Health impacts of war: case studies of New Zealand veterans of the First World War.

AIM: Armed conflict remains a tragic feature of the modern world and so it is necessary to continue to study its health impacts. Even the study of historical conflicts is relevant given that certain health impacts are common to most wars e.g., post-traumatic stress disorder (PTSD). METHODS: This study built on a previous quantitative analysis of a randomly selected group of 200 New Zealand veterans from the First World War (WWI). From this sample we selected 10 cases that illustrated particular themes around morbidity impacts. RESULTS: The theme of severity of impacts was illustrated with a case who was severely wounded and died from suicide when back in New Zealand, and another case with severe PTSD. The theme of the high frequency of non-fatal conditions was revealed with cases illustrating new diagnoses (a case with n=8 diagnoses), hospitalisations for new conditions (n=6), non-fatal injury events (n=3) and for sexually transmitted infections (n=3). The theme of chronic debility as a consequence of various conditions was illustrated with cases who had suffered from being gassed or having gastroenteritis, malaria or pandemic influenza. CONCLUSION: These 10 selected cases reiterate how severe and extensive the morbidity burden for military personnel in WWI could be. Also illustrated is how the morbidity could contribute to adverse impacts on some of their lives after returning to New Zealand.

The unseen casualties of the First World War: insights from a randomly selected military sample.

AIMS: Studies of the morbidity burden of military personnel participating in the First World War (WWI) have tended to focus on specific outcomes (e.g., injuries). Therefore, we aimed for a more complete assessment. METHODS: From a random sample of active war service-exposed New Zealand WWI veterans used in previously published work, we examined a random subsample of 200 personnel. Data on diagnoses, hospitalisations and outcomes were extracted from the online archival military files. RESULTS: These personnel experienced a very high morbidity burden with 94% having at least one new condition diagnosed during their military service (mean: 2.4 per individual; range: 0 to 8). The relative severity of these conditions was reflected by the high level of hospitalisation (89% at least once; mean: 1.8 hospitalisations for new conditions per individual) and 59% of personnel being deemed no longer fit for military service at some stage. More of the new diagnoses were for infectious diseases than for conflict-related injuries (117 vs 50 cases per 100 personnel). Respiratory conditions such as influenza, pneumonia and tuberculosis affected 33% of personnel, and 14% were diagnosed with sexually transmitted infections. Diseases reflecting hazardous environmental conditions were relatively common e.g., for dysentery/gastroenteritis in 12% and scabies in 5% of personnel. Diagnoses suggestive of post-traumatic stress disorder (PTSD) were present in 10% and chemical warfare injuries in 6%. CONCLUSIONS: The overall morbidity burden of this military force in WWI was very high, and much higher than the previous official estimates.

COVID-19: Acing the Treatment.

Angiotensin converting enzyme 2 is the functional receptor that the SARS-Cov-2 virus requires to enter cells and cause dysregulated inflammatory conditions that contribute towards acute lung injuries. The renin-angiotensin-aldosterone system with its physiological surveillance and regulation system can be implicated in both harm and therapeutic benefit. The initial observational studies suggesting the discontinuation of angiotensin converting enzyme inhibitors and angiotensin receptor blockers have been firmly rebutted by international societies. On the contrary, these therapeutics may confer a survival benefit in COVID-19 infections. Understanding the biological plausibility of this pathway alongside the emerging therapeutic evidence may yield new modes of treatment. Such developments appear fundamentally important in the battle against the inevitable emergence of new variants and their potential to drive future waves of COVID-19 pandemics.

A survey of the smokefree status of pedestrian-only spaces in 10 New Zealand local government areas.

AIM: To describe the smokefree status and signage of outdoor pedestrian-only plazas/malls/boulevards in 10 New Zealand local government (council) areas. METHODS: The 10 council areas were a convenience sample. Council websites were examined for smokefree policies, and a systematic attempt was made to identify the five largest pedestrian-only sites with permanent seating in each council area (10 sites each for two larger cities). Field visits were conducted to all selected sites during January-May 2021. RESULTS: Smokefree policies with components covering smokefree outdoor plazas/malls/boulevards were common (80%; 8/10 councils), albeit with some gaps (eg, around signage and vaping policy). A total of 60 relevant pedestrianised sites with permanent seating were identified and surveyed. Of these, 63% were officially designated smokefree. Smokefree signage was only present in 15% (9/60) of all the sites and in 24% (9/38) of the designated smokefree sites. In these designated sites, the average number of smokefree signs was only 1.4 (range: 0 to 14). Issues identified with the signs included small size, being only a small part of a larger other sign, limited use of te reo Maori wording and not covering vaping. At sites where tables were present, 12% had ash trays on the tables (none at smokefree sites). CONCLUSIONS: Smokefree plazas/malls/boulevards in this survey had multiple policy and signage deficiencies that are inconsistent with achieving the national Smokefree 2025 goal. There is scope to address these issues with an upgrade to the national smokefree law.

Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey.

AIMS: To identify the extent of the provision of handwashing amenities in public toilets at the time of the COVID-19 pandemic, and also to make comparisons with a related pre-pandemic survey. METHODS: We collected data from 400 toilet facilities that were open to the public: all those in three contiguous city council territories (228) and a further convenience sample of 172 around other parts of New Zealand. Comparisons were made with the data on the same facilities included in a 2012/2013 survey. RESULTS: Of the toilets in this survey, 2.5% had no water for handwashing and 14.8% had no soap. There was COVID-19-related health messaging signage in 19.5% of toilets, with posters of the COVID-19 QR code used for contact tracing in 12.3%, and generic handwashing signage in 1.8%. The handwashing water had 'no-touch' activation at 28.0% of toilets, and 18.5% of toilets had no-touch bowl flushing. Toilet bowl lids were not present at 32.8%, and 2.3% of toilets had damage that would impair their functionality (eg, broken toilet seats). This new survey found significantly increased provision of soap (risk ratio = 1.47; 95%CI: 1.25 to 1.72), but no increased provision of water, at the 128 sites that had also been examined in the previous survey. CONCLUSIONS: Although handwashing is probably a much less critical COVID-19 control intervention than reducing aerosol transmission, it should still be strongly supported. Yet this survey found multiple deficiencies with handwashing amenities at public toilets and only modest improvements since a previous survey.

The epidemiology of attacks on statues: New Zealand as a case study.

OBJECTIVES: We aimed to describe the epidemiology of statue attacks along with statue representativeness relative to modern day demographics in one case study country: New Zealand. METHODS: We performed Internet searches for the existence of outdoor statues of named individuals and historical attacks in New Zealand (NZ), combined a national survey with field visits to all identified statues to examine for injuries and repairs. RESULTS: Of the 123 statues identified, nearly a quarter (n = 28, 23%) had been attacked at least once (total of 45 separate attack events), with the number of attacks increasing from the 1990s. Attacks involved paint/graffiti (14% of all statues at least once), nose removal/damage (7%), decapitation (5%), and total destruction (2%). The risk of attack was relatively higher for statues of royalty (50%), military personnel (33%), explorers (29%), and politicians (25%), compared to other reasons for fame (eg, 0% for sports players). Statue subjects involved in colonialism or direct harm to Maori (Indigenous population), had 6.61 (95%CI: 2.30 to 19.9) greater odds (adjusted odds ratio) of being attacked than other subjects. Most of the statue subjects were of men (87%) and Europeans (93%). Other ethnicities were 6% Maori (comprising 15% of the population) and 1% each for Asian and Pacific peoples, who comprise 12% and 7% of the population respectively. CONCLUSIONS: This national survey found an association between statue attacks and the role of statue subjects in colonialism or direct harm to the Indigenous population. Furthermore, the demography of the statue subjects may represent historical and current social power relationships-with under-representation of women and non-European ethnic groups.

Health impacts for New Zealand military personnel from the South African War of 1899-1902.

AIM: We aimed to update and provide more complete epidemiological information on the health impacts of the South African War on New Zealand military personnel. METHODS: Mortality datasets were identified and analysed. Systematic searches were conducted to identify additional war-attributable deaths in the post-war period. To estimate the morbidity burden, we analysed a random sample of archival military files of 100 military personnel. Lifespan analyses of veterans included those by level of combat exposure (eg, a non-combat sample came from a troopship that arrived at the time the war ended). RESULTS: We identified 10 additional war-attributable deaths (and removed three non-attributable deaths) to give a new New Zealand total of 239 war-attributable deaths. Given the average age of death of 26 years, this equates to the loss of 10,300 years of life. Most deaths (59%) were from disease rather than directly from the conflict (30%). Over a third (39%; 95%CI: 30%-49%) of personnel were estimated to have had some form of reported illness (26%) or injury (14%). The lifespan analysis of veterans suggested no substantive differences by exposure to combat (68.5 [combat] vs 69.1 years [non-combat]) and similarly when compared to a matched New Zealand male population. CONCLUSIONS: The mortality burden was larger and the morbidity impacts on the New Zealand military personnel in this war were much more substantive than revealed in the prior historical literature. There is a need to more fully describe historical conflicts so that their adverse health impacts are properly understood.

Poor smoke-free status of airports in a country with a smoke-free goal: New Zealand.

BACKGROUND: To survey the smoke-free status of airports in New Zealand (NZ), a country with a smoke-free goal for 2025, and where public indoor areas are required to be smoke-free. METHODS: A cross-sectional survey of a convenience sample of airports with data collection on smoke-free signage, observed smoking behaviour, cigarette butt litter and designated smoking areas. RESULTS: A total of 23 airports were surveyed, including all those for the 10 most populous urban areas in NZ (82% of all airports with scheduled flights on the main islands). There were no smoke-free signs found at entrances/exits to the terminal building in 26% of airports, with a mean of 1.7 such signs per entrance/exit. Only one airport had any signage stating that all the grounds were smoke-free. Qualitatively, the signage was often small in size (<15 cm diameter). There was also ambiguity as to what the signage related to (indoors or outdoors). Observed smoking and vaping outside of the main entrances/exits was relatively uncommon, but the great majority of these sites (91%) had discarded cigarette butts present. Most airports (70%) had some form of designated or implied outdoor smoking area, with 38% of these areas being within 10 m distance of a terminal entrance/exit. CONCLUSIONS: Despite this country having a smoke-free goal, it has largely deficient smoke-free policies at its airports. There is a case to make airport grounds entirely smoke-free as part of an upgrade of the national smoke-free law.

Smoke-free cars legislation: it works but New Zealand should still rigorously evaluate its upcoming law.

In this viewpoint we briefly review the evidence for smoke-free car legislation. We find that this legislation has been consistently associated with reduced secondhand exposure in cars with children/youth in all nine jurisdictions studied. Despite this, there are various aspects of this intervention that warrant further study-especially determining its impact on reducing tobacco-related ethnic inequalities. So we argue that the New Zealand Ministry of Health should invest in a thorough evaluation of this important upcoming public health intervention. This could both help the country in further refining the design of the law (if necessary) and would also be a valuable contribution to advancing the knowledge base for international tobacco control.

Personal protective equipment (PPE) and infection among healthcare workers - What is the evidence?

BACKGROUND: The worldwide outbreak of coronavirus disease-19 (COVID-19) has already put healthcare workers (HCWs) at a high risk of infection. The question of how to give HCWs the best protection against infection is a priority. METHODS: We searched systematic reviews and original studies in Medline (via Ovid) and Chinese Wan Fang digital database from inception to May, 2020, using terms 'coronavirus', 'health personnel', and 'personal protective equipment' to find evidence about the use of full-body PPEs and other PPEs by HCW exposed highly infectious diseases. RESULTS: Covering more of the body could provide better protection for HCWs. Of importance, it is not just the provision of PPE but the skills in donning and doffing of PPE that are important, this being a key time for potential transmission of pathogen to the HCW and in due time from them to others. In relation to face masks, the evidence indicates that a higher-level specification of face masks and respirators (such as N95) seems to be essential to protect HCWs from coronavirus infection. In community setting, the use of masks in the case of well individuals could be beneficial. Evidence specifically around PPE and protection from the COVID-19 virus is limited. CONCLUSION: Covering more of the body, and a higher-level specification of masks and respirators could provide better protection for HCWs. Community mask usecould be beneficial. High quality studies still need to examine the protection of PPE against COVID-19.

The long-term supply of tobacco and nicotine: some goals, principles and policy implications.

There is a growing literature on regulating the supply of tobacco products to achieve tobacco-free goals. This article suggests three goals and eight principles that could underpin regulatory approaches to the supply of tobacco and non-prescription nicotine products. The primary principles are that tobacco and nicotine products should not be seen as normal consumer products, should not be supplied for profit, and that the tax revenue from the supply of the products should first be used to reduce tobacco and nicotine use.