The second wave of 2009 pandemic influenza A(H1N1) in New Zealand, January-October 2010.

This paper uses data from multiple surveillance systems to describe the experience in New Zealand with the second complete wave of pandemic influenza A(H1N1)2009 in 2010. Measures such as hospitalisation rates suggest the overall impact of influenza A(H1N1)2009 in 2010 was between half and two thirds that of the first wave in 2009. There was considerable regional and sub-regional variation with a tendency for higher activity in areas that experienced low rates in 2009. Demographic characteristics of the second wave were similar to those in 2009 with highest rates seen in children under the age of five years, and in indigenous Maori and Pacific peoples. Hospital services including intensive care units were not under as much pressure as in 2009. Immunisation appears to have contributed to the reduced impact of the pandemic in 2010, particularly for those aged 60 years and older.

Transmissibility of 2009 pandemic influenza A(H1N1) in New Zealand: effective reproduction number and influence of age, ethnicity and importations.

The first wave of pandemic influenza A(H1N1) has subsided in New Zealand as in other southern hemisphere countries. This study aimed to estimate the effective reproduction number (R) of 2009 pandemic influenza A(H1N1) taking into account imported cases. It also aimed to show the temporal variation of R throughout the New Zealand epidemic, changes in age- and ethnicity-specific cumulative incidence, and the effect of school holidays. Using a new modelling method to account for imported cases, we have calculated the peak R during the containment phase of the pandemic as 1.55 (95% confidence interval: 1.16 to 1.86). This value is less than previously estimated in the country early in the pandemic but in line with more recent estimates in other parts of the world. Results also indicated an increase in the proportion of notifications among school-age children after the school holiday (3-19 July 2009). This finding provides support for the potential effectiveness of timely school closures, although such disruptive interventions need to be balanced against the severity of the pandemic.

Pandemic influenza A(H1N1)v in New Zealand: the experience from April to August 2009.

Following the detection of imported cases of pandemic influenza A(H1N1)v on 25 April 2009, New Zealand implemented containment measures that appeared to slow establishment of the pandemic during May. The pandemic accelerated markedly in June, reaching a peak within four to six weeks, and has been declining since mid-July. By 23 August there had been 3,179 recorded cases (97.8% reported as confirmed), including 972 hospitalisations, 114 intensive care admissions, and 16 deaths. Influenza-like illness (ILI) surveillance in general practice suggests that 7.5% (95% CI: 3.4-11.2) of the population of New Zealand had symptomatic infection, giving a case fatality ratio of 0.005%. Hospitalisations were markedly higher for Maori (age standardised relative risk (RR)=3.0, 95% CI: 2.9-3.2) and Pacific peoples (RR=6.7, 95% CI: 6.2-7.1) compared with Europeans and others. The apparent decline of the pandemic (shown by all surveillance systems) cannot be fully explained. New Zealand remains in the middle of its traditional influenza season, the influenza A(H1N1)v virus appears relatively infectious, and we estimate that only about 11% of the population have been infected by this novel agent.

How to recognize and manage psychological distress in cancer patients.

Psychological distress is common in cancer patients, however, it is often unrecognized and untreated. We aimed to identify barriers to cancer patients expressing their psychological concerns, and to recommend strategies to assist oncologists to elicit, recognize, and manage psychological distress in their patients. Medline, Psychlit, and the Cochrane databases were searched for articles relating to the detection of emotional distress in patients. Patients can provide verbal and non-verbal information about their emotional state. However, many patients may not reveal emotional issues as they believe it is not a doctor's role to help with their emotional concerns. Moreover, patients may normalize or somatize their feelings. Anxiety and depression can mimic physical symptoms of cancer or treatments, and consequently emotional distress may not be detected. Techniques such as active listening, using open questions and emotional words, responding appropriately to patients' emotional cues, and a patient-centred consulting style can assist in detection. Screening tools for psychological distress and patient question prompt sheets administered prior to the consultation can also be useful. In conclusion, the application of basic communication techniques enhances detection of patients' emotional concerns. Training oncologists in these techniques should improve the psychosocial care of cancer patients.

Immunity to hepatitis B in two birth cohorts given plasma-derived or yeast-derived vaccine.

AIM: To determine the antibody response to either yeast-derived or low-dose, plasma-derived hepatitis B vaccine, in two cohorts of infants monitored by an immunisation coordinator and immunised by general practitioners. METHODS: Infants born to two cohorts of non-carrier mothers in Northland were followed up, the first receiving a low-dose, plasma-derived vaccine, the second a yeast-derived vaccine. An immunisation coordinator enrolled the mothers into the programme during pregnancy, promoted full immunisation against hepatitis B and later obtained blood samples from their babies. In each cohort, four subsamples of babies, randomly assigned, were bled for estimation of antibody levels to hepatitis B at ages 18, 30, 42 and 54 months (1 1/2, 2 1/2, 3 1/2, 4 1/2 years). No infant was bled more than once. RESULTS: In both cohorts, antibody levels declined significantly with age. By age 4 1/2 years, 5.1% of children (95% confidence interval (CI): 3.5-7.1) immunised with yeast-derived vaccine were estimated to have antibody levels to hepatitis B below the acceptable level for protection of 10 IU/L. The proportion for those immunised with plasma-derived vaccine was 14.3% (95% CI: 7.4-24.1). CONCLUSIONS: Children receiving yeast-derived vaccine do not require a second booster dose at school entry, although this might be considered at age 11. There are grounds to suggest that those who received low-dose, plasma-derived vaccine (prior to 1990) should be offered a booster before age 11.

Lead based paint hazards in early childhood centres in the Wellington region.

AIM: To determine the frequency of exposure to lead based paint (LBP) in early childhood centres (ECCs) in the Wellington region. METHODS: Senior staff at sixty nine randomly selected licensed ECCs in the Wellington region were contacted. Fifty two centres consented to participate. Senior staff at these centres were interviewed and centres built before 1980 were examined for damaged LBP surfaces accessible to children. The survey was carried out between July 1995 and January 1996. A centre was considered to be LBP positive if it had at least one damaged LBP surface accessible to children in the course of a normal day's activities. RESULTS: Fifty two per cent of surveyed centres were LBP positive. LBP hazards were detected in 60% of buildings built before 1965 and 30% of buildings constructed between 1965 and 1980, and were found more frequently in Te Kohanga Reo and childcare centres. Although children aged 2 years and under constituted only 27% of all children attending surveyed centres, over half (53%) of the children in this age group attended centres with an LBP hazard. Staff at ECCs were often uncertain about the causes and outcomes of lead toxicity and expressed a desire for further education. CONCLUSION: There is significant potential for exposure to lead in early childhood centres in Wellington as a consequence of accessible damaged lead based paint surfaces.

The characteristics and outcomes for patients presenting with unintentional domestic injuries to general practice.

AIM: To describe domestic unintentional injuries in three large, computerised general practices in the Wellington area. METHOD: Details of all domestic injuries were recorded from Accident Compensation Corporation (ACC) forms. RESULTS: Initial consultations for domestic unintentional injuries counted for 29.4% of all injuries for which ACC forms were completed and represented 1.2% of all patient contacts. The very young and elderly presented more frequently with domestic unintentional injuries. The types of injury and the injury incident varied between age groups. Most (75%) of the injured patients were treated by the practices without referral. CONCLUSION: Most (96%) of the patients who presented with domestic unintentional injuries were registered patients of the practices. This relationship provides an important opportunity for general practitioners to advise patients about accident prevention. More research is needed to compare the presentation of domestic unintentional injuries in general practice and in hospitals with accidents in the community.

Evaluation of an otitis media with effusion screening pilot programme.

AIM: To evaluate an otitis media with effusion (OME) pilot screening programme carried out in a low socioeconomic status population. METHODS: The evaluation methodology involved a literature review, key informant interviews and evaluation of the programme according to standard screening criteria. Operational analysis was carried out in which inputs, outputs and costs were analysed. RESULTS: 731 children were screened. The proportion of the target population screened was 91.2%. Forty nine point seven percent (363) of children tested had bilateral OME on at least one occasion, of whom 25.3% (92) were referred to otorhinolaryngology (ORL). The average cost of screening each child was $46.10, of detecting a case of bilateral OME $92.85, and of detecting a case requiring referral $117.03. CONCLUSIONS: The programme demonstrated that a low socioeconomic status population can be successfully screened; that the high rate of spontaneous resolution of OME should be taken into account when designing screening protocols; that screening has significant impact on secondary services; and, screening is likely to have other benefits arising from more frequent contact with children and parents. The operational success of the pilot gives no indication, however, concerning the long term outcomes of tympanometry screening. The authors conclude that further research is required to establish the long term benefits of OME screening, and resource requirements.

Assessment of the risk of transmission of N meningitidis in a classroom setting.

AIM: To evaluate the risk of colonisation with N meningitidis among university classroom contacts of a student with invasive meningococcal disease. METHODS: Throat cultures were obtained from classmates and faculty exposed to a university student with meningococcal disease. Exposures to the index case were quantified using a questionnaire. RESULTS: None of the 41 students and staff from whom cultures were obtained showed evidence of colonisation with N meningitidis. The contacts had spent an average of 13.5 h in class with the index case during the 2 days prior to the onset of her illness. CONCLUSIONS: The risk of colonisation with N meningitidis among casual university classroom contacts appears to be low. This study lends support to decisions to withhold chemoprophylaxis in most instances of such contact.

Delivery of hepatitis B immunisations in a selection of computerised general practices.

AIM: To assess the value of computerised general practices in providing information concerning the delivery of hepatitis B immunisation. METHODS: Hepatitis B immunisation data from August 1990 to June 1991 were collected from 27 general practices participating in a sentinel network. RESULTS: The study identified significant limitations in the use of data from computerised general practices for estimating hepatitis B immunisation coverage. While an accurate coverage figure could not be estimated, the results did suggest that hepatitis B coverage for three doses was at least 59.5% and that its use was very similar to the triple vaccine and measles/MMR for the third dose. Hepatitis B immunisation delivery outside the desirable time periods was common at 44%, suggesting a fairly disrupted immunisation schedule for many children. CONCLUSIONS: The relatively infrequent delivery of hepatitis B vaccine at the same time as other vaccinations may reflect provider concern about administering multiple injections at the same visit. Further improvement in the collection of data by computerised practices is necessary before the full value of this data source can be realised. Improvements in reminder/recall systems would improve the efficiency with which hepatitis B immunisation is delivered.

Meningococcal disease in New Zealand: an audit of disease notification and contact management.

AIMS: To determine variations in practice across New Zealand for the notification and contact management of meningococcal disease and recommend action. METHODS: A retrospective survey using a questionnaire conducted during August and September 1992. The disease notification component of the audit looked only at process (post notification) rather than completeness of notification. RESULTS: The results indicated that there was considerable variation in practice across the country. Concerns expressed by respondents related to the availability of and payment for prescribed prophylactic antibiotics, contact definition, protocol availability and the appropriate delegation of duties. Deficiencies were identified in the above areas of concern as well as in follow-up procedures for contacts, record keeping and communication. CONCLUSIONS: Major variations in practice across the country which may be counterproductive to outbreak control should be minimised. A minority of area health boards (AHBs) and districts have well developed protocols that could be the basis for developing standards of good practice for the whole country.

Impact of a promotion program for hepatitis B immunisation.

This study compared levels of hepatitis B immunisation in a group of 524 infants in Northland, New Zealand, with levels in the remainder of the country. The Northland sample had specific encouragement from an immunisation coordinator and had been followed from birth. Levels throughout the rest of the country were estimated from four samples totalling 317 infants whose parents were interviewed when the child was at least two years old. The cross-sectional nationwide sample had fewer children 'fully immunised' by two years of age (minimum estimate 61.8 per cent, maximum estimate 69.7 per cent) than the cohort of children (not lost to follow-up) who were encouraged to have the immunisations in Northland (77.5 per cent) (Z = 4.73, P < 0.001 for comparison with the minimum nationwide estimate; Z = 2.45, P = 0.014 for comparison with the maximum estimate). Of the Northland cohort, 13.5 per cent were lost to follow-up before the scheduled completion of the hepatitis B vaccinations. Assuming that every child lost to follow-up was not fully immunised, the efforts of the immunisation promotion program operated by a nurse coordinator increased the percentage of children fully immunised by between about 7.8 per cent and 15.7 per cent. A promotion program for hepatitis B immunisation, operated by an immunisation coordinator, is an effective tool for increasing immunisation coverage.

Public health and the reforms: the New Zealand experience.

The main aim of a national public health service is to conserve and improve the population's health. The health service reforms introduced in 1992 proposed the establishment of a Public Health Commission, which was to be responsible for health monitoring, public health policy advice and the purchase of public health services. These reforms, implemented in 1993, while emphasising a purchaser-provider separation also earmarked a budget for public health activities to be administered by the Commission. Such protection of funding is unusual. Public health activities span a wide range of measures to protect and promote health as well as to prevent disease. Many of these measures have been, and will continue to be, carried out at a local level. The results of some of these measures are not usually seen in the short term. Improvement of the population's health also requires proactive measures which are outside the traditional health service. The demonstration of quantifiable benefits to the public's health from such measures may require an even longer term. It is mainly in this area of activity, however, that the achievements of the Commission will be judged. Beginning with a short summary of the history of public health services in New Zealand, this paper looks briefly at the events that led to the establishment of the Public Health Commission, before moving on to describe its achievements to date, the challenges it faces and its impact on public health service provision. Based on such observations and an analysis of the strengths and weaknesses of the Commission, the paper attempts an appraisal of the public health function in the reformed health service, a function that will almost certainly be observed with interest in other countries. Certain ways of improving the public health function are outlined in the conclusions.

International health teaching: a survey of 100 medical schools in developed countries.

The survey reported here was designed to assess the availability of international health teaching to medical students in developed countries. For the purpose of this enquiry international health teaching was defined as any instruction on comparative morbidity or mortality, service provision, demographic change and disease prevalence in non-industrialized developing countries. The results indicated that this topic is not regarded as being of high priority in the majority of institutions.

Communicable disease in New Zealand.

Communicable diseases remain a major problem in New Zealand; one which often only comes to the attention of management when an outbreak occurs and health care dollars are required for disease control. Hepatitis B and rheumatic fever remain the two diseases that place New Zealand in the developing nation league. Overall, the impact on mortality is low (only 5% in the 1-14 year age group) as is the impact on potential years of life lost. Morbidity figures are not known with any degree of accuracy as they are dependent on a notification system acknowledged to be deficient and hospital discharge data which include only a fraction of cases for a few serious diseases. The main preventive action hinges on the childhood immunisation programme which has undergone recent change. The true impact of environmental hygiene measures, health promotion and education has not been evaluated.

Occupational risk of hepatitis B for police and customs personnel.

A cross-sectional study was undertaken in 1987 to establish whether New Zealand police and customs officers are at excess risk of hepatitis B virus infection as a consequence of occupational exposure to human blood and penetrating injury. The study population comprised all full-time police (n = 5,193) and customs officers (n = 1,026) excluding only a small number on special duty who had already been immunized. The control group comprised the civilians employed by both organizations (n = 964). The prevalence of hepatitis B markers in the control group, when standardized for age, sex, and ethnic distribution, was 13.4%, which agrees well with New Zealand blood donor figures. The prevalence ratios for police officers and customs officers compared with the civilians (adjusted for age, sex, and ethnic distributions) were 0.82 (95% confidence interval (CI) 0.63-1.06) and 0.49 (95% CI 0.34-0.70), respectively. Multivariate analysis was used to further explore the differences in marker prevalence among the three groups, but failed to demonstrate any significant association between occupational variables and marker prevalence. There was an association between time spent living in high-risk areas of the country and marker prevalence. The authors conclude that the question as to whether police personnel should be immunized begs the wider issue of whether or not the whole New Zealand population should be so protected.

Domestic unintentional injuries presenting to the accident and emergency departments in the Wellington region.

A prospective descriptive study of domestic unintentional injuries attending accident and emergency (A & E) departments in the Wellington region is presented. In a three month period there were 2207 such attendances. There was no difference in the proportion of males and females seen. A disproportionate number of the very young (under five years of age) and the elderly (65 years and over) attended A & E departments for these injuries. Approximately one-quarter of the attendances were for cuts or lacerations (26.6%) and one-fifth were for fractures (18.0%). Crude estimates of distance indicate that, on average, people travel greater distances for fractures than for other injuries. General practitioners referred one-tenth (10.6%) of all the attendances. Outcomes from the A & E attendances were: 70.4% were discharged, 7.7% were admitted to hospital, 14.6% were referred to outpatient clinics, and 7.2% were referred back to their general practitioners. There were no deaths in A & E departments.