The other thing that we've been investigating is potential use of a digital platform also to provide access. The NHS in the UK has a great program called Your Covid Recovery, and we've attended some training sessions and met with the Department of Health around potentially employing something like that. It's an online platform; it looks like an app. Patients can enter their symptoms and monitor their symptoms. They can participate in a graded walking program—an exercise program. They can access lots of resources, and they can also communicate with the health service as required. A great way of scaling our service up would actually be to triage the milder symptoms into a program like that so that they can self-manage, and then the tertiary services can really focus their resources where they're needed more, in severe disease.

Prof. Irving : General practice has got a real role to play, because they'll know the patients. If you ask enough questions, at least 50 per cent of people have got background issues that COVID is then bringing to the fore. Whether a general practitioner has got the time to do it, and how you might incentivise general practitioners, are questions for your committee, I think. But, as I've mentioned, we based our model of care on exactly what GPs do in terms of validating symptoms, supporting the patient, not dumping the patient but keeping in touch with them and then using targeted tests or targeted referrals to rule out the very occasional, nasty thing, such as myocarditis or PEs or asthma, and so on.

Dr ANANDA-RAJAH: Can I ask one more question, Chair. Regarding return to work, how do you negotiate this with employers? It's quite challenging for some of these people. They've had a lot of people not validate their symptoms; there's a lot of testimonial injustice. How do you help them with that negotiation with their employers?

Prof. Irving : Yes, I think that's a very good question. I guess we've got the weight of the multidisciplinary clinic. I have no difficulty writing the appropriate letters, and if I get stuck I ask our liaison psychiatrist to help out as well. But I can imagine it would be much more difficult for an isolated GP to do that. Again, that might be something that your committee thinks about. Someone, possibly tongue in cheek, suggested there should be a post COVID JobSeeker. The notion that everybody gets better but doing too much too quickly and not addressing issues is a roadblock, is really important. Going back to too much work too quickly is one of the roadblocks. I'm amazed by the number of people at work to whom you say, 'Look, I only want you to work four hours,' and they say, 'No, I can't possibly work a shift that is less than eight or 10 or 12 hours.'

CHAIR: Dr Ryan?

Dr RYAN: Sorry I was a bit late. I missed you presentation. Lou, did you cover how you're funding your clinic, or is it just funded by the hospital?

Prof. Irving : We initially covered it. I was the boss at the time, so I just sort of expanded respiratory outpatient and did it myself, but more recently it's a Medicare clinic, and we're billing item numbers. The integrated allied health service is being funded by the hospital for 12 months and then being reviewed. It's only in the credit to the hospital to do it. To be fair, quite a few of the early patients were our own staff and that was our incentive.

Dr RYAN: I'm just thinking about the fact that obviously there's no item number for long COVID at this point, and that is something that might be helpful down the track.

Prof. Irving : Absolutely, particularly for [inaudible] and allied health, a local phycologist or a local exercise physiotherapist to be involved.

Dr RYAN: I don't have any other questions at this point, thank you.

CHAIR: I have a few questions I'd like to ask. First of all, thank you for your evidence. It's really interesting. Ms McConnell, Professor Irving, who can refer to your clinic?

Prof. Irving : Predominantly GPs. We've got referral criteria that we can send, and we will put in a written submission, but we also get referrals from hospital managers saying, 'A colleague is still suffering,' and we obviously prioritise those. Those are the two main referral sources.

CHAIR: Can you get referrals from Victoria?

Prof. Irving : Yes.

CHAIR: Ms McConnell—

Ms McConnell : Our service is a touch different as we're not Medicare billing. We can accept referrals from GPs in the community, but we'll also accept self-referrals from staff. We'll see some referrals from the emergency department and then from Lou's respiratory service and also from other outpatient areas—perhaps a referral has come through to a different outpatient clinic but it's more appropriate in our service.

CHAIR: You'll accept GPs and allied health—

Ms McConnell : Correct. We will accept from GPs. We wouldn't particularly accept from another allied health service. We'd prefer that a patient has been through their GP and has had any necessary testing done to rule out palpitations or tachycardia or anything like that. We prefer them to come from a GP which sign off for exercise essentially. If we have patients referred who are within the catchment of another hospital that has a comparable service—the Austin or the Alfred, for example—we will refer on to them, but, if they come from an area outside of that that doesn't have a comparable service, we'll accept them. We see most of our patients, 90 per cent of our patients, via telehealth, anyway, so the distance is not particularly a barrier.

CHAIR: So you have telehealth consultations.

Dr ANANDA-RAJAH: I have a question regarding income loss. A lot of these people are taking time off work. They may need help with child care, particularly if they're women. Asking women to rest is impossible. I don't know how you're actually achieving this. Can you talk us through what kinds of measures and what kinds of financial supports we should be thinking about for these people?

CHAIR: It's probably a bit out of the scope of the clinics to provide that answer [inaudible] welcome to hear.

Prof. Irving : In the subgroup of patients who work at [inaudible] in the health service, particularly if they were infected at work, which was relatively common to start with, and a known angle occurs: we've been very firm about the use of injury assist or some form of work cover. I think you can apply it to other people in other industries. There is a time limit. My feeling is that in most cases there will be substantial improvement within two years—we're not looking at NDIS-like lifelong support—but I've got no doubt there will be people who are permanently 'scarred' by their experience because it's been a terrifying existential loss-of-control type of experience. With careful management they will substantially improve in terms of how they can live their lives, including returning to work. But they need support.

CHAIR: Going a step back, Ms McConnell, you're not billing through a care plan from GPs for your clinic at all?

Ms McConnell : No, not for our clinic. Perhaps as a discharge option we would ask the GP to provide a care plan if they were eligible, if they'd had symptoms for longer than six months. But many have not. That probably comes back to the finances question as well. We try and intervene early. If patients don't have sick leave or the finances to support themselves on reduced work, that's obviously important. We might ask a GP to do a mental healthcare plan for patients to access psychology and things like that. It might be quicker than accessing our service at present, given the wait times. But, no, not for the actual service.

CHAIR: For general practitioners, will you provide a telehealth service for either clinic?

Ms McConnell : For general practice themselves?


Ms McConnell : We generally communicate that by letters on admission and discharge all phone calls with the GPs. We haven't had any GPs ask us to join them for any telehealth sessions at this stage.

Prof. Irving : I think we've got to find a way of handing back to the GP or including the GP in the session. We have a couple of GPs who attend our multidisciplinary meeting, at the end of each outpatient, where we discuss each patient. They're local GPs who are part of a staff clinic, who often know the patient. Relating to the broad realm of GPs is really difficult but I think it's going to be essential.

CHAIR: A couple of other things. First of all, Professor Irving, you mentioned that some people who have had severe illness can end up with chronic symptoms. How many do you think will end up with lifelong symptoms, things like bronchiectasis or asthma, and are you also seeing patients with other illnesses precipitated by COVID such as diabetes, DVTs, et cetera?

Prof. Irving : The group called type 1, the people with severe lung injury—their lungs don't return entirely to normal. After about a year there is still some fibrosis. But in general they are 60 to 80 per cent improved because of remodelling of the fibrosis. We haven't seen other diseases such as diabetes. The [inaudible] get better, obviously. I haven't seen myocarditis but other people are seeing that. I think there will be 10 per cent of people left with some form of physical attrition. We saw that with influenza as well and the risk of cardiovascular disease down the track and so on. So I don't think there's any doubt that there will be long-term scarring and abnormality in a small group.

Another thing I didn't mention is that autonomic dysfunction is very common in this group, but other groups are describing sympathetic abnormality. It doesn't seem to cause much bother apart from the occasional patient who becomes hypotensive. If these patients are wearing smart watches they can see if their heart rate is 120. We have done exercise tests on this group and we haven't found any sort of major physiological abnormality. It is an indication that there is something going on, but it doesn't explain the severity of symptoms.

CHAIR: Ms McConnell, you were mentioning before that you had a multidisciplinary program. How great a need do you think there is for that, and have you had much uptake?

Ms McConnell : We have not deployed that yet, so I couldn't comment on the uptake. I certainly have met with the UK NHS a few times. They have great uptake. They have thousands of patients enrolled currently. Their trust works similarly to our hospital services. So patients are allocated to the hospital that is looking after them in their area. So they still sit under the care or the clinical governance of that hospital. I believe with our patient protocol we have had 270 referrals in the first five months. We only opened to GP referrals in July, so in the last three months there have been a lot of those. I think a large proportion of those patients would be really keen to take up a program like this. As I mentioned, the median age is 43. So our patients are all quite tech literate and they complete a lot of their outcome measures online anyway. They communicate with the service via email. So I think that, from that perspective, the uptake would be really good. There is quite a good appetite for it. I think a lot of these patients, as we've mentioned, need reassurance and access to Australian-specific quality resources that we're lacking at the moment. I think a lot of them would be quite satisfied with that. We found that they got to the end of their 12-week digital program. We could enrol them in a tertiary one if needed, but I think we would reduce the demand on the tertiary services if we could do something like that.

Mrs McINTOSH: I am really interested in a few points you made around the people who are presenting at your clinic—words like 'high achievers' and 'active people'. Could you talk about this a bit more. Are you saying that they may have had pre-existing mental health conditions as well on top of that? Could you tell us more about the people specifically.

Prof. Irving : Of the people I saw there were a couple who had severe background issues. These were young people with post-traumatic stress, fibromyalgia and chronic fatigue on a range of medication. Yesterday, I saw a 40-year-old ED physician who was incapacitated for six months and was able to achieve a structured return to activity—a four-hour rather than 12-hour shift and walking rather than running 20 kilometres. Miraculously, he was back to normal. I did an exercise test on him yesterday, for example, and he was completely normal. So some people have a background and some haven't. It's been very difficult times. The world was facing an existential crisis. Even if you were previously normal and you then become infected with the virus, it's clearly doing something pathophysiologically but not enough that we can actually pick on our standard test. But it interacts with the whole person. So I guess I'm saying programs like Carly's are really important because they apply a uniform approach to a large number of people, but there are also individuals who've got their own individual issues that need to be addressed. And that's why I think GPs are going to be really important. It's a combination of the person and the virus, and a whole lot of combinations can come out of that.

Mrs McINTOSH: Thank you.

CHAIR: We're almost out of time. Does anyone have any other questions?

Dr ANANDA-RAJAH: Just with respect to data collection, Chair.

CHAIR: Sure.

Dr ANANDA-RAJAH: I know we don't have a lot of time. It'll be good, once your study is complete, if we can have a look at some of that data and how you are collecting it and your learnings from it. That would be great. We obviously want to get some data harmonisation throughout the country.

Prof. Ir ving : So, Calvary is collecting data, but there's also a psychiatrist, Alex Holmes, who's developed a questionnaire that is very similar to international questionnaires. The Victorian health department have actually taken it up and are going to apply it to a large dataset of people in Victoria who were infected plus a control group, and they've sublet it to an organisation that does polling cum questionnaires and so on. So that's already in place.

CHAIR: Good. Thank you very much. Would it be possible for us to get a copy of the questionnaire?

Prof. Irving : Yes, absolutely. I will ask Alex to send it to you, plus we will make a submission that summarises what we've discussed this morning.

CHAIR: That's fantastic, and if you could include your referral criteria as well, that would be great. I'd like to thank both of you for coming today and giving us some of your very valuable time. It's been really important, and we are all very grateful for your very interesting and comprehensive evidence. We would love to see your submission. If you've been asked to provide any additional information, please forward it to the secretariat, if you could, by Friday 28 October this year. You'll be sent a transcript of your evidence and will have an opportunity to request corrections to any transcription errors that you see. Thank you once again on behalf of the committee. It's been very important to hear from you. If we do come to Melbourne we would love to see your clinic and visit you in person. Thanks once again you for your evidence, Professor Irving and Ms McConnell.

Prof. Irving : Thank you for your interest. Take care.

Ms McConnell : Thank you.