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PAEDIATRICSOCIETY
NEW ZEALAND
PAEDIATRICSOCIETY
NEW ZEALAND
The burden of preventable breathing diseases
in children and young people
Full Document
Edited by Innes Asher and Cass Byrnes
“Trying to Catch Our Breath”
The burden of preventable breathing diseases in children and young people
The Asthma and Respiratory Foundation of New Zealand
Edited by Innes Asher and Cass Byrnes
PAEDIATRICSOCIETY
NEW ZEALAND
PAEDIATRICSOCIETY
NEW ZEALAND
iv
ISBN 0-473-10881-X
Disclaimer: This publication is intended to provide accurate and adequate information on the matters contained herein and every effort has been made to ensure its accuracy. However, it has been written, edited and published and made available to all persons and entities strictly on the basis that its authors, editors and publishers are fully excluded from any liability or responsibility by all or any of them in any way to any person or entity for anything done or omitted to be done by any person or entity in reliance, whether totally or partially, on the contents of this publication for any purpose whatsoever.
Design & layout: Tadd Clayton, ISAAC Data Manager, Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland.
© 2006 The Asthma and Respiratory Foundation of NZ (Inc.)Level 1, Panama House, Panama StreetPO Box 1459WellingtonNew Zealand
Ph: +64 4 499 4592Fax: +64 4 499 4594Email: [email protected]: www.asthmanz.co.nz
No part of this publication may be reproduced by any process in any language without written consent of the copyright holders. The opinions expressed in this bulletin are those of the authors and not necessarily attributable to the publisher.
v
Contents
List of Figures viiiList of Tables ixContributors xExecutive Summary xiKey Recommendations xiPreface xiv
Part One 1Chapter 1: The Socioeconomic Context of Respiratory Disease 2
1.1 Recommendations 5Chapter 2: Healthcare Delivery 7
2.1 Recommendations 8Chapter 3: The Context for Maori Tamariki and Taitamariki 9
3.1 Respiratory Disease and Maori Children 93.2 SomeSpecificExamples–Asthma,Bronchiectasis,Pneumonia 103.3 Summary 123.4 Recommendations 123.5 Glossary: 12
Chapter4: TheContextforPacificChildren 136.1 Recommendations 16
Chapter5:ImmunisationDelivery 175.1 Low Coverage 175.2 Improving Coverage 185.3 Recommendations 19
Part Two 21Chapter6: TheBurdenof Smoking-relatedRespiratoryIllnessinChildrenand 22 YoungPeople
6.1 SmokingPrevalenceinNewZealand 226.2 Exposureof childrentocigarettesmoke 236.3 HealthRisksandBurden 256.4 Preventionof AdolescentUptake 266.5 Recommendations 26
Chapter7: NewZealand’sExcessivePertussisDiseaseBurden 287.1 ClinicalPertussis 287.2 PertussisMortality 287.3 PertussisMorbidity 297.4 WhyDoesNewZealandHaveSoMuchPertussis? 327.5 Summary 337.6 Recommendations 34
vi
Chapter8: WhatDoesPneumoniaCostNewZealand? 358.1 ClinicalPneumonia 358.2 HowCommonisPneumonia? 358.3 ArePneumoniaHospitalisationsAvoidable? 378.4 Measurementof theCostof TreatingChildrenWithAcutePneumonia 378.5 ChildhoodPneumoniaLeadingtoHealthProblemsforAdults 388.6 SummaryandConclusions 398.7 Recommendations 39
Chapter9: TheBurdenof BronchiolitisinNewZealand 409.1 Rates of Infection 409.2 HospitalisationforBronchiolitisinNewZealand 419.3 RiskFactorsforAdmission 429.4 Mortality 429.5 Financial Costs 439.6 Prevention 449.7 Summary 459.8 Recommendations 45
Chapter10: TuberculosisinChildren 4710.1 Recommendations 50
Chapter11: TheBurdenof BronchiectasisinNewZealandChildren 5111.1Bronchiectasis 5111.2 Rates of Disease 5111.3Aetiology 5311.4 Socioeconomic Considerations 5411.5 Mortality 5411.6Future 5511.7 Recommendations 55
Chapter12: ObstructiveSleepApnoeainChildren 5612.1Definitions 5612.2Prevalence 5612.3Morbidity 5712.4 Diagnosis 5712.5 Treatment 5812.6EconomicBurden 5812.7SummaryandRecommendations 58
Chapter13:Asthma 6013.1Prevalence 6013.2Morbidity 6113.3SocioeconomicandEthnicFactors 6313.4Summary 6513.5 Recommendations 65
vii
References 67
viii
Figure: Top10Causesof PotentiallyAvoidableAdmissions,0-24Years,1999. xiv
Figure1-1: Percentagechangeinaveragehouseholdequivalentdisposableincome 2 bydecile1982-2001(inequivalent2001dollars).
Figure1-2: Thepopulationof NewZealandin5yearagebands,withtheproportion 3 in poverty estimated in red.
Figure1-3: TheChildPovertyLeague. 4
Figure1-4: Maximumperweekrealfamilyassistance1986-2008. 5
Figure3-1: Populationpyramidof theMaori&non-Maoripopulations,2000. 9
Figure4-1: NewZealandinfantmortalitybyethnicgroup. 14
Figure4-2: AmbulatorysensitivehospitalisationsforNZunder5yearolds, 15 byethnicity,1996-2002.
Figure4-3: Respiratoryinfectionadmissions,CountiesManukau,childrenunder 15 15years,1999.
Figure6-1: Prevalenceof cigarettesmoking(%)(15+years),1976–2002. 22
Figure7-1: FiveyearmovingaveragepertussismortalityrateinNewZealand 29 per100,000personyears1872to1990.
Figure7-2: Globalannualreportedincidenceof childhoodvaccinepreventable 30 diseases,1980-99.
Figure7-3: PertussisincidenceintheWesternPacificregionper100,000 31 population1990-99.
Figure7-4: Internationalcomparisonof averageannualpertussishospitaldischarge 33 ratesduringthe1980sand1990s.
Figure8-1: Paediatricpneumoniahospitalisationratesbyageandethnicgroupin 36 Auckland,1993to1996.
Figure10-1: Incidenceof TuberculosisbyYearNewZealand,1970-2003. 47
Figure10-2: DeprivationinchildhoodTBcasesversusallNZchildren. 50
Figure11-1: CTscanof bronchiectasisillustratingtypicalfeaturesof airway 52 dilatationwithsputumplugging.
Figure11-2: NewZealandbronchiectasisstudy. 52
Figure11-3: X-rayillustratingbronchiectasis. 53
Figure11-4: Starshipbronchiectasisclinic. 53
Figure12-1: Sixtysecondsof arecordingduringsleep,showinganobstructive 57 event lasting 15 seconds.
Figure13-2: Changeinprevalenceof recentwheeze,asthma,andfrequentwheeze 61 between1985studyof 8-10yroldchildreninAucklandand1993 ISAACstudyof 6-7yroldchildreninAuckland.
Figure13-3: AsthmaHospitalAdmissionsinNewZealand,1989–99. 62
List of Figures
ix
Table1-1: Changesinpolicyadverselyaffectingchildhealth. 3
Table5-1: Immunisationcoverageestimatesforpertussisantigen. 17
Table6-1: Prevalenceof smokinginNZpregnantmothers1990-91. 23
Table6-2: Prevalenceof tobaccosmoking,1996. 23
Table6-3: ActiononSmokingandHealth(ASH)studiesof prevalenceof tobacco 24 smokinginYear10(15yrolds).
Table6-4: Estimatedrespiratoryhealthrisksandburdenof healtheffectsin 25 NewZealandchildren.
Table7-1: AveragemonthlyB. pertussisisolateratesper100,000. 32
Table8-1: Estimatedannualcostsof pneumoniainNewZealandbasedupon 38 hospitaladmissions,emergencydepartmentvisitsandGeneral Practitionerconsultations.
Table9-1: Numbersof potentiallyavoidablehospitalisationsforbronchiolitisper 41 thousandchildren.
Table10-1: NeonatalBCGEligibilityCriteria2002. 48
List of Tables
x
Contributors
ProfessorInnesAsherDepartmentof PaediatricsTheUniversityof AucklandHonoraryConsultantPaediatricRespiratoryMedicineStarshipChildren’sHealthAuckland
DrCassByrnesSeniorLecturerDepartmentof PaediatricsTheUniversityof AucklandHonoraryConsultantPaediatricRespiratoryMedicineStarshipChildren’sHealthAuckland
AssociateProfessorCameronGrantDepartmentof PaediatricsTheUniversityof AucklandPaediatricianStarshipChildren’sHealthAuckland
Dr Matire HarwoodDirector,MaoriandPacificHealthResearchProgrammeMedicalResearchInstituteof NewZealandWellington
AssociateProfessorRichardMilneManaging DirectorHealthOutcomesAssociatesLtdSchoolof PopulationHealthTheUniversityof AucklandAuckland
DrGillianNixonPaediatricRespiratoryandSleepSpecialistStarshipChildren’sHealthHonoraryClinicalSeniorLecturerDepartmentof PaediatricsTheUniversityof AucklandAuckland
DrPhilipPattemoreSeniorLecturerDepartmentof PaediatricsChristchurchSchoolof MedicineUniversityof OtagoChristchurch
DrTeuilaPercivalPaediatricianKidzFirstSouthAucklandHealthPresidentof PasifikaMedicalAssociationManukauCity
AssociateProfessorJimReidDepartmentof GeneralPracticeUniversityof OtagoDunedin
Dr Ian ShawPaediatricianSouthlandHospitalInvercargill
DrNikkiTurnerDirector,ImmunisationAdvisoryCentreSchoolof PopulationHealthUniversityof AucklandAuckland
Dr Lesley VossPaediatricInfectiousDiseaseSpecialistStarshipChildren’sHealthAuckland
xi
Executive Summary
InNewZealandtherearefartoomanychildrenstrugglingtobreatheduetorespiratorydiseases.
This monograph documents the situation for whooping cough,pneumonia, bronchiolitis, tuberculosis, bronchiectasis, obstructivesleepapnoea,asthma,andsmokingrelatedrespiratoryillness.
Inseekingreasonsforthehighratesof theseconditions,theauthorshavedemonstratedrelationshipswithpoorhousing,poverty,poornutrition, ethnic disparities, access to primary, secondary andtertiaryhealthcare,publicawareness,healthprofessionaleducation,smokingandairpollution.
Recommendations address the root influences on these factors,manyof whichrequirechangesingovernmentpolicy,andactionsfromtheMinistryof HealthandDistrictHealthBoards.
Itisimportanttoactnow,becauseof theenormouspersonal,socialandeconomiccostof thecurrentsituation,andtheneedtoinvestinthefutureof NewZealandthroughimprovingthehealthof ourchildren.
Key Recommendations
For Government:
Introduceagovernmentalobligationtomonitorandreportonchild poverty.
Createstrategiesandatimelinetoreduceandeliminatechildpoverty.
Strengthen the New Zealand housing strategy to providesufficient resources to enable universal access of children touncrowded,insulatedandaffordablehousing.
Resourcetheprovisionof easilyaccessible,freeprimaryhealthcare,24hoursaday,7daysaweek,andfreeprescriptions,forchildrenandyoungpeople.
Continueincreasesinthetaxandrealpriceof tobacco.
Seek to eliminate the subtle marketing of tobacco to youngpeople through international films, sports coverage, andsponsorshipof educationalgroupsormaterial.
Requiretobaccocompaniestoshowgraphichealthwarningsoncigarette packets.
Introduce government policies to encourage healthier eating,andencouragephysicalexercise.
Legislate for compulsory vehicle exhaust emission testing aspartof Warrantof Fitnesstoreduceairpollution.
Develop an inter-sectorial approach to prevention of tuberculosis(TB)(immigration,housing,health,educationandjusticesectors).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
“The primary determinants of
disease are mainly economic and social,
and therefore its remedies must also be economic
and social. Medicine and politics cannot and should not be
kept apart.”
Sir Geoffrey Rose, The Strategy of Preventive
Medicine, 1992.
“The primary determinants of
disease are mainly economic and social,
and therefore its remedies must also be economic
and social. Medicine and politics cannot and should not be
kept apart.”
Sir Geoffrey Rose, The Strategy of Preventive
Medicine, 1992.
“Our children and young people
deserve to grow up in supportive families
with adequate incomes; to have a
secure home and to have their health
and education needs met; to live lives
free from violence and crime; and to
be able to fulfil their potential as human
beings. Children and young people are our
future, and we neglect them at our peril.”
Right Honourable Helen Clark, Prime Minister, Opening
speech to Parliament, February 2002
xii
For the Ministry of Health:
Monitorandreportonnational indicatorsof childandyouthrespiratory health and wellbeing with accurate ethnicity data,andsetaccountabletargetsfortheirimprovement.
IncluderespiratoryillnessasahealthpriorityintheNZHealthStrategy.
Develop initiatives which lead to increased capacity of Maori healthworkforcetoworkwithtamarikiandtheirwhanau.
Increase immunisation levels focusing particularly onearly immunisation for pertussis through a broad publiccommunication strategy, improved funding for immunisationservicedelivery,andcompletionof therolloutof theNationalImmunisationRegister.
Develop more well resourced and accessible programmes topreventandtreatobesity.
Implement widespread education of the public and healthprofessionalsabouttheconditionsinthisdocument.
ImplementthePaediatricSocietyof NewZealanddocuments:a)3bestpracticeevidence-basedguidelines,2005:(i)Managementof asthmainchildrenaged1-15years;(ii)Wheezeandchest infectionin infantsunder1year;and(iii)Assessmentof sleepdisorderedbreathinginchildhood.
b)Through theEyesof theChild,RespiratoryServices1998withupdate,RespiratoryServiceGuidelines,2003.
c)NationalReviewof SleepServicesforChildrenandYoungPeople,2002.
For the Ministry of Transport:
Introducecompulsoryvehicleemissiontestingforallvehiclesaspart of Warrant of Fitness.
ForDistrictHealthBoards(DHBs):
Monitor and report on DHB indicators of child and youthrespiratory health and wellbeing with accurate ethnicity data,andsetaccountabletargetsfortheirimprovement.
DistrictHealthBoardswhichidentifyhighratesof respiratorydisease in children should develop local strategies to reducetheselevels,andmonitortheoutcomes.
District Health Boards with poorly serviced areas need todevelop strategies to address service delivery and health care provision for respiratory diseases.
DistrictHealthBoardsneedtohavespecificstrategiesforMaorichildrenandyoungpeople.
DistrictHealthBoardsneedtohavespecificstrategiesforPacificchildrenandyoungpeople.
Develop the capacity of Maori health work force to work with tamarikiandtheirwhanau.
11.
12.
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14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
“I visited a family who had almost no furniture in the house. They had taken their child to the doctor one evening in the previous week for an asthma attack. They spent $80 for the visit and the medications. This was their entire food budget for the following week. They were eating white bread and butter.”
Claire Richards, Asthma Nurse Educator, Porirua Asthma Service.
xiii
Develop strategies to improve early childhood nutrition,includingbreast-feedingrates.
Implement a Systems approach to identify smoking and smoke exposure in every patient, including exposure of children totobaccosmokeinthehome.Identificationneedstobepatient-friendlybutshouldensurethatallinvolvedhealthprofessionalsare aware that patients are exposed to this major risk to health.
Improve policies, education and programmes to aid smokeaddictedpeopletoreduceandgiveupsmokingtoreducethesmoke exposure of infants. This would include support of smokingcessationamongadults andparents,usinga systemsapproach.
Develop more accessible programmes to prevent and treatobesity.
Implement widespread education of the public and healthprofessionalsabouttheconditionsinthisdocument.
Continuing implementation of TB control programmes todetectinfectiouscasesof TBbeforespreadtochildrenoccursand implementation of programmes in the health system,immigrationandhousingtohelpreducespreadof disease.
Developmentof community-basededucationprogrammesinatriskgroupstoremovethestigmaof TBandbronchiectasis.
Increase general public and medical staff awareness of keyrespiratory symptoms including snoring, and persistentproductiveormucousycoughinachildof morethan6-8weeksduration.
ImplementthePaediatricSocietyof NewZealanddocuments:a)3bestpracticeevidence-basedguidelines,2005:(i)Managementof asthmainchildrenaged1-15years;(ii)Wheezeandchest infectionin infantsunder1year;and(iii)Assessmentof sleepdisorderedbreathinginchildhood.
b)Through theEyesof theChild,RespiratoryServices1998withupdate,RespiratoryServiceGuidelines,2003.
c)NationalReviewof SleepServicesforChildrenandYoungPeople,2002.
For universities, other tertiary education institutions and healthproviders:
Develop the capacity of Maori health work force to work with tamarikiandtheirwhanau.
Developthecapacityof Pacifichealthworkforcetoworkwiththeir children and families.
Promote further research into prevention of pneumonia,bronchiectasisandsleepbreathingproblemsinchildren.
25.
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xiv
Preface
It is disturbing that many children in New Zealand suffer frombreathingdifficultyandrespiratorydiseases,andthatourratesforsomeconditionsarehigherthancomparablecountries.Whatismostdisturbingisthatmuchof thisburdenof diseaseispreventable.
This document discusses the context of respiratory disease inNewZealand, describes themajor diseases and their effects, andrecommendswhatcanbedonetoreducetheburdentoindividualchildren,theirfamilies,andsociety,withimmediateandlong-termbenefits. This document and the summary version were writtenbecauseof seriousconcernamongNewZealandpaediatriciansthatthesediseasesshouldbedocumentedandaddressed.Theauthorsof thechaptersareNewZealandauthoritiesintheirfield.
Included in thisdocument are smoking related respiratory illnessand the major lower respiratory diseases: pertussis, pneumonia,bronchiolitis, tuberculosis,bronchiectasis andasthma. In additionchildren with obstructive sleep apnoea are discussed. Upperrespiratoryinfectionsareverycommon,butarenotcoveredinthisdocument: the common cold, tonsillopharyngitis, otitis media,sinusitisandviralcroup.Suddenunexpecteddeathininfancyisalsonotincluded.
Is it possible to describe these conditions as preventable? Thistermimpliesthatsomeactionscouldbetakentoavoidtheillnessoccurringinthefirstplace,ortopreventtheconditionworseningorbecoming severeorpersistent,or to avoidhospital admission.OurMinistryof Health categoriseshospitalisations aspotentiallyavoidableorunavoidable.AmongtheTop10causesof potentiallyavoidablehospitaladmissionsinNewZealandersaged0-24years,themajorityarerespiratoryconditions(Figure).
Abundant researchhas identifiedmanyof the issueswhichneedtobeaddressedtopreventtheseconditions,butaneedforfurtherresearchhasbeenidentifiedinspecificareas.Thismonographgives
“We cannot waste our precious children.Not another one, not another day.It is long past time for us to act on their behalf.”
Nelson Mandela and Graça Machel. From Global Movement for Children, a letter to the people of the world, May 2000.
“We cannot waste our precious children.Not another one, not another day.It is long past time for us to act on their behalf.”
Nelson Mandela and Graça Machel. From Global Movement for Children, a letter to the people of the world, May 2000.
GastroenteritisDental conditions
Cellulitis
Convulsions
Urinary infection
Asthma
Acute bronchiolitis
Pneumonia
Other respiratoryinfections
ENT infections
Figure: Top 10 Causes of Potentially Avoidable Admissions, 0-24 Years, 19991.
xv
informationabouttherespiratoryhealthof NewZealandchildren,and the size of the burden to these children, their families andsociety, andmakes recommendations to improve outcomes. Thescope of factorswhichmay help reduce the high rates of theseconditions are listed as recommendations the end of each chapter. These indicate that far reaching changes are needed in Government policy and its implementation across all sectors, District HealthBoardperformance,andpublicandhealthprofessionaleducation.
Inaddition, thePaediatricSocietyof NewZealandhas identifiedmany changes to service delivery which will address these diseases and these recommendations require implementation: Throughthe Eyes of the Child, Respiratory Services (1998) (updated asRespiratory Service Guidelines 2003); National Review of SleepServicesforchildrenandyoungpeople inNewZealand:facilitiesandexpertise(2002);Managementof asthmainchildrenaged1-15years (2005);Wheeze and chest infection in infants under 1 year(2005);andAssessmentof sleepdisorderedbreathinginchildhood(2005).
Part One
The New Zealand Context of Childhood Respiratory Disease
2
Chapter 1: The Socioeconomic Context of Respiratory Disease
“I visited a family who had almost no furniture in the house. They had taken their child to the doctor one evening in the previous week for an asthma attack. They spent $80 for the visit and the medications. This was their entire food budget for the following week. They were eating white bread and butter.”
Claire Richards, Asthma Nurse Educator, Porirua AsthmaService.
Since themid1980sNewZealandersexperiencedunprecedentedsweepingeconomicandsocialreforms.Thesewerearguablygreaterthan any other industrialised country. Despite this there was nomonitoringof theimpactof thereformsonthedailylivesof NewZealanders, andespeciallyno regard for their impactonchildrenand child health2. The policy changes were associated with increasing inequality andpoverty (Figure1-1).Those likely tohavehad themostadverseimpactonthehealthof childrenarelistedinTable1-1.
Many of these policy changes directly resulted in a deteriorationof the financial situation of many low income households withchildren.Thedisadvantagewasaddedtobytheincreasedcostof rentalhousing5,6.Itisnotsurprisingthatthesechangeshadmajorimpactsonhealthbecauseincomeiswidelyrecognisedasthemostimportant health determinant7,8. Income determines the abilityto purchase nutritional food; the size, adequacy and location of housing6; the ability to afford to heat the home, to buy clothing,bedding,soapandtowels;theabilitytopayforphoneandtransport,participate in sport, visit the doctor, and access medicines andeducation.Manyfamiliesbecameunabletoaffordalltheseessentialitems for their children. The proportion of children living in poverty (defined as living in a householdwith an income below60%of themedianfamilyincomenetof housingcosts)increasedfrom16% in 1987/88 to a staggering 29% (300,000 children) in
Innes AsherInnes Asher
-15
-10
-5
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10
Deciles of household income
Change(%)
Decile 1 - poorest10% of populationDecile 10 - richest10% of population
-15
-10
-5
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10
Deciles of household income
Change(%)
Decile 1 - poorest10% of populationDecile 10 - richest10% of population
Figure 1-1: Percentage change in average household equivalent disposable income by decile 1982-2001 (in equivalent 2001 dollars)3,4.This graph shows the percentage change in average household disposable income according to how well off the family is. Each of these categories – deciles – represents 10% of households. In decile 1 are the poorest families. In decile 10 are the most affluent. Over this 20 year period the rich have got richer (not including capital gain). At the same time families in the lowest deciles have less disposable income now than they did 2 decades ago (before housing costs are counted).
Figure 1-1: Percentage change in average household equivalent disposable income by decile 1982-2001 (in equivalent 2001 dollars)3,4.This graph shows the percentage change in average household disposable income according to how well off the family is. Each of these categories – deciles – represents 10% of households. In decile 1 are the poorest families. In decile 10 are the most affluent. Over this 20 year period the rich have got richer (not including capital gain). At the same time families in the lowest deciles have less disposable income now than they did 2 decades ago (before housing costs are counted).
3
2000/20019(Figure1-2).NewZealandhasoneof theworstratesof childpovertyinrichcountries10(Figure1-3).ItispuzzlingthatNewZealand’s senseof fairness andcare for thevulnerable anddependent,exemplifiedbythenon-meanstestedinflation-adjustedbenefits for super-annuitants, has not extended to the mostvulnerablemembersof ourpopulation–ourchildren–onwhomthefutureof NewZealanddepends11.
Thedeterioratingoutcomesforthehealthandwellbeingof children,andtheirrelationshiptoinadequateincomeshavebeendocumentedinnumerousgovernmental4,9,12-15andnon-governmentalreports2,10,16-20 over the last decade. There have been somemodestmeasuresintroducedsince2001whichhavebeguntoredressthedeficitsforchildren.Thisincludesthebuildingof somenewstatehouses(thecurrentwaiting list stands at about11,000), theHealthyHousingProjectwhichhasimprovedthesizeandqualityof somestatehouses,improved participation in early childhood and tertiary education,moremoneyinjectedintoprimaryhealthcare,thedevelopmentof MaoriandPacifichealthproviders,andthe2004Budget’s“WorkingforFamilies”package.This latterstrategywilleventually improvefamily incomes where parents are in work, but will not be fullyimplemented until 2007. However, the poorest 175,000 children(approximately20%)supportedbyparentsonbenefitswill largelymissout,andremainoninadequateincometomeetessentialneeds18 (Figure1-4).
1984 Market-based reforms introduced.•
1986 GST introduced on all basic consumption including food, clothing and health services.
•
1986-2008 Family income support not indexed.•
1991 Benefits cut.•
1991 The universal family benefit abolished.•
1991 The Employment Contracts Act introduced.•
1992-1999 11,000 state houses sold off.•
1993-2000 Market rents for state houses.•
1996 Child Tax Credit introduced excluding the poorest children.•
1984 Market-based reforms introduced.•
1986 GST introduced on all basic consumption including food, clothing and health services.
•
1986-2008 Family income support not indexed.•
1991 Benefits cut.•
1991 The universal family benefit abolished.•
1991 The Employment Contracts Act introduced.•
1992-1999 11,000 state houses sold off.•
1993-2000 Market rents for state houses.•
1996 Child Tax Credit introduced excluding the poorest children.•
Table 1-1: Changes in policy adversely
affecting child health.
Table 1-1: Changes in policy adversely
affecting child health.
200 150 100 50 0 50 100 150 200
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
Population (1,000s)
Male Female
Poverty
Age(Years)
Figure 1-2: The population of New Zealand in 5 year
age bands, with the proportion in poverty
estimated in red12.
4
It is vital that the income for children’s basic needs is protectedregardlessof thesourceof theirparents’income,butthe“Workingfor Families” package fails to do this. The Ministry of Social Developmentprojectsthatonly30%of childreninpovertywillbeliftedoutof povertyby2007.ToattainthisfiguretheMinistryhaveusedapovertylinebasedon60%of medianfamilyincomebeforehousingcosts,andthattherewillbe100%uptakeof thepackage21. Howeverbasedonpastexperiencesuchahighuptakerateisveryunlikely.
Thecumulativeeffectsof longterminadequatenutrition,crowdedsubstandard housing and living conditions, and unaffordable orinaccessibleprimaryhealthcareoverthelast15-20yearshavetakenalastingtollonthehealthof hundredsof thousandsof NewZealandchildrencausinglossof wellbeing,andevenpermanentdisabilityinsome.NewZealandchildrenhaveveryhighratesof preventable
0 5 10 15 20 25 30
% of Children Living Below National Poverty Lines
2.4
2.8
3.4
4.2
6.8
6.8
7.5
7.7
8.8
9.1
9.8
10.2
10.2
12.4
12.7
13.3
14.3
14.7
14.9
15.4
15.6
15.7
16.3
16.6
21.9
Denmark
Finland
Norway
Sweden
Switzerland
Czech Republic
France
Belgium
Hungary
Luxembourg
Netherlands
Germany
Austria
Greece
Spain
Poland
Japan
Australia
Canada
UK
Portugal
Ireland
New Zealand
Italy
USA
Mexico27.7
Figure 1-3: The Child Poverty League10.The bars show the percentage of children living in relative poverty defined as households with income below 50% of the national median income in 2001. While MSD have corrected these figures to a slightly improved 14.6% in 2001, their figure has risen to 15% in 2004, showing deterioration.
5
diseasesandinjurycomparedwithothersimilarcountriesliketheUKandAustralia,whichhavemoregenerouseconomicsupportforfamilieswithchildren.Untilthepooreconomicsituationof NewZealand children remaining in poverty is addressed this alarmingsituationwillcontinueintothenextdecades.
Respiratory or “breathing” disorders feature highly among thehealthburden,but,apartfromasthma,theyhavehadlittlepublicrecognition.ComparedwithourneighbouringPacificnationswehavehigherratesof admissionfordiseasessuchaspneumoniaandwhoopingcough.Thedanger is thatweareaccustomed to thesehighratesof diseaseasthe“normal”childhealthpictureinNewZealand,eventhoughtheratesareexceedinglyhighincomparisonwithotherOECDcountries,andsomedevelopingcountrieshavebetterpreventivehealthpolicies,andthusbetteroutcomes.
The New Zealand government has made good progress inintroducing policy changes which result in reduction of environmentaltobaccoexposure.Incontrast,ourtrackrecordonairpollutionispoorbyinternationalstandards.Themainsourceof air pollution in New Zealand is from vehicle exhaust emissions,fromwhichabout400NewZealandadultsdieeachyear23. There areserioushealtheffectsfromvehicleexhaustemissionsonchildrentoo,includingincreasedriskof wheezingunderoneyear24,increasedchronic cough, and increasedasthmasymptoms.NewZealand istheonlyOECDcountrywhichdoesnothavecompulsoryvehicleexhaustemissiontestingaspartof thewarrantof fitness.In2003adecision was made to change the Transport Law to includecompulsory vehicle exhaust emission testing from mid 2006.HoweverinMay2005thisdecisionwasmodifiedsothecheckwillnowlookonlyattheemissionof clearlyvisible,densesmokeandwillmissallnon-visiblepollutants,andthusNewZealandwillnotmeet international emission standards.
“…Do you know what it feels like
When you’re having dinner and the
power runs out The kids are in
the shower and the water runs out
Three babies are crying ‘cause their
powder run out Instead of buying food every week
they’re paying bills so every night they’ve
got somewhere to sleep…”
From NO ARTIFICIAL FLAVOURS CD, released 2003
(Courtesy of EMI).
“…Do you know what it feels like
When you’re having dinner and the
power runs out The kids are in
the shower and the water runs out
Three babies are crying ‘cause their
powder run out Instead of buying food every week
they’re paying bills so every night they’ve
got somewhere to sleep…”
From NO ARTIFICIAL FLAVOURS CD, released 2003
(Courtesy of EMI).
$0
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1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
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2008
Year
2004Dollars
Family Support and CTC or IWP forthose eligible‘raw’ Family Support
Family Support after core benefit loss,for those ineligible for IWP
Figure 1-4: Maximum per week real family assistance 1986-2008.
One child family (in equivalent 2004 dollars)22. From 1986 to 2005 family support fell in real terms. When the “Working for Families” package is fully rolled out
in 2007, families entitled to in work payments will have a significant income boost. But about 175,000
poor children will have inadequate inflation adjustments after their parents’ core benefit is
cut, miss out on in work payments and fall further behind. (CTC = child tax credit,
IWP= In work payment).
6
1.1 Recommendations
Requirechildimpactreportsforallgovernmentpolicies.Monitor and report on child poverty.Adopt clear goals for reduction in child poverty, extendingpoliciesbeyond“Workingforfamilies”.Ensure an adequate safety net for all children so that basicnecessitiescanbeafforded,regardlessof thesourceof incomeof their parents.Ensureanadequateincomesupportforalllowincomefamilieswithchildren,allowingforinflationandrealgrowthinwages.Provide adequate long term funding of the New ZealandHousing Strategy, including increased investment in healthyaffordablestatehousing.Monitor and report on indicators of child and youth healthandwellbeing,includingrespiratoryhealth,andsetaccountabletargets for their improvement.Enact legislation for compulsory testing of vehicle exhaustemissions.
•••
•
•
•
•
•
A couple on the sickness benefit with one child has not had any increase in their family assistance since 1996. From April 1 2005 they got $7.50 per week after their core benefit reduction and nothing more until 2007 when they will get another $10 per week.
A couple on the sickness benefit with one child has not had any increase in their family assistance since 1996. From April 1 2005 they got $7.50 per week after their core benefit reduction and nothing more until 2007 when they will get another $10 per week.
Income determines the ability to purchase nutritional food; the size, adequacy and location of housing; the ability to afford to heat the home, to buy clothing, bedding, soap and towels; the ability to pay for phone and transport, participate in sport, visit the doctor, and access medicines and education. Many families became unable to afford all these essential items for their children.
Income determines the ability to purchase nutritional food; the size, adequacy and location of housing; the ability to afford to heat the home, to buy clothing, bedding, soap and towels; the ability to pay for phone and transport, participate in sport, visit the doctor, and access medicines and education. Many families became unable to afford all these essential items for their children.
7
Chapter 2: Healthcare Delivery
Approximately 95% of all health care delivery in New Zealandis fromPrimaryHealthproviders– generalmedicalpractitioners,nurses,andpharmacistsbeinginthefrontline.ThisisrecognisedinthePrimaryHealthCareStrategyauthorisedbytheMinisterof Health, the Honourable Annette King, in February 200125. This document promises that “Doctors, nurses, community healthworkers and others in primary health care will work together to reducehealthinequalitiesandtoaddressthecausesof poorhealthstatus.Serviceswillbereadilyavailableatacostpeoplecanafford.”Whilemuchhasbeenachievedinthefouryearssincepublication,for some families the cost is still too high for them to afford visits to thedoctor.SomeGeneralPracticesareaccessfundedwhichisatanoverallhigherlevelthanthosewhichareinterimfunded.Oftenthesepracticesareinthesamegeographicareaandconsultationchargesdifferasaresultof overallbulkfunding.Progressishoweverbeingmadeonuniversalaccessfunding.
HealthdeliveryinNewZealandhasundergoneanumberof socialandeconomic reforms in the last twodecades. It is tobehopedthat thechanges implementedby thecurrentgovernmentwillbegiventimeto“beddown”beforefurtherchangeiscontemplated.Continual restructuring is confusing to the public, disruptive tothehealthprofessionals, confusing tomanagement, andcostly. Itisoftenaccompaniedby increasingandchangingbureaucracyforhealth professionals, whose primary task should be health caredelivery. Many general practitioners now estimate that at least one thirdof theirtimeisengagedincompliancerequirementsandpaperwork.
Forchildrenandyoungpeopletoaccesshealthcaretheremustbeavailability,trustintheprovider,trustintheappropriatenessof theprovision of the service including cultural appropriateness,confidentiality,anditmustbeaffordable.ThePrimaryHealthCareStrategydoesmuchtoadvancetheaffordability,butinmostcasespaymentisstillarequirement.ForalongtimeallchildreninNewZealandundertheageof sixweretreatedfree,andinmanycasesthisstillapplies,withthedoctorbeingpreparedtoacceptamuchlowerfeethantheusual.Howeverasthisbenefithaseroded,theconceptof freeaccessisnowfarfromuniversal.
Thecost especiallyof afterhours services canbehigh formanyparents.Onecanarguethatsomefinancialcontributiontoamedicalservice may project some value to it, but the quantum of thatpaymentshouldnotbeabarriertoseekingmedicalattention.Thereisstillevidencethatinsomepartsof thecountrythecostof seeingadoctor(especiallyforoutof hoursservices)isstilladisincentive.
Prescriptionchargeswereintroducedinthemid-1980s.Theseextracostsareunaffordable for somefamilies, evenwithacommunityservice card, who have to make decisions about which, if any,prescriptionitemstopayfor.Thismayresultininadequatetreatment
Jim ReidJim Reid
While much has been achieved in
the four years since publication of the
Primary Health Care Strategy, for some families the
cost is still too high for them to afford
visits to the doctor.
While much has been achieved in
the four years since publication of the
Primary Health Care Strategy, for some families the
cost is still too high for them to afford
visits to the doctor.
The concept of free access is far
from universal.
The concept of free access is far
from universal.
The cost of after hours services can be high
for many parents.
The cost of after hours services can be high
for many parents.
The prescription charges are
unaffordable for some families, even
with a community services card.
The prescription charges are
unaffordable for some families, even
with a community services card.
8
andpooroutcomes.
While adequate access to primary health care is paramount, onemustnotforgettheimportanceof appropriatecontactwithspecialistcare.Againthisneedstobeavailablewithinreasonabletime,andatreasonablecost.Inthiscountryinmanycasesitisaccessedviathepublichospitalsystematnocosttothepatient.Onmanyoccasionsthe waiting time in this system is inappropriately long.
2.1 Recommendations
Theprovisionof easilyaccessed,affordableprimaryhealthcareisof paramountimportance.Paymentshouldnotbeabarriertomedicalcare.Allchildrenshouldhaveageneralmedicalpractitionerwhocanprovidecontinuingcare.Thereshouldbeappropriateaccess tospecialistcarewithinareasonabletimeframe.
•
••
•
There is still evidence that in some parts of the country the cost of seeing a doctor (especially for out of hours services) is still a disincentive.
There is still evidence that in some parts of the country the cost of seeing a doctor (especially for out of hours services) is still a disincentive.
The public hospital waiting time for specialist review on many occasions is inappropriately long.
The public hospital waiting time for specialist review on many occasions is inappropriately long.
9
Chapter 3: The Context for Maori Tamariki and Taitamariki
3.1 Respiratory Disease and Maori Children
Theburdenof paediatricrespiratorydiseasefallsheavilyonMaori.Inequalitiesinincidenceandmortalityrates,thequalityof careandresultantdisabilityexistformostinfectiousandnoncommunicablerespiratory disease in Maori children compared with non-Maorichildren.Importantly,asthmaandrangatahihealtharetwoof theeight health priorities inHeKorowaiOranga, theMaori Healthstrategy26,highlightingthesignificantimpactrespiratorydiseasehasonWhanauora.
Maorichildrenareavaluedpartof ourcommunityandtheirrightsto wellbeing are guaranteed in both the Treaty of Waitangi andnationaland international statutes.Maorichildrencurrentlymakeup25%of allchildrenlivinginNewZealandandmorethanathirdof theMaoripopulationisaged14yearsandyounger(comparedwith20%of thenon-Maoripopulation)27(Figure3-1).
Sadly they are also a groupwho aremost at riskof poorhealthcaused by the unequal distribution of and access to sufficientdisposable income, adequate housing, educational opportunitiesandeffective,availableandacceptablehealthcare28. Woven in with the social and economic determinants of health is the impact of ethnicity.Maoriatalleducational,occupationalandincomelevelshave poorer health status than non-Maori28. Smoking prevalence amongMaoriwomenof child-bearingagerangesupto60%29.Anyimprovementsinsocioeconomicstatus,housingandeducationwilladvance the wellbeing of Maori children suffering respiratorydisease but the betterment of Maori political status will alsocontributetohealthgain.
Healthcareservicesplayimportantroles.Thequalityof healthcareprovided to Maori children must be monitored to ensure thatservices are working to reduce health disparities and to attainequitableoutcomes.Thereforethecollectionof accurateethnicity
Matire HarwoodMatire Harwood
The burden of paediatric respiratory
disease falls heavily on Maori.
The burden of paediatric respiratory
disease falls heavily on Maori.
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
Age(Years)
10 8 6 4 2 0 2 4 6 8 10
Percent in Each Age Group
Male Female
Maori
non-Maori
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
Age(Years)
10 8 6 4 2 0 2 4 6 8 10
Percent in Each Age Group
Male Female
Maori
non-Maori
Figure 3-1: Population pyramid of the
Maori & non-Maori populations, 200027.
Figure 3-1: Population pyramid of the
Maori & non-Maori populations, 200027.
10
data is necessary so that the standard of care for Maori children with respiratory illness can be measured against best practice.Evidencebasedguidelines,suchasguidelinesforthemanagementof paediatric asthma, community acquired pneumonia andtuberculosis, have examples of audit tools for clinicians andconsumerstoutiliseforthispurpose.ManyDistrictHealthBoards(DHBs) have also identified specific targets forMaori, child andrespiratory health that may assist providers.
3.2 Some Specific Examples – Asthma, Bronchiectasis,Pneumonia
3.2.1 AsthmaandMaoriChildren
Although theprevalenceof paediatricasthma inNewZealand issimilarforMaoriandnon-Maori30,Maorichildrenwithasthma:
Have more severe symptoms when presenting to the health providerforroutineoracutecare30;Requirehospitalisationforasthmaalmosttwiceasoftenasnon-Maori children30-32;andRequiremoretimeoff schoolbecauseof asthma31.
Despite an increased need for adequate asthma management,Maori children with asthma appear to be further disadvantagedwhen it comes to acceptable asthma care.They are less likely toreceiveadequateeducation,tohaveanasthmaactionplanandtobe prescribed preventive medication33-35. Other commonly cited barriersforMaoriwithasthmaincludecostforconsultation,accesstotransportandtelephoneandtheattitudeof thedoctor/providerincludingbiasanddiscrimination31,36.
Anumberof initiativeshavebeendevelopedbyMaoritofacilitatethe provision of quality asthma care and include the TuKotahiMaoriAsthmaSociety,MaorihealthservicesprovidingcustomisedActionPlansandMaoriasthmaeducators/nursesandAuahiKoreprogrammes to help parents quit smoking. Marae based asthmaprogrammes that take a partnership approach are also effective37. Newornovel approaches to asthma care that incorporateMaoriinitiativesalongsidebestpracticeguidelinesmustbeencouragedif wewishtoimprovethequalityof asthmacaredeliveredtotamariki,taitamarikiandtheirwhanau.
3.2.2 Bronchiectasis
Despite its decline in other developed countries, bronchiectasisappearstoaprobleminAuckland38andothercentresinNewZealand.SignificantlymoreMaoriandPacificchildrenhaveadiagnosisof bronchiectasis(byhighresolutionCTscanof thechest)thannon-MaorinonPacificchildrenlivinginAuckland38. Of note the Maori andPacificchildrenwithbronchiectasisalsoappearedtoexperiencemore socioeconomic deprivation and have lower immunisationrates.
•
•
•
Maori at all educational, occupational and income levels have poorer health status than non-Maori.
Maori at all educational, occupational and income levels have poorer health status than non-Maori.
The quality of health care provided to Maori children must be monitored to ensure that services are working to reduce health disparities and to attain equitable outcomes.
The quality of health care provided to Maori children must be monitored to ensure that services are working to reduce health disparities and to attain equitable outcomes.
11
Researchers highlight the fact that only the more severe cases are identifiedandthereforechildrenwith‘moderate’diseaseandtheirhealthcareprovidersmaynotbeawarethattheyhavebronchiectasis.Acall for improvedmethodsof detectionare sought inorder toidentifyandmanagechildrenwithbronchiectasis38.
3.2.3 Pneumonia
Evidence points to a long standing history of Maori being atincreasedriskfromtheeffectsof introducedrespiratoryinfectionssincethecolonisationof NewZealand.
Betweenthe1850’sand1860’snearlyhalf of theMaoripopulationwaswipedoutbymeaslesandthecommoncold.The1918influenzaepidemiccausedfurtherdevastation.Over8000peoplediedfromthediseaseinNewZealandandhistorianshavesuggestedthateveryfamily livinginNZatthetimewasaffectedbyit.TheimpactonMaoriwashugeandsignificantinequalitiesinmortalityratesexistedwith rates forMaori over seven times higher than rates forNZEuropeans(42.3/1000versus5.8/1000).
“When the influenza epidemic hit, it decimated Maori communities across New Zealand. Masters of knowledge were lost. The skills of carvers and weavers were buried with them - and fear stirred. For the traditional arts and crafts were the chronicles of the culture, carving and weaving centuries of history, recording families, language and every facet of every tribe”.
TePuiawebsite(http://www.nzmaori.co.nz/aboutus/history.html).
Overtimeimprovementsinpublicandprimaryhealthcarehasledtoadeclineinmostof themajorrespiratorytractinfectionsinNewZealandbutMaori andMaori children still continue to carry thegreatest burden.Maori children have higher rates of communityacquiredpneumonia39andbasedoncomparisonsof vitalsignsandintensityof therapy,arehospitalisedwithmoreseverepneumoniathanEuropeanchildreninNewZealand40.
Theincidenceof tuberculosishasdecreasedforadultsinNZoverrecentyearsbutdisturbingly,therehasbeennosuchreductioninpaediatric rates41. Significant ethnic disparities in tuberculosisincidence rates exist and Maori children aged less than 15 years accountfor15%of allcasesof TBcomparedwith3%of Europeanand17%of Pacificchildren42.
“There is no great virtue in encouraging healthy lifestyles in poor areas without also attempting to redress the structural inequalities that limit human lives and aspirations…
In short, health promotion will be of limited value if it is not accompanied by fundamental changes that guarantee human dignity and full inclusion in society and the economy.”
MasonDurie,MaoriOra,2001.
Maori children with asthma are less likely
to receive adequate education, to have an
asthma action plan and to be prescribed
preventive medication.
Maori children with asthma are less likely
to receive adequate education, to have an
asthma action plan and to be prescribed
preventive medication.
New or novel approaches to asthma care that incorporate
Maori initiatives alongside best
practice guidelines must be encouraged.
New or novel approaches to asthma care that incorporate
Maori initiatives alongside best
practice guidelines must be encouraged.
Maori children have higher rates of
community acquired pneumonia and are hospitalised
with more severe pneumonia than
European children in New Zealand.
Maori children have higher rates of
community acquired pneumonia and are hospitalised
with more severe pneumonia than
European children in New Zealand.
12
3.3 Summary
PaediatricrespiratorydiseaseisapriorityforMaori.Maoritamarikiandtaitamarikiareasignificantpartof theMaoricommunityandcontributetoNewZealand’syoungpeople- theirwellbeingmustbeprotected.Ourgoalistoremovetheinequalitiesinrespiratoryillnessrates,healthcareandhealthoutcomesthatexistforMaorichildren.
3.4 Recommendations
Appropriate public health action that addresses widercontextual and environmental factors that impact on therespiratory health Maori children such as improved housing,removalof socioeconomicbarriers,effectivetobaccocessationprogrammes.Ensurequalityandevidencebasedhealthcareforallchildren.Collect accurate ethnicity data and monitor appropriateoutcomes.Develop the capacity of Maori health work force to work with tamarikiandtheirwhanau.
3.5 Glossary:
AuahiKore SmokeFreeHe Korowai Oranga Maori Health Strategy Marae Meetingsiteforwhanau,hapu,iwi (tribalaffiliation)Maori Indigenouspeopleof NewZealandRangatahi YoungpeopleTamariki Children Taitamariki Teenagers TuKotahi NamefortheMaoriAsthmaSocietyWhanau Extendedfamily
•
••
•
13
Chapter4: TheContextforPacificChildren
“If you want sight and insight into my psyche, you will have to speak to the gods which inhabit it. You have to eavesdrop on the dialogue between my ancestors and my soul. You have to address my sense of belonging.
I am not an individual, I am an integral part of the cosmos. I share my divinity with my ancestors, the land, the seas and the skies. I am not an individual because I share a tofi with my family, my village and my nation.
I belong to my family and my family belongs to me. I belong to my village and my village belongs to me. This is the essence of my sense of belonging.
These are the reference points which define who I am, and they are reference points for other Samoans. Any service which seriously wishes to address our health must take these into account.”
Honourable Tuiatua Tupua Tamasese Efi, Former PrimeMinisterof WesternSamoa,ExcerptfromaddresstoPacificMedicalAssociationConference,Auckland,2000.
PacificpeopleinNewZealandaremadeupof manydifferentethnicgroupswithoriginsinthePacificIslandnations.ThelargestgroupsarefromSamoa,Tonga,Nuie,CookIslands,TuvaluandTokelau.As a collective group Pacific peoplemake up 6.5% of theNewZealand population. Languages and culture and strength of acculturation vary between groups but there are also manycommonalitieswhichthedifferentethnicgroupssharesuchasthemigration experience, marginalisation, and cultural barriers toaccessing health and social services. The Pacific population isrelativelyyouthfulgroupcomparedwithgreaterNewZealandwith39%of Pacificagedlessthan15yearsof agecomparedwithjustover20%of totalNewZealandbeinginthesameagegroup43.
“I am not an individual, I am an integral part of the cosmos. I share my divinity with my ancestors, the land, the seas and the skies. I am not an individual because I share a tofi with my family, my village and my nation.
I belong to my family and my family belongs to me. I belong to my village and my village belongs to me. This is the essence of my sense of belonging.
These are the reference points which define who I am, and they are reference points for other Samoans. Any service which seriously wishes to address our health must take these into account.”
TuiatuaTupuaTamaseseEfi.
Compared with most New Zealanders, Pacific children aredisadvantagedinhealth,housing,educationandhouseholdincome2,43. Pacificfamilieshavelowerhouseholdmedianannualincomethanthatof allotherethnicgroupsandunemploymentratescontinue
Teuila PercivalTeuila Percival
Compared with most New Zealanders,
Pacific children are disadvantaged in
health, housing, education and
household income.
Compared with most New Zealanders,
Pacific children are disadvantaged in
health, housing, education and
household income.
14
to be higher than fellowNewZealanders2. Forty-twopercent of Pacificpeopleliveinthemostdeprivedneighbourhoods(NZDep01Decile10)comparedwith10%of totalNewZealanders44.PacificfamiliesarealsomorelikelytoliveinovercrowdedandpoorhousingcomparedwithotherNewZealanders2,45.Asmanyas1in3Pacificchildren in Auckland live in overcrowded homes46. In the PIFT(Pacific Islands First TwoYears of Life&Transition to School)longitudinalstudyof SouthAucklandPacificchildren,overathirdof mothers reported that their homes were damp and over half reportedproblemswithcoldhousing47.Pacificchildrenaremorelikely to live in larger families. Over one third live in families with fourormoredependentchildrencomparedwith16%inthenationalpopulation.Whereas29%liveinextendedfamilies,Pacificchildrenare also increasingly living in single parent led families43.
Pacific children continue to experience poorer health status thanotherNewZealandchildren.Pacificinfantmortalityratesarehigherthan other New Zealanders48 (Figure 4-1). Pacific children havehospitalisation rates for preventable diseases higher than Maori,European and other ethnic groups49. Respiratory disease is a particular concern forPacificchildren.Theirhospitalisation ratesare almost three times that of other children for lower respiratory tract infections48,50.ComparedwithNZEuropeanchildrentheyalsohave more severe disease when hospitalised with pneumonia50. Pacific children have disproportionately high rates of (non-cysticfibrosis)bronchiectasisthoughttobemainlyduetosocioeconomicdeprivationandlowimmunisation38.
Pacificchildrenalsohavea50%higherhospitalisationrateforasthmathantheNewZealandaverage49.Prevalenceratesforotherdiseasessuchasrheumaticfever,tuberculosisandmeningococcaldiseasearesimilarlyhigherthanthatof allotherNewZealandchildren48.
Pacificfamiliesfaceeconomic,culturalandlanguagebarriersintheirinteractions with health and social services. Limited access to care and lessqualityor effectivenessof care is supportedby thevery highratesof hospitalisationforconditionssuchasasthmawhich
Pacific children have hospitalisation rates for preventable diseases higher than Maori, European and other ethnic groups.
Pacific children have hospitalisation rates for preventable diseases higher than Maori, European and other ethnic groups.
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Deathsper 1000live births
MaoriPacificOther
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Deathsper 1000live births
MaoriPacificOther
Figure 4-1: New Zealand infant mortality by ethnic group51.
Figure 4-1: New Zealand infant mortality by ethnic group51.
0
20
40
60
80
100
120
1996/97 1997/98 1998/99 2000/01 2001/02
Year
Rateper
1000Population
Maori
Pacific
Other
0
20
40
60
80
100
120
1996/97 1997/98 1998/99 2000/01 2001/02
Year
Rateper
1000Population
Maori
Pacific
Other
Figure 4-2: Ambulatory sensitive
hospitalisations for NZ under 5 year olds, by
ethnicity, 1996-200249.
Figure 4-2: Ambulatory sensitive
hospitalisations for NZ under 5 year olds, by
ethnicity, 1996-200249.
15
to be higher than fellowNewZealanders2. Forty-twopercent of Pacificpeopleliveinthemostdeprivedneighbourhoods(NZDep01Decile10)comparedwith10%of totalNewZealanders44.PacificfamiliesarealsomorelikelytoliveinovercrowdedandpoorhousingcomparedwithotherNewZealanders2,45.Asmanyas1in3Pacificchildren in Auckland live in overcrowded homes46. In the PIFT(Pacific Islands First TwoYears of Life&Transition to School)longitudinalstudyof SouthAucklandPacificchildren,overathirdof mothers reported that their homes were damp and over half reportedproblemswithcoldhousing47.Pacificchildrenaremorelikely to live in larger families. Over one third live in families with fourormoredependentchildrencomparedwith16%inthenationalpopulation.Whereas29%liveinextendedfamilies,Pacificchildrenare also increasingly living in single parent led families43.
Pacific children continue to experience poorer health status thanotherNewZealandchildren.Pacificinfantmortalityratesarehigherthan other New Zealanders48 (Figure 4-1). Pacific children havehospitalisation rates for preventable diseases higher than Maori,European and other ethnic groups49. Respiratory disease is a particular concern forPacificchildren.Theirhospitalisation ratesare almost three times that of other children for lower respiratory tract infections48,50.ComparedwithNZEuropeanchildrentheyalsohave more severe disease when hospitalised with pneumonia50. Pacific children have disproportionately high rates of (non-cysticfibrosis)bronchiectasisthoughttobemainlyduetosocioeconomicdeprivationandlowimmunisation38.
Pacificchildrenalsohavea50%higherhospitalisationrateforasthmathantheNewZealandaverage49.Prevalenceratesforotherdiseasessuchasrheumaticfever,tuberculosisandmeningococcaldiseasearesimilarlyhigherthanthatof allotherNewZealandchildren48.
Pacificfamiliesfaceeconomic,culturalandlanguagebarriersintheirinteractions with health and social services. Limited access to care and lessqualityor effectivenessof care is supportedby thevery highratesof hospitalisationforconditionssuchasasthmawhich
Pacific children have hospitalisation rates for preventable diseases higher than Maori, European and other ethnic groups.
Pacific children have hospitalisation rates for preventable diseases higher than Maori, European and other ethnic groups.
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Deathsper 1000live births
MaoriPacificOther
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Year
Deathsper 1000live births
MaoriPacificOther
Figure 4-1: New Zealand infant mortality by ethnic group51.
Figure 4-1: New Zealand infant mortality by ethnic group51.
0
20
40
60
80
100
120
1996/97 1997/98 1998/99 2000/01 2001/02
Year
Rateper
1000Population
Maori
Pacific
Other
0
20
40
60
80
100
120
1996/97 1997/98 1998/99 2000/01 2001/02
Year
Rateper
1000Population
Maori
Pacific
Other
Figure 4-2: Ambulatory sensitive
hospitalisations for NZ under 5 year olds, by
ethnicity, 1996-200249.
Figure 4-2: Ambulatory sensitive
hospitalisations for NZ under 5 year olds, by
ethnicity, 1996-200249.
arepreventable throughgoodcommunitybasedhealthcare.Thepictureof healthserviceusagebyPacificpeopleisnotableinthatthey are more likely to forego visiting a GP than other NewZealanderseventhoughtheyrecognisethereisaneed48,52. The most common reason given is cost. Similarly the commonest reason given fornotpickingupaprescriptioniscost.Pacificpeoplearealsolesslikely to be seen as secondary care outpatients and less likely toattend primary care for screening or health promotion. Other factors impacting on Pacific children’s health are environmental tobaccosmoke exposure with almost one third of Pacific adults stillsmoking48,49.Lessthanhalf of Pacificbabiesarestillfullybreast-fedat three months48of agewithafurtherrapiddeclineinratesinthesixtotwelvemonthsagegroup.
As a group, Pacific children are excessively burdened with poorhealth and socioeconomic disadvantage. The poor health seen represents both increased prevalence and severity of disease.Respiratorydiseaseistheleadingcauseof morbidityorillhealthforPacificchildren.Muchof thisrespiratorymorbidityispreventable.Ethnic diversity and differing languages, culture and degree of
Pacific children have a 50% higher hospitalisation rate for asthma than the
New Zealand average.
Pacific children have a 50% higher hospitalisation rate for asthma than the
New Zealand average.
Figure 4-3: Respiratory infection admissions,
Counties Manukau, children under 15
years, 19991.
Figure 4-3: Respiratory infection admissions,
Counties Manukau, children under 15
years, 19991.
0
2
4
6
8
10
12
Bronchiolitis Pneumonia Other Respiratory
Rateper
100,000
Maori
Pacific
Other
0
2
4
6
8
10
12
Bronchiolitis Pneumonia Other Respiratory
Rateper
100,000
Maori
Pacific
Other
16
acculturationaffecttheabilityof Pacificchildrenandtheirfamiliesto access effective health care and social services.
Socioeconomic disadvantage continues to impact negatively onPacificchildren’shealth.ThepovertyandpoorhousingconditionsexperiencedbyPacificchildren,aswellastheaccesstoeffectivefirstlineprimaryhealthservicesneedtobeaddressed.
ThewayforwardforPacificchildrenandtheirfamiliesrequiresacommitment to health promotion and addressing the underlyingdeterminantsof ourchildren’shealthsuchaseducation,housingandhousehold income. Investing in ourPacific children’s educationalsuccess isparticularly important inaddressingtheongoinghealthand economic disparities in the long term52. Improving access to healthservicesaswellastheireffectivenessforPacificchildrenandfamiliesisalsoneeded.Thisrequiresamoreindepthunderstandingof ourchangingcommunitiesandtheissuestheyfacebyhealthcareprovidersandtheirfunders.
Improving the health andwell-being of Pacific children requiresmediumandlongtermstrategiesforpositivechange.
“A society that enjoys high levels of participation, connection and cohesion will have a more productive and successful economy…The objective of an inclusive economy is to improve the well-being of New Zealanders…Policy should address its primary effort to improve the outcomes for Maori and Pacific who do worse than the median…Improving literacy and numeracy skills of Maori and Pacific primary school students is the priority for further development.”
TowardsanInclusiveEconomy,Treasury,NZGovernment,2001.
6.1 Recommendations
A commitment to focus on and reduce disparities betweenPacificandotherNZchildren.Focusonhealthpromotionandprevention.Improving access to and effectiveness of health services.Improvingtheeducationalsuccessof Pacificchildren.
•
•••
Pacific people are more likely to forego visiting a GP than other New Zealanders. The most common reason given is cost. Similarly the commonest reason given for not picking up a prescription is cost.
Pacific people are more likely to forego visiting a GP than other New Zealanders. The most common reason given is cost. Similarly the commonest reason given for not picking up a prescription is cost.
Respiratory disease is the leading causes of morbidity or ill health for Pacific children. Much is preventable.
Respiratory disease is the leading causes of morbidity or ill health for Pacific children. Much is preventable.
The poverty and poor housing conditions experienced by Pacific children, as well as the access to effective first line primary health services need to be addressed.
The poverty and poor housing conditions experienced by Pacific children, as well as the access to effective first line primary health services need to be addressed.
17
Chapter 5: Immunisation Delivery
Immunisation is well recognised as one of the most importantpublichealthachievementsof the20thcentury53.
The gains are enormous – smallpox disease has been eradicated,poliomyelitis is close to eradication, and rates of diseases suchas measles, pertussis, haemophilus influenza and hepatitis B inour children are considerably lessened. Furthermore there is aninternational explosion in vaccine technology and new important vaccines are entering the world market giving potential to tackle other significant childhood diseases such as pneumococcal,meningococcal, rotavirusdiseases, andpertussis for adolescents54. However while there is enormous potential to gainmuch bettercontrolof thesediseasestheabilitytodeliverhasnotmatchedtheabilityof thetechnology.Childrencontinuetosufferunnecessarilyfromhighratesof vaccine-preventablediseasesinNZdespitetheavailabilityof highqualitysafeandeffectivevaccines.
5.1 Low Coverage
NewZealandhasapoorrecordwithimmunisationcoveragewithimmunisationrateswellbelowthetargetssetinnationalstrategies. Thereisnocurrentlyavailablenationalcoveragedata,howeverratesareunlikelytohaveimprovedmuchoverthe1992nationalcoveragesurvey55whichshowedlessthan60%of childrenfullyimmunisedbytwoyearsof age,andmorealarminglyonly42%of Maoriand45%of Pacificchildrenfullyimmunisedbytwoyears.
The effect of low coverage translates into high disease rates, asevidenced by pertussis: currently NZ is suffering a pertussisepidemic,ontargettobeworsethanthelastepidemicin1999-2001whentherewerenearly7,000casesnotified56(seeChapter7).
NewZealandisintheprocessof developinganationalimmunisationregister. Currently this is up and running for the epidemicmeningococcalBvaccinedeliveryprogramme,andisplannedtobe
Nikki TurnerNikki Turner
Children continue to suffer unnecessarily
from high rates of vaccine-preventable
diseases in NZ despite the availability of
high quality safe and effective vaccines.
Children continue to suffer unnecessarily
from high rates of vaccine-preventable
diseases in NZ despite the availability of
high quality safe and effective vaccines.
Country % Immunised Year of Estimate
Niue 100 1997
Tokelau 100 1994
Sweden 99 1997
Samoa 99 1997
France 97 1997
UK 95 1997
Tonga 95 1997
USA 94 1995
Canada 93 1994
Cook Islands 91 1997
Australia 86 1997
New Zealand 84 1994
New Zealand 81 1998**dataobtainedfromtheNZMinistryof HealthImmunisationCoverageSurveillancereport
Country % Immunised Year of Estimate
Niue 100 1997
Tokelau 100 1994
Sweden 99 1997
Samoa 99 1997
France 97 1997
UK 95 1997
Tonga 95 1997
USA 94 1995
Canada 93 1994
Cook Islands 91 1997
Australia 86 1997
New Zealand 84 1994
New Zealand 81 1998**dataobtainedfromtheNZMinistryof HealthImmunisationCoverageSurveillancereport
Table 5-1: Immunisation coverage estimates
for pertussis antigen(from World Health Organisation data).
Table 5-1: Immunisation coverage estimates
for pertussis antigen(from World Health Organisation data).
18
introduced progressively around the country from later in 2005,enrollingallchildrenfrombirth.Thiswillbevitaltoolforbeingabletotracklostchildrenandtomonitorprogresswithimmunisationcoverage.Until this ispresentwehavenoaccuratecoveragedata,and no easy way of finding children who have missed out onimmunisationservices.
5.2 Improving Coverage
Internationalliteraturehasclearthemesonhowtogainandmaintainhigh immunisationcoverage.These includeenhancingaccessandprovider-basedinterventionsandstrategiestoincreasecommunitydemand57. Key aspects of delivery include financing the systemeffectively, focusing on provider practice, appropriate integratedinformationsystemsandcommunitysupport57.
Despite the disappointing national picture, local initiatives haveshownitispossibletoachieveandmaintainhighercoveragerates58. These all take local flavour, but show the key characteristics of committed teams and integrated processes at the primary health care level.
NZ research in 200259 highlighted one of the most significantbarrierstoraisingcoverageidentifiedbygeneralpractitionerswaslackof fundingtoproviders.Thisisstronglybackedbyinternationalliteraturethatshowsclearrelationshipsbetweenimprovingcoveragewith financial and quality support to health professionals. Theinadequacy of the immunisation benefit subsidy, particularly tocoverthecostsof thehardertoaccesschildren,hasbeenfrequentlyhighlighted60.
Themost consistentmessage coming through fromparental andhealthprofessional research is thatoneof thebiggestbarriers toachieving immunisation inNewZealand is parental concerns61-63. ThisisalsoreflectedbyparentsintheMaoricommunity64.Forourmost vulnerable children, parents frequently have considerablelogistic, financial and at times cultural barriers to overcome tocompleteanimmunisationevent.Itdoesnottakemuchtoseedadegreeof doubtorfearinastrugglingparenttomakethelikelihoodof achievingafullandtimelycourseof immunisationevenmoreremote.
ThecurrentNZapproachtoimmunisationservicedeliveryisclearlyinadequate.If wearetohaveagenuinecommitmenttoimprovingimmunisationratesforourchildren,thereneedtobemoreresourcesprovidedboth at the servicedelivery end, and at the communitysupport and awareness end. Furthermore a real commitment tohealth gains for our children must include consideration of theimportantnewvaccines,andnewvaccinestrategiesthatarebeingtakenupbymanymoreprogressivechild-focusedWesterncountries.Untilsuchtimeourchildrenwillcontinuetosufferunnecessarily.
The effect of low coverage translates into high disease rates.
The effect of low coverage translates into high disease rates.
We have no accurate coverage data, and no easy way of finding children who have missed out on immunisation services.
We have no accurate coverage data, and no easy way of finding children who have missed out on immunisation services.
Local initiatives have shown it is possible to achieve and maintain higher coverage rates.
Local initiatives have shown it is possible to achieve and maintain higher coverage rates.
One of the most significant barriers to raising coverage identified by general practitioners was lack of funding to providers.
One of the most significant barriers to raising coverage identified by general practitioners was lack of funding to providers.
19
5.3 Recommendations
Improvefundingattheprimaryhealthcarelevelforimmunisationservice delivery.Completetherolloutof theNationalImmunisationRegister.ResourcelocalservicedeliverytoutilisetheNIRdatatofollowupchildrenidentifiedasincompletelyandun-immunised.Increase resources for immunisation health promotion andcommunication strategies, particularly targeting Maori andPacificchildren.Focuson thepotential gainswithnewvaccines–particularlyconjugatemeningococcal,pneumococcalandvaricella.
•
••
•
•
Parents frequently have considerable
logistic, financial and at times cultural barriers to overcome
to complete an immunisation event.
Parents frequently have considerable
logistic, financial and at times cultural barriers to overcome
to complete an immunisation event.
Part Two
The Burden of Specific Diseases
22
Chapter6: TheBurdenof Smoking-relatedRespiratory Illness in Children and Young People
Cigarette smoke contains many chemicals including cell poisons,carcinogens, and substances active on blood vessels such asnicotineitself,whichisalsohighlyaddictivewheninhaled.Itisnotsurprisingthatexposuretosignificantamountsof cigarettesmokehas detrimental effects on the embryo and foetus (exposed viatobaccoconstituentsinmother’sbloodthatcrosstheplacenta)andonchildren(exposedviasidestreamandexhaledsmokeandvolatilesmokeconstituentsonclothing).
In a country with good nutrition, sanitation and immunisationsystems,cigarettesmokeistheleadingpreventablecauseof diseaseand death in children.
6.1 SmokingPrevalenceinNewZealand(Figure6-1)
Regional smokingprevalence ranges considerably. In2002,LakesDHB region prevalence was the highest at 38% and Northland,WestCoast,Whanganui,Bayof Plenty,HuttValleyandTairawhitiallhadprevalencesgreaterorequalto30%.Capital&Coast,andMidCentral had the lowest smoking rates at 21% and SouthCanterbury,Waitemata,Canterbury,TaranakiandWairarapaallhadprevalenceslessorequalto24%65.
“Maori smoking prevalence rates are double those of non-Maori. About half of all Maori adults over 15 years of age smoke. Smoking prevalence among Maori women of child bearing age ranges up to 60% and estimates of smoking among pregnant Maori women range from 40%-80%.”
DrMarewaGlover,June2004,Social&CommunityHealth,Schoolof PopulationHealth,Universityof Auckland29.
Philip PattemorePhilip Pattemore
0
5
10
15
20
25
30
35
40
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
Percent
0
5
10
15
20
25
30
35
40
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
Percent
Figure 6-1: Prevalence of cigarette smoking (%) (15+ years), 1976–200265
(Source: 1976 and 1981 Censuses of Population and Dwellings, Department of Statistics 1983–2000. ACNielsen (NZ) Ltd.).
Figure 6-1: Prevalence of cigarette smoking (%) (15+ years), 1976–200265
(Source: 1976 and 1981 Censuses of Population and Dwellings, Department of Statistics 1983–2000. ACNielsen (NZ) Ltd.).
A crude estimate of exposure is 14,000-19,000 NZ babies exposed in utero per year.
A crude estimate of exposure is 14,000-19,000 NZ babies exposed in utero per year.
Cigarette smoke contains many chemicals including cell poisons, carcinogens, and substances active on blood vessels.
Cigarette smoke contains many chemicals including cell poisons, carcinogens, and substances active on blood vessels.
23
6.2 Exposureof childrentocigarettesmoke(Table6-1)
6.2.1 InUtero
In 2002, cotinine-validated rates of smoking in pregnancy inChristchurchwereestimatedat28%66,animprovementfrom33%in 199667. A study in 2003 from the Wellington-Kapiti areadocumented 22.2% women and 54.6% Maori women reportedsmoking at conception68. Yet the Christchurch and Wellington-Kapiti areas have among the lowest prevalences of smoking among NewZealandregions.
Acrudeestimateof exposureis14,000-19,000NZbabiesexposedinutero peryear,basedonapossiblerangeof overallpregnancysmoking rates of 25-33% and 55,000-57,000 live births annually(birthratefromStatisticsNewZealand).
6.2.2 IntheHome(Table6-2)
In a country with good nutrition, sanitation and
immunisation systems, cigarette smoke is the
leading preventable cause of disease and
death in children.
In a country with good nutrition, sanitation and
immunisation systems, cigarette smoke is the
leading preventable cause of disease and
death in children.
Table 6-1: Prevalence of smoking in NZ pregnant
mothers 1990-9169.Category Smoking Prevalence (%)
Overall 33.0
Maternal age: <20 years 63.7
Maternal education: <11 years 60.0
Marital status: married 21.1
Marital status: de facto 58.0
Marital status: single 64.8
Employment status: unemployed 57.6
Ethnicity: European 23.0
Ethnicity: Maori 68.4
Ethnicity: Pacific Island 23.6
Category Ethnicity/Location Smoking Prevalence
(%)
New Zealand homes with a smoker who smokes inside
Overall 28
European 24
Maori 48
Pacific Island 34
Where New Zealanders smoke
Inside the home 25
Outside and inside 57
Outside 30
Don’t smoke at home 2
Where New Zealanders smoke in households with children aged under 5 years
Inside the home 22
Outside and inside 36
Outside 40
Don’t smoke at home 2
Table 6-2: Prevalence of tobacco smoking, 199671.
24
“National survey data indicate that at least 18% of all New Zealanders and 30% of Maori are exposed to second hand smoke in the home. Surveys of high school students indicate home second hand smoke exposure levels of 30% or more. The exposure appears to have decreased during 1996–2003 for Maori and the general population (p<0.001 for trend for both), with low-income households more likely to be exposed than others. There is an absence of exposure data for many specific population groups including pregnant women and infants.”70
StatisticsNewZealandestimatesthatthenumberof childrenunder15inNewZealandin2005is880,790.If 30%of theseareexposedtosmokinginthehomeassuggestedbythefiguresforhighschoolstudentsinTable6-2,thisequatestoapproximately250,000childrenexposed. If theloweroverallfigureof 18%of allNewZealandersexposedtosmokeinthehomeisused,160,000childrenwouldbeexposed.Recentdataabouttheproportionof smokerswithchildrensmokinginsidearelacking,butthe1996datasuggestedover50%of childrenunderfivewho livedwitha smokerwereexposed tosmoking inside the home71.
Inaquasi-experimentalstudyof smokingindoorsversusoutdoors,ETSexposureof infantswas5–8 timeshigher inhouseholdsof smokerstryingtoprotecttheirchildrenbysmokingoutdoorsthaninhouseholdsof non-smokers.ETSexposureof infantswas2-6timeshigherinhouseholdsof smokerswhosmokedindoorsthaninhouseholdsof smokerswhosmokedoutdoors72.
“During 1999–2003, over 90% of both Maori and the general population disagreed with the statement that it was ‘OK to smoke around children.”73
6.2.3 ActiveSmoking(Table6-3)
“Over one-third of the students who smoked had purchased tobacco products from commercial sources in the month before the survey; most frequently from dairies and service stations. For more than one-third of smokers (35.7%), being younger than 18 years was not a barrier to purchasing tobacco products. During 2002, the retail value of tobacco sales to those 14–16 years, alone, was estimated to be in excess of $18 million, with around $12.5 million of this going to the Government as taxes.”75
MajorindependentriskfactorsandpopulationattributablerisksforsmokingamongNZfourthformchildrenidentifiedbyFordetal
ETS exposure of infants was 5–8 times higher in households of smokers trying to protect their children by smoking outdoors than in households of non-smokers.
ETS exposure of infants was 5–8 times higher in households of smokers trying to protect their children by smoking outdoors than in households of non-smokers.
Category Year Girls (%) Boys (%)
Daily smokers 1999 17 14
2001 15 12
2003 14 10
Smoking daily, weekly or monthly
1999 32 25
2001 28 21
2003 25 17
Table 6-3: Action on Smoking and Health (ASH) studies of prevalence of tobacco smoking in Year 10 (15 yr olds)(figures rounded to nearest 1%)74.
25
were:parentalsmoking(22.9%),poorknowledgeof adversehealtheffects(7.3%)andwatchingtelevisedsports(13.4%).Thesethreefactorsaccountedfor36.1%of thetotalsmokingprevalence76.
“The effect of both parents smoking on the risk of daily smoking by students varied significantly (p <0.0001) between ethnic groups, being strongest for Asian students (adjusted relative risk (RR) = 6.64 compared with students of non-smoking parents), intermediate for European (RR
= 3.11) and Pacific (RR = 3.05) students, and weakest for Maori (RR = 1.74). Adolescent smoking was also positively associated with pocket money amount and living in a home where people smoked. Two thirds of daily smoking could be explained by the combined exposure to one or more of the following factors: parental smoking, pocket money >$5 per week, and smoking in the house.”77
6.3 HealthRisksandBurden(Table6-4)
Thefigure given inTable 6-4 for hospital admissionsmaybe anunderestimate,andwouldimplyamuchlowerattributableriskthan14%.
Non-respiratoryriskstochildrenbeforeandafterbirthincludea2foldincreasedriskof miscarriageorstillbirth99-101,a1.5foldriskof meningococcaldisease(or50casesannually)102,103,andanincreasedriskof burnsordeathfromhousefires104.
Insummary,exposuretocigarettesmokecausesawidespectrumof significant health effects in children, both before and after birth,
The estimated annual burden of childhood
illness due to smoking in New Zealand is:
50 deaths, 500 admissions to
hospital, 27,000 general
practitioner consultations for
respiratory illness and asthma,
1,500 glue ear operations and
15,000 episodes of asthma.
Table 6-4: Estimated respiratory health
risks and burden of health effects in New
Zealand children.Estimates in the right
hand column are based on reference 78
and are independent of the risks quoted
from the literature in the centre column.
Conditions Increase in Risk
Estimated Annual Burden of Childhood Illness Due to Smoking78
Sudden infant death syndrome (SIDS) (50% of cases attributable)79-81
2-5 fold 50 deaths
Infant lung function82-84 Decreased
Infant wheezing83,84 Increased
Infant admission to hospital, any cause (14% of admissions attributable)85
1.5 fold 500 admissions
Respiratory illnesses including:Otitis media86-88
Pharyngotonsillitis89
Rhinitis & sinusitis90-92
Bronchitis, bronchiolitis & pneumonia93-98
1.5-4 fold 27,000 general practitioner consultations for respiratory illness and asthma1,500 glue ear operations
Severity of asthma and other chronic respiratory disorders
Increased 15,000 episodes of asthma
Physical fitness and lung function
Decreased
Likelihood of smoking uptake77 1.7-6.6 fold
26
and increases the risk of children becoming smokers themselves.Theprevalenceof smokinginadultsandinteenagersisshowingaveryslowdeclinebut,disappointingly,asmanyasathirdof pregnantmothers and parents of small children continue to expose theirchildren to cigarette smoke. A large number of illnesses,hospitalisations, operations, and even deaths in children are theresult.
6.4 Preventionof AdolescentUptake
Thestrategiesthatbestpreventadolescentuptakeof smokingaredebatedandmanyseethisasanareawhichhasnoprovenstrategyas yet. We know already some of the important risk factors for teen smoking.These include being exposed to smoking by significantothers, especially parents and peers, availability and affordabilityof cigarettes, and the effect of smoking teenage rolemodels ontelevisionor infilms.Subtlemarketingstrategiessuchas tobaccosponsorship and advertising in televised international sporting events mayplayapart.Educationlevelisalsoinverselyassociatedwiththeriskof takingupsmoking,butthereislittleevidencetosuggestthateducation in the school about smoking is effective in preventingteenagesmoking,althoughitincreasesknowledgeabouttheeffectsof smoking.Basedontheserisksthemostlogicalstrategieswouldappeartobeindecreasingorderof priority:i.Decreasetherateof parentalsmokingandsmokingbyadultsinthecommunityii.Increasepricingviaexcise,anddecreasevisibilityandaccessibilityof cigarettes to minors.iii.RecommendR-ratingof moviesshowingsmoking.Alternativelydeveloppre-moviecounter-tobaccoadvertising(thishasbeentrialedsuccessfullyinAuckland).iv.Prohibittobaccocompanysponsorshipof educationalpackages(suchasI’vegotthePower)orinitiatives(suchasLifeEducation).v.Continue education of young schoolchildren about the effectsof tobaccosmokingaspartof healtheducation.Thisatleastgiveschildrenabackgroundknowledgeaboutsomeof therisks.
6.5 Recommendations
Supportof smokingcessationamongadultsandparentsislikelyto have the largest and most immediate effect on the health of children.Pregnancy and parenthood are key times to intervene in thevicious cycle of smoking and its effects for the followingreasons:− Smokingcessationwillhave immediatehealthbenefits for
the child.− Parents and prospective parents are often in contactwith
health professionals so that many opportunities exist todiscussthehealthissues.
− Many or most parents are prepared to forgo some of their ownpleasuresforthesakeof achild’shealth,andachild’shealth is a potential motivator.
•
•
As many as a third of pregnant mothers and parents of small children continue to expose their children to cigarette smoke.
As many as a third of pregnant mothers and parents of small children continue to expose their children to cigarette smoke.
“…the He Papa Pounamu - Building Bridges programme, which targets at-risk rangatahi/youth, is now being supported by British American Tobacco (BAT). However as noted by former ASH UK Director Clive Bates: “It’s like the Mafia godfather going to church on Sunday and putting a thousand dollars on the collection plate - it’s what they do during the week that matters.”
Leigh Sturgiss, Tobacco Control Update.
“…the He Papa Pounamu - Building Bridges programme, which targets at-risk rangatahi/youth, is now being supported by British American Tobacco (BAT). However as noted by former ASH UK Director Clive Bates: “It’s like the Mafia godfather going to church on Sunday and putting a thousand dollars on the collection plate - it’s what they do during the week that matters.”
Leigh Sturgiss, Tobacco Control Update.
27
Asystemsapproachinprimaryandhospitalcareisrecommendedtoidentifyandcounselparentsandpregnantwomenwiththeaimof helpingthem(indescendingorderof priority)toquit,toreducetheirsmoking,toeliminatesmokinginindoorareasincluding motor vehicles, and to wear discardable smokingjacketsinoutsidesmokingareas.Continuedincreaseinthetaxandrealpriceof cigarettesislikelyto be themost effective tool for reducing the prevalence of smoking in thepopulation,particularlyamong theyoungandthedisadvantaged.Pressurehasbeenbrought tobearon thegovernmenttousesuchtaxtoinvestbackintobaccocontrolpolicyandsmokingcessation,butthisisunlikelytosucceed.Continued education of the public, parents, and childrenregarding the effects of tobacco smoking. This is unlikelyto succeed on its own, but is a necessary part of a tobaccocontrolstrategy.Schooleducationstrategieshaveyettoprovethemselves.Colourgraphicwarningsoncigarettepacketshavehadsomesuccessinothercountries.Reducingtheprofileof smokingandcounterstrategies.Reducingthe subtle yet effective marketing of cigarettes to youth viabrand sponsorship and placement in films and coverage of international sporting events (such as the Grand Prix) is adifficulttask,butcouldbetackledthroughcensorshipof suchfilms,andcounter-advertisingbeforesuchfilms.
•
•
•
•
“Mrs Turia said that Europeans bought
land 160 years ago in exchange for goods - including tobacco.“The effects of that
transformation have been significant. Our
people are dying of cancer and suffering
strokes and heart attacks at a rate
we can ill-afford.”“Twink out the
Goldie pipe.”
Gisborne Herald, 22 April 2005
28
Chapter 7: New Zealand’s Excessive Pertussis DiseaseBurden
7.1 Clinical Pertussis
Pertussis(whoopingcough)isanillnesscharacterisedbyprolongedcoughing.Itismostsevereandsometimesfatalinbabies.Typicallytherearefourphasestotheillnesscausedbyinfectionwith Bordetella pertussis.Theincubationphaselasts7to10daysandnomorethan14days.Itisfollowedbyacatarrhalphase(likethecommoncold)lasting7to10days,aparoxysmalcoughingphaselastingfrom1to4 weeks and a convalescent phase lasting 2 weeks to several months105,106.
Theinitialclinicalillnessduringthecatarrhalphaseresemblesamildupperrespiratorytractinfectionwithrhinorrhoea,mildconjunctivalinjection, tearing,occasionalsneezing,andamildcough.Fever isminororabsent.Theparoxysmalphase ischaracterisedbyboutsof persistent,severe,hackingcoughwhichincreasesinseverityandfrequencyfortwotothreeweeksandthenslowlyimprovesoverthesubsequentweekstomonthsof convalescence105.
Pertussis is a disease with a wide clinical spectrum with only aproportion of those with an infection following this clinical pattern. Atypicaldiseaseoccursininfants,whocanpresentwithapnoeaandcyanosispriortotheonsetof paroxysmalcough.Priorimmunisationreducestheseverityof clinicalpertussis.
7.2 Pertussis Mortality
7.2.1 PertussisinthePre-immunisationEra
Pertussiswasamajorcauseof deathindevelopedcountriesduringthe 19thcenturyandthefirsthalf of the20thcentury.IntheUnitedStatesduringthe1930spertussisresultedinmoreinfantdeathsthanmeasles,diphtheria,poliomyelitisandscarletfevercombined,andfrom1940to1948of allinfectionsonlypneumonia,diarrhoeaanddysenterycausedmorechildhooddeathsthanpertussis107,108.
7.2.2 Effectof MassImmunisation
Consistentwithotherdevelopedcountries thenumberof deathsand themortality rate from pertussis inNewZealand decreasedduring the laterpartof the19thcenturyandthefirsthalf of the20th century. The mortality rate started to decline prior to massimmunisation.AsshowninFigure7-1therateof declineincreasedwhen immunisationwas introduced. The pertussismortality rateinthe1990s(0.004per100,000)iscomparablewithcontemporaryestimatesfromotherdevelopedcountries109,110.
Although mortality rates have declined dramatically pertussiscontinues tokill infants inNewZealand.One infanthasdiedof pertussis in Starship Children’sHospital each year from 2000 to2005.Consistentwiththeexperienceof otherdevelopedcountries
Cameron GrantCameron Grant
Pertussis is most severe and sometimes fatal in babies.
Pertussis is most severe and sometimes fatal in babies.
29
infants die despite intensive care112-115.DatafromtheUnitedStatesindicatesthatthenumberof infantsdyingfrompertussisincreasedin the 1990s compared with the 1980s114.
7.2.3 PertussisMortalityisUnderestimated
The number of deaths from pertussis is underestimated. Thepotential for deaths caused by pertussis to be underestimatedis greater than formanyof theother infectiousdiseases.As theprolonged coughing attacks and associated vomiting can lead tomalnutrition, pertussis predisposes children to death from otherillnessessuchasgastroenteritisandmeasles.BasedupondatafromtheUnitedStatesinthe1980sand1990sandtheUnitedKingdomin 1990s it is estimated that only approximately one third of all pertussisdeathsareidentifiedasbeingduetopertussis116-119.
7.3 Pertussis Morbidity
7.3.1 Underestimationof DiseaseIncidence
Pertussismorbidityisunderestimatedtoanevengreaterextentthanpertussismortality.Estimatesof theproportionof pertussiscasesthatarenotifiedhavevariedbetween6%and25%,i.e.thereare4to16 times more people with pertussis than are notified120. The proportion notified is higher in epidemic compared with non-epidemic time intervals and decreases with increasing age116.
7.3.2 Historical Trends
Althoughareductioninpertussismortalityratesbeganwellbeforeimmunisation,areductioninpertussisincidenceratesdidnotoccuruntilmassimmunisationwasintroduced.InfactreportedpertussisincidenceincreasedintheUnitedStatesfrom1910to1930-1935108.
Followingtheintroductionof massimmunisationpertussisincidencefelldramaticallyinEuropeanandNorthAmericancountries.Theannual pertussis incidence rate per 100,000 in Canada decreasedfrom 160 during 1934-43 to 14 during 1964-73; inEngland and
Pertussis continues to kill infants in
New Zealand.
Pertussis continues to kill infants in
New Zealand.
Pertussis vaccineintroduced
1872-7
6
1878-8
2
1884-8
8
1890-9
4
1896-0
0
1902-0
6
1908-1
2
1914-1
8
1920-2
4
1926-3
0
1932-3
6
1938-4
2
1944-4
8
1950-5
4
1956-6
0
1962-6
6
1968-7
2
1974-7
8
1980-8
4
1986-9
0
Year
0.001
0.01
0.1
1
10
100
Numberof deaths
per 100,000
Figure 7-1: Five year moving average
pertussis mortality rate in New Zealand per 100,000 person
years 1872 to 1990111.
30
Walesfrom230in1940-49to51in1974-75;andintheUnitedStatesfrom157during1932-41to0.5to1.5during1973-85105,109,121,122.
7.3.3 GlobalPertussisIncidence
Figure7-2showsthenumberof reportedcasesof measles,pertussis,diphtheria,polioandtetanus in theworld, reportedtotheWHOannuallyfrom1980to1999.Ascanbeseen,pertussisisthesecondmostfrequentof thechildhoodvaccinepreventablediseases.Thenumberof casesof eachof thesediseaseshasdecreasedsubstantiallyoverthis20yearperiod.In1999thenumberof reportedcasesof pertussiswas18timeshigherthanthenumberof reportedcasesof diphtheria,13timeshigherthanthenumberof reportedcasesof polio, four times higher than the number of reported cases of tetanusandonesixththenumberof reportedcasesof measles123.
7.3.4 Determinantsof InternationalIncidenceVariability
Countries with consistently low pertussis incidence rates sincethe introduction of mass immunisation have in common highimmunisationcoveragethathasbeensustainedoverseveraldecades.Examples of such countries include Hungary, the former EastGermany,Poland,SamoaandTonga123-125.
A reduction in coverage results in a prompt increase in diseaseincidence. England and Japan experienced increases in pertussisincidencefollowingareductioninvaccinecoverageandwithdrawalof vaccine respectively126-130.
Variability invaccineefficacyashasoccurred inCanadaandTheNetherlandsalsoaffectsdiseaseincidence131-133.
7.3.5 NewZealandinComparisonWithitsPacificNeighbours
The reported incidenceof pertussis is notdirectly related to theeconomicwealthof acountry.Forexample, inthePacificregionthetwocountrieswiththehighestincidenceratesduringthe1990s,AustraliaandNewZealand,arebothdevelopedcountries.TheCook
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Numberof Cases(Millions)
MeaslesPertussisDiphtheriaPolioTetanus
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Numberof Cases(Millions)
MeaslesPertussisDiphtheriaPolioTetanus
Figure 7-2: Global annual reported incidence of childhood vaccine preventable diseases, 1980-99123.
Figure 7-2: Global annual reported incidence of childhood vaccine preventable diseases, 1980-99123.
31
IslandsandTonga, twootherPacificnationswith lowerpertussisincidenceratesthanNewZealand,arealsoclassifiedbytheWHOasdevelopingcountries(Figure7-3)123.
Aspertussis only became a notifiable disease inNewZealand in1996, the under estimation of disease incidence is likely to havebeengreaterduringthefirsthalf of thisdecade134. Compared with a notification system that includes a clinical case definition, thelaboratorycasedefinitionusedpriorto1996resultedinafivefoldunderestimation of the incidence of pertussis in New Zealand.Although thedatapresented inFigure7-3suggests thatpertussisincidenceinNewZealandwassimilartotheotherwesternPacificcountries,itismoreprobablethatpertussisincidenceratesinNewZealandwereelevatedthroughoutwholedecade.
7.3.6 PertussisDiseaseBurden inNewZealandComparedWithOtherDevelopedCountries
7.3.6.1 NotificationRates
ThepertussisnotificationrateinNewZealandin1996,anepidemicyear,was 19.8 per 100,000135. This incidence rate was more than seventimesgreaterthanthatfortheUnitedStatesin1993136. Of note,thenumberof notificationsduringthe1993epidemicintheUnitedStateswasmorethaninanyof thepreceding25years136.
7.3.6.2 LaboratoryIsolateData
Comparisonsof pertussis incidence inNewZealandwith that intheUnitedKingdomandtheUnitedStateshavebeenmadeusinglaboratoryisolatedata137. The average monthly positive isolate rates per100,000inNewZealandduringthreeepidemicyears;1982,1986and1991werecomparedwiththosefromtheUnitedKingdomforthesamethreeepidemicyears.ThecomparisonisshowninTable7-1. In 1982 the isolate rate inNewZealand was 1.3 times lessthanintheUnitedKingdom,butin1991therateinNewZealandwasmorethansixtimesgreater.Thechangeinrelativefrequencyoccurredbecausetheisolateratedecreasedsixfold intheUnited
Cook Islands and Tonga have lower pertussis incidence rates
than New Zealand.
Cook Islands and Tonga have lower pertussis incidence rates
than New Zealand.
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
0
10
20
30
40
50
60
Incidenceper 100,000population
AustraliaChinaJapanMalaysiaNew ZealandPhilippinesSamoaVietnam
Figure 7-3: Pertussis incidence in the Western Pacific
region per 100,000 population 1990-99123.
32
Kingdom from 1982 to 1991 whereas it remained relatively constant inNewZealand.
Overthis10yeartimeperiodtheimmunisationrateintheUnitedKingdom increased from 30% to 90%126,128. In contrast, theimmunisationrateinNewZealandremainedbetween70and85%138-
140.
The B. pertussis isolate rate in New Zealand from 1980 to 1989was compared with that over the same period from the UnitedStates.Over thisdecade thenumberof positive isolatesper yearper100,000populationwas3.75forNewZealandand0.37fortheUnitedStates137.
7.3.6.3 Hospitalisation Rates
InFigure7-4theaverageannualpertussishospitaldischargeratesinNewZealand during the 1980s and 1990s are comparedwiththose reported from other developed countries during the sametime periods110,118,141-143. The pertussis hospital discharge rates inNewZealandhavebeenfiveto10timeshigherthanthosereportedfromEnglandandWalesandtheUnitedStates.Onlythepertussishospitalisation rate reported from Sweden in the early 1980s was higher than that inNewZealand,with the former rate reportedfollowingthediscontinuationof pertussisimmunisationin1979141. Theaveragelengthof hospitalstayforpertussisinNewZealandissimilartothatreportedfromtheUnitedStates110,116.
7.4 Why Does New Zealand Have So Much Pertussis?
New Zealand has an excessive disease burden from pertussisprimarilybecauseof lowimmunisationcoverageandevenloweron-timeimmunisationcoverage.NewZealandhasneverhadandstilldoes not have a primary care system capable of deliveringimmunisationsontimetoallof itschildren144,145.Until the1980s,New Zealand’s immunisation schedule was influenced more bydecisionsaimedat reducingadversevaccinereactionsrather thanmaximisingpopulationprotection138,146.Pertussisvaccinesused inNewZealandhavebeenshowntobeefficaciousinothercountries147-150.ThevaccineefficacyestimatesperformedinNewZealandhavebeenconsistentwiththeinternationalefficacydata138,151.
Therehasonlybeenasmallincreaseinimmunisationcoverageoverthe past 25 years. Currently between 80% and 90% of childrenreceive the primary series with only 50% to 60% of childrenreceivingtheseimmunisationsontime138-140,152-158.NewZealandhaslower immunisation rates than most of its Pacific neighbours159.
The pertussis hospital discharge rates in New Zealand have been five to 10 times higher than those reported from England and Wales and the United States.
The pertussis hospital discharge rates in New Zealand have been five to 10 times higher than those reported from England and Wales and the United States.
Year Positive Isolate Rate per 100,000
New Zealand United Kingdom
1982 0.77 1.03
1986 0.46 0.34
1991 1.08 0.17
Table 7-1: Average monthly B. pertussis isolate rates per 100,000138.
33
InNewZealanddelayedreceiptof anyof thethree infantdosesof pertussisvaccineisassociatedwithafivefoldincreasedriskof hospitaladmissionwithpertussis160.
Consistent with other countries, delay in receipt of the firstimmunisationdosepredictssubsequentincompleteimmunisation161. Povertyrelatedfactorsareimportantbarrierstoimmunisation153,155. There is widespread public support for immunisation in NewZealandbutpoorunderstandingof theimmunisationscheduleandthe true contraindications to immunisation140,161. Compared with theemphasisthisareahasreceivedinternationally,researchtodateonhealthsystembarrierstoimmunisationinNewZealandhasbeenrelatively sparse60,162.
Clearandcomprehensive recommendationshave repeatedlybeenmadeforimprovingimmunisationinNewZealand163,164.Alackof accountability in the health care system and frequent changes tohealth policy haveprevented these recommendations frombeingintroduced165.
7.5 Summary
7.5.1 PertussisMortality
Becauseof itspropensity tostrikeveryearly in lifepertussiswasoneof thebiggestkillersof childreninthepre-immunisationera.Thedeclineinpertussismortalityrates,whichcommencedpriortoimmunisation,wasacceleratedbymassimmunisation.
Pertussis continues to kill infants and, in the developed world,intensivecarecannotalwayspreventdeath.Thenumberof deathsfrom pertussis is underestimated by a factor of three. Pertussisis known to kill at least one infant each year in New Zealand.InformationfromtheUnitedStates indicates that thenumberof pertussisdeathsininfantsmaybeincreasing.
New Zealand has an excessive disease
burden from pertussis primarily because
of low immunisation coverage and even
lower on-time immunisation
coverage. New Zealand has never had and still does not have a primary care system
capable of delivering immunisations
on time to all of its children.
New Zealand has an excessive disease
burden from pertussis primarily because
of low immunisation coverage and even
lower on-time immunisation
coverage. New Zealand has never had and still does not have a primary care system
capable of delivering immunisations
on time to all of its children.
Only 50% to 60% of children receive the primary series of immunisations
on time.
Only 50% to 60% of children receive the primary series of immunisations
on time.
Figure 7-4: International comparison of average
annual pertussis hospital discharge rates
during the 1980s and 1990s110,118,141-143.
1980-89 1990-97
Decade
0
1
2
3
4
5
6
7
8
9
10
Numberper 100,000
New ZealandUnited StatesEngland & WalesSwedenCanada
34
7.5.2 PertussisMorbidity
Pertussisincidenceratesareunderestimated4to16fold.Thedegreeof underestimation increases with increasing age and decreasingdisease severity.
Priortoimmunisationpertussisincidencewasnotdecreasing.Theintroductionof massimmunisationwasassociatedwithaprofoundreduction in the incidence of pertussis. Between 1930 and 1980therewere5to100foldreductionsinpertussisincidenceinCanada,EnglandandWalesandtheUnitedStates.
Countries with consistently low pertussis incidence rates sincethe introduction of mass immunisation have in common highimmunisationcoverageratessustainedoverseveraldecades.Higherpertussisincidenceratesinsomecountriesnow,andinothersintherecentpast,havebeenduetolowerimmunisationcoverage,andtoalesserextent,lowervaccineefficacy.
ThepertussisincidencerateinNewZealandisalsohigherthanthatinmostotherPacificnations.Baseduponcomparisonsof nationalpassive surveillance data, laboratory isolate data and hospitaldischargeratesthepertussisincidenceInNewZealandisbetween5and10timesgreaterthanintheUnitedKingdomortheUnitedStates.
7.5.3 WhyDoesNewZealandHaveSoMuchPertussis?
New Zealand has an excessive disease burden from pertussisprimarilybecauseof lowimmunisationcoverageandevenlower“on-time”immunisationcoverage.Immunisationcoveragehasincreasedminimally inNewZealand over the past 25 years.NewZealandcontinuestostruggletoovercomethepovertyrelatedbarriersthatcurrently prevent a significant proportion of our children frombeingprotectedagainstvaccinepreventablediseases.
7.6 Recommendations
Pertussis continues to kill infants and infants die despitepaediatric intensive care. Therefore young infants in whomthere is any clinical suspicionof pertussis need tobe closelymonitored.Theprincipalreasonforstartingtheimmunisationscheduleatasyounganageaspossibleistoprotectinfantsfrompertussis.The timely delivery of the immunisation schedule preventsinfantsdyingfrompertussis.Thereiscompellingevidencefrommanycountrieswhichshowsthatif NewZealandweretoincreaseitsimmunisationcoverageto95%thepertussisdiseaseincidencewoulddecrease10fold.
•
•
•
35
Chapter 8: What Does Pneumonia Cost New Zealand?
8.1 Clinical Pneumonia
Most children with pneumonia present with cough or difficultybreathing,butonlytheminorityof childrenwiththesesymptomshave pneumonia166. Among children with pneumonia in NewZealand,manyaremanagedinprimarycaresettings,butthosewithmore severe symptoms are admitted to hospital.
Inpreschoolagedchildrenwhohavecoughordifficultybreathingthe World Health Organization (WHO) have defined three keyclinical signs that should be usedwhen decidingwhether or notachildhaspneumonia.Theseclinical signsare tachypnoea,chestindrawingandabsenceof wheezing167.Achildhaspneumonia if s/hehastachypnoeaorindrawingandnowheeze.
Tachypnoea is defined by theWHO as a respiratory rate greaterthan60breathsperminuteif thechildislessthan2monthsof age,a respiratoryrategreater than50breathsperminuteforchildrenagedtwoto12monthsandarespiratoryrategreaterthan40breathsper minute for children aged 12 months to five years167. Chest indrawing is defined as retraction of the lower chest wall oninspiration166. A chest radiograph is helpful for identifyingcomplications of pneumonia such as a pleural effusion. Inter-observer agreement between radiologists has been shown to bepoor when categorising children’s chest radiographs as normal,equivocal or indicative of pneumonia or when differentiatingchildren who have a proven viral or bacterial aetiology for theirpneumonia168,169.
8.2 How Common is Pneumonia?
Pneumoniaremainsacommonandserioushealthprobleminbothdevelopedanddevelopingcountries.Itisfundamentallydifferentinchildrencomparedwithadults.Theannualincidenceof pneumoniainchildrenyoungerthanfiveyearsof ageis34to40casesper1,000inEuropeandNorthAmerica,higherthanatanyothertimeof life,exceptperhapsforadults75yearsof ageorolder170.
Comparedwiththedevelopedworld,pneumoniainthedevelopingworldismorecommonandmoresevere.Itisthemostfrequentkillerof children inthedevelopingworld.In2000,of the10.8millionestimatedchildrenlessthanfiveyearsof agewhodied,between14and24%of thesedeathswerefrompneumonia171.
Paediatric pneumonia ismore common inNewZealand than inotherdeveloped countries.Basedupon allNewZealandhospitalICD-9 discharge diagnoses for pneumonia in 1998/1999, thenationalpneumoniahospitaladmissionrateforchildrenaged0to14 years was 4.0 per 1,000172. Contemporary statistics from the UnitedStatesdemonstratedahospitaladmissionrate inthesameagegroupof 0.5to1.0per1,000,i.e.aboutfiveto10timeslower
Cameron GrantCameron Grant
Richard MilneRichard Milne
Pneumonia is fundamentally
different in children compared with adults.
Pneumonia is
Paediatric pneumonia is more common in New Zealand than
in other developed countries.
36
thaninAuckland173.
Pneumonia hospital admission rates are highest for the youngestchildren.Baseduponthenational1998/1999statistics,thehospitaladmissionrateforpneumoniaper100,000childrenwas1,534forchildrenagedlessthan2years,562forchildrenaged2to4years,170 for children aged 5 to 9 years and 73 for children aged 10 to 14 years172.Thisamountsto3,261childrenhospitalisedwithpneumoniaeachyearinNewZealand;1,673childrenlessthantwoyearsof age,909childrenagedtwotofouryears,466childrenagedfivetonineyears and 212 children aged 10 to 14 years.
In New Zealand pneumonia hospital admission rates vary withethnicity. Based upon data from Starship Children’s Hospital inAuckland,thepneumoniaadmissionrateforPacificchildren0to14yearsof ageis14.0per1000,forMaorichildren6.7per1000andforEuropean/other children2.7per1,000174. It shouldbenotedthat even fornon-Maori,non-Pacific (‘European/other’) childrenthepneumoniahospitalisationrateisthreetofivetimegreaterthancontemporary rates from the United States173. The difference in hospitalisationratesismostsignificantfortheyoungestchildren.Asshown in Figure 8-1, between four and five percent of Pacificchildren, between two and three percent of Maori children andalmostonepercentof European/otherchildrenlessthantwoyearsof agefromwestAuckland,centralAucklandandthenorthshorearehospitalisedwithpneumoniaeachyear.
Itisimportanttorememberthatonlyaproportionof childrenwithpneumoniaarehospitalised.Forexample,onlyapproximatelyhalf of the children who are diagnosed with pneumonia at StarshipChildren’sHospitalareadmittedtohospital.Particularlyforschoolagedchildren,asignificantproportionof thosewithpneumoniaaremanagedinemergencydepartmentsorinthecommunitywithoutadmission to hospital.
Over 3,000 children are hospitalised with pneumonia each year in New Zealand.
0
5
10
15
20
25
30
35
40
45
50
0 to 1 2 to 4 5 to 14
Age (Years)
Rateper
1000
Pacific
Maori
European/Other
Figure 8-1: Paediatric pneumonia hospitalisation rates by age and ethnic group in Auckland, 1993 to 1996174.
For ‘European/other’ children, the pneumonia hospitalisation rate is three to five time greater than contemporary rates from the United States.
37
8.3 ArePneumoniaHospitalisationsAvoidable?
Children inNewZealand are being hospitalised at an increasingrate.From1988to1995therewasanaverageannual increaseof five percent in the hospitalisation rate for children 0 to 14 yearsof age175.Paediatrichospitaladmissionratesarealsoincreasinginotherdevelopedcountries176-178.
Overthesametimeperiodthathospitaladmissionrateshavebeenincreasing there has been an increase in the proportion of hospitalisations thatareavoidable.Anavoidablehospitalisation isonethatcouldbepreventedbygoodqualityprimaryoroutpatientcare.Avoidable hospitalisations include those for conditions thatare almost always avoidable, for example, vaccine preventablediseases;andthoseforconditionsforwhichmosthospitalisationsareavoidable,forexamplepneumoniaandasthma179-181.
Ananalysisof nationalhospitaldischargedatafrom1989to1998demonstratedthatby1998one inthreehospitaladmissionswerepotentially avoidable. In two thirds of these, the interventionnecessary to avoid the hospital admission was more effective primary health care services181.Agestandardisedratesof avoidablehospitalisations in Maori and Pacific people in 1997-98 were60% and 70% higher than in European/other New Zealanders.Respiratoryinfectionsarethelargestcontributortoboththeethnicandsocioeconomicexcessesinavoidablehospitalisations182.
8.4 Measurement of the Cost of Treating Children With AcutePneumonia
Costestimatesdependupontheperspective,forexamplethecosttotheindividual,thefamily,thehealthcaresystem,orsociety.Thetruecostof anydiseasethatcausesprematuredeath isextremelydifficulttomeasure.Forexample,howdoyouquantifythecosttoafamilyof thelossof achild’slife?
Thedirectmedicalcostof pneumoniainNewZealandchildrenaged0to14yearshasbeenestimatedbaseduponhospitaladmissions,emergency department visits and general practitioner visits172. These costsexcludeanyof thenon-medicalcostsor indirectcostssuchastransporttotheGeneralPractitioner,daysof parentalworklost,daysof schoolabsencebychildren,andalltheintangiblecostssuchasstressinfamiliescausedbyacuteillnessinchildren.
Table 8-1 shows the estimated costs of hospital admissions andemergency department visits for children less than 15 years of age. EachyearNewZealandspendsoverfivemilliondollarsoninpatienthospital costs and more than one million dollars on emergency departmentcostsforpaediatricpneumonia.
The costs of primary care for children with pneumonia can beestimated from a study conducted by theDunedin research unitof theRoyalNewZealandCollegeof GeneralPractitioners183.Allconsultationandprescribingrecordsfrom29NewZealandpractices
One in three hospital admissions were
potentially avoidable. In two thirds of these,
the intervention necessary to avoid the
hospital admission was more effective
primary health care services.
Respiratory infections are the
largest contributor to both the ethnic
and socioeconomic excesses in avoidable
hospitalisations
Each year New Zealand spends over
five million dollars on inpatient hospital costs and more than
one million dollars on emergency
department costs for paediatric pneumonia.
38
forthetimeperiod1January2000to31December2000formedthestudydatabase.Thetotalpopulationof thedatabasewas136,629,of whom7,019patients(5.1%)wereagedlessthantwoyears.Generalpracticeconsultationsbychildrenwithpneumoniawereidentifiedfromthisdatabase.Theper-patientcostsof thesevisitsforgeneralmedicalservices,prescribedantibioticsandchestradiographswereestimated.Anestimatewasalsomadeof thenumberof childrenthatwouldhavebeenseenbyallgeneralpractitionersinNewZealandand, from this, the total primary care costs for pneumoniawereestimated.BasedupontheseestimatesNewZealandspendsalmost$400,000 on primary care for pneumonia each year for childrenagedzeroto14years,includingbothGovernmentcostsand patient co-paymentsforpharmaceuticals(Table8-1).
Therefore in summary, based upon the directmedical costs only,pneumoniainchildrenunder15yearsof agecostsNewZealandatleast seven million dollars per year.
8.5 Childhood Pneumonia Leading to Health Problems for Adults
It is difficult to emphasise how much the above calculationsunderestimatethetruecostof pneumonia.Asdescribed,onlythedirectmedicalcostshavebeenmeasured.Itmustalsobenotedthatthesehaveonlybeenestimatedfortheacuteepisodeof pneumonia.Noestimatehasbeenmadeof thesubsequenthealthcarecoststhatoccur. Longitudinal studies that have followed populations of children though into adult life have demonstrated that havingpneumoniaasayoungchildisassociatedwithpoorerlungfunctioninadultlife184.
Table 8-1: Estimated annual costs of pneumonia in New Zealand based upon hospital admissions, emergency department visits and General Practitioner consultations.
Age Group (Years) Total
0 to 1 2 to 4 5 to 9 10 to 14
Hospital admissions
Number of children admitted to hospital with pneumonia
1702 948 490 193 3,333
Costs per admission* $1,560 $1,263 $1,709 $1,486
Emergency department cost for each admission
$191 $191 $191 $191
Costs per year $2,980,202 $1,378,392 $931,000 $323,661 $5,613,255
Emergency department consultations without admission to hospital
Number of children† 2049 1906 845 922 5,722
Emergency department cost per visit
$191 $191 $191 $191
Annual costs for emergency department visits‡
$391,359 $364,046 $161,395 $176,102 $1,092,902
General practitioner consultations§
National cost estimateπ $125,550 $122,570 $109,324 $32,356 $389,800
Total $3,497,111 $1,865,008 $1,202,719 $532,119 $7,095,957
* Based on Starship Children’s Hospital ward plus general paediatrics charges.† Estimates based on the proportion of children that present to Starship Children’s Hospital Emergency Department who are diagnosed with and treated for pneumonia but are not admitted to hospital.‡ Cost based upon Starship Children’s Hospital Emergency Department.§ Includes General Medical Services benefit, and charges for antibiotics and chest radiographs.π Extrapolated from Royal New Zealand College of General Practitioners database183.
Longitudinal studies that have followed populations of children though into adult life have demonstrated that having pneumonia as a young child is associated with poorer lung function in adult life.
39
Somechildrenwithpneumoniahaveasevereillness,whichleavesthemwithdamagedlungs.Thisdamagecanbepermanentandcanleadtochroniclungdisease,forexamplebronchiectasis(seeChapter9),andeventuallyrespiratoryfailureinadultlife.BasedupondatafromtheUnitedStates,chronic lungdisease is thefourth leadingcauseof deathinadults185.
8.6 Summary and Conclusions
Pneumonia occurs in toomany of our children. Large numbersof youngchildrenarehospitalisedeachyearwithpneumoniaandforsomethissignalsthebeginningof achronic illnessthat leadstoprematuredeath.Atleastsevenmilliondollarsisrequiredeachyeartomeetthedirectmedicalcostsof community,emergencyandinpatienthealthcareforNewZealandchildrenwithpneumonia.
8.7 Recommendations
ForNewZealandtobelessembarrassedbyitspneumoniaproblemwillrequirefocusedsustainedeffortthatincludes:
Improved access to higher quality primary health care for allchildren.Moreeffectiveearlychildhoodpolicyrelatingtoimmunisationandnutrition.A fundamental improvement in the indoor environment inwhichourchildrenarenurtured.
•
•
•
40
Chapter9: TheBurdenof BronchiolitisinNewZealand
Acutelowerrespiratorytractinfectionsareanimportantcauseof mortality among children less than 5 years of age and remain the leadingcauseof disability-adjustedlifeyearslostworldwide.Thisisdisproportionatelybornebychildrenindevelopingregionswhereitis estimated that 4.3 million children aged less than 5 years die annually of lower respiratory tract infections (LRTI)186. However there is also substantial childhoodmorbidity andmortality fromlowerrespiratorytractinfectionsindevelopedcountries,includingNewZealand.
Bronchiolitis affects children less than 2 years of age with peakincidence occurring at 3-6 months. It is a virally induced lowerrespiratory tract infection (LRTI) that results in increasedmucusproductionandnarrowedairways.After a4-5dayprodrome, thechildrenpresentwitharaisedbreathingrate,wheeze,increasedworkof breathing, fever and can have difficulty feeding.The childrenbecome unwell over the first 3 days, then usually recover in 2-4dayswithnospecific treatment.Between0.5%-2%of previouslyhealthy children require hospitalisation for supportive treatmentwithfeeding,fluids,oxygenandmorerarelyventilatorysupport187,188. Themortalityof thoseadmittedislessthan1%.However20%haveaprotractedcourse,20%haveapnoea,and7%requireventilationalthoughinpreviouslyhealthyinfantsonly1.8%aretransferredtointensivecareunits.InaNewZealandstudy8%of theseinfantshadapnoeapriortoadmissionand3.1%requiredventilation189.
Whileanumberof virusescancausethisillness,themajorcauseisRespiratorySyncytialVirus(RSV).RSVisrecognisedasacommonserious infection worldwide since the 1960s and it remains thenumberonecauseof viralbronchiolitisandpneumoniaininfants.Annualseasonaloutbreaksof RSVinfectionoccur.Spreadrequiresclosecontactwithinfectedindividualsorsurfacescontaminatedbysecretions, usually by exhaled droplets but, for example, it canremainviableonthecotrailfor6hours190.
9.1 Rates of Infection
RSVinfectionisvirtuallyuniversal.Inthe1980safollowupof 125childrenlessthan12monthsof ageshowedthat68%hadanRSVinfectionbytheendof thefirstwinter,97%bythesecondyearand100%hadbeeninfectedbytheendof thethirdyear191.InastudyfromHongKongovera4yearperiod86%of thosewithbronchiolitiswhohadvirusesrecoveredhadRSV192. Most children will therefore have2-4RSV infections in thefirst7yearsof life.Althoughthesymptomscanbemildorrestrictedtotheupperairway,itcanresultinseriousinfectioninbothnormalandhighriskindividualsineitherfirstorsubsequentillnesses.It is this severe disease that we seek to prevent.
Cass Byrnes
Acute lower respiratory tract infections remain the leading cause of disability-adjusted life years lost world-wide.
Bronchiolitis affects children less than 2 years of age with peak incidence occurring between 3 and 6 months.
41
9.2 HospitalisationforBronchiolitisinNewZealand
Currently more than 3000 infants per year are admitted forbronchiolitisinNewZealand.Ratesof admissionforbronchiolitiswere 26.6/1000 children under 1 year in 1988 increasing to58.1/1000 in1998, an increaseof 118%189. The Top Ten report1 isthefirstsignificantoverviewof thekeyindicatorsof childandyouthhealthintheAucklandandWaikatoregions.Itcovers556,000youngpeopleagedbetween0-24yearsfrom1995-1999.Thereportanalysesthetoptencausesof potentiallyavoidablehospitalisations–infectiousdiseasesdominatethepictureinallareasandallethnicgroups.Withinthetopten;asthma,bronchiolitis,pneumoniaand‘other’ respiratory infection are all listed separately indicating theimportance of respiratory disease. The percentage of potentially avoidablehospital admissionshas risen throughoutNewZealandfrom1995 to2000 from32%to34%but this reached38.8% inSouthAucklandand37.7%inruralWaikato.
Infants and young children have substantially higher rates of hospitalisationsfortreatmentof LRTIsthantheotheragegroups.Forthewholeof NewZealand,theadmissionrateforchildrenlessthan 1 year of age for LRTI (predominantly bronchiolitis andpneumonia) was 102.6/1000 but up to 176.5/1000 in certainregions.
Bronchiolitis is responsible for anaverageof 2.8/1000avoidableadmissionsacrossthecountrybutishigherinsomeof theseregionssuchas4.6/1000inSouthAuckland.Itislistedasthethirdcauseof preventableadmissioninbothMaoriandPacificIslandcommunities.Againtherearehigherlevelsincertainregionssuchas6.9/1000inUrban Waikato Maori and 8.4/1000 in South Auckland PacificIslandcommunities(Table9-1).
InNewZealand in1998,409 infantswereadmitted into5majorhospitals.Of these8%wereex-premature (<32weeksgestation),and53%wereaged less than6months189. While there was some variationbetweenthehospitalsintermsof management,overall:
59%requiredoxygen;21%requirednasogastricfluids;22%intravenousfluids;34%hadantibiotics;42%hadbronchodilators;and60%hadachestx-ray.
Respiratory secretions collected for viral studies showed 59%werepositiveforRSV.Theoverallproportionof infantsrequiringsupportive treatmentwas65%whichwashigher thanaprevious
••••••
In a New Zealand study of the infants
admitted to hospital for bronchiolitis – 8% had apnoea and 3.1%
required ventilation.
New Zealand South Auckland Urban Waikato
Overall 2.8 4.6 3.5
Maori 4.2 6.0 6.9
Pacific Island 6.3 8.4 5.0
Table 9-1: Numbers of potentially avoidable
hospitalisations for bronchiolitis per
thousand children.Modified from Causes
of Potentially Avoidable Hospitalisation Age
standardised rates for 0-24 years of age per
1,000 population 1999 – The Top Ten report
with permission1.
42
study in Christchurch in 1986-1988193 where only 25% requireda similar intervention. Risk factors for requiring oxygen were; ahighriskinfant,youngeragegroupandhigherrespiratoryrateonadmission. The mean length of stay was 3.4 days and did not differ significantlybetween centres.Thefivehospitals studied admitted1900 infantsoutof thetotalof 3210thatyear.Comparedtothepreviousstudytheincreasedadmissionratewasnotduetoadmittinginfants who were less severely ill. In fact thresholds for admission appear to have risen over the last 10 years.
9.3 RiskFactorsforAdmission
Residence in an area of social and material deprivation increases the riskof admissionforbronchiolitis.Thiswasincreasedby1.5timesin a Sheffield study (England) evenwhen smoking exposurewastakenintoaccount194.In10centresintheUnitedKingdomtherateof admissionswashigherforbothRSVandnonRSVinfectionsinindustrial rather than suburbanor rural areasbutdisease severitywassimilar.Theincidenceof hospitaladmissionsinNewcastleduetoRSVwasanalysedbysocialclassandwaslowestinclass1(leastdeprived)wheretheincidencewas6per100,000comparedwith38per100,000forthefivemoredeprivedclasses195.
InMalmo,Sweden(1998/9),infantslivingintheareawiththehighestsocialburdenwerehospitalisedtwiceasoftenasthosefromtherestof thecity,althoughagaintheseverityof diseasewassimilar.Theadmissionratecorrelatedsignificantlywithlowpercapitaincomeand the percentage of immigrants in the area196.InHouston,infantsborn to low income families showedahospitalisation ratehigherthaninfantsborntomiddleincomefamilies197.InNewYorkState,rates of hospitalisation for LRTI in children living in inner city areas wasdocumentedat22.5/1000children,farhigherthanthosefromasuburbanareaat7.5/1000children198.Acase-controlstudyinruralAlaska showed that risk factors for RSV hospitalisation includedhouseholdcrowdingwhilebreast-feedingwasprotective199.
9.4 Mortality
Underlyingconditionsmayincreasetheriskforbothhospitalisationandmortalityincludingprematurity,chroniclungdisease,congenitalheartdisease,immunecompromiseandinfantslessthan3monthsof age.HoweverstudiesinCanada,USA,AustraliaandEuropeandnotedthat58-80%of hospitalisationforbronchiolitisoccurredinotherwise healthy children200-202.
From1996to1998intheUnitedStates,theannualinfantmortalityratewas2.0per100,000livebirths.Themedianageof deathwas3monthsandthemajorityof thedeaths(55%)occurredbetween1to3monthsof age.Themostsignificantriskfactorfordeathwaslowbirthweight.Abirthweightof lessthan1500gramsgavea25timesgreaterrisk,andabirthweightof lessthan2500gramsgavea5timesgreaterriskof dyingcomparedwithnormalbirthweightbabies. Other infant characteristics associated with an increasedmortality risk included a shorter gestational age, a low 5-minute
The major cause of bronchiolitis is Respiratory Syncytial Virus (RSV) infection.
It is the severe disease associated with low socioeconomic status, overcrowding, smoking and reduced breast-feeding that we seek to prevent.
43
apgarscore,multiplebirth,andahighlivebirthorder(oragreaternumberof siblings).Maternalcharacteristicswerebeingunmarried,of youngage(lessthan25years),smokingduringpregnancy,andalowereducationlevel190.Manyof theidentifiedriskfactorscanbeassociatedwithlowersocioeconomicstatus.
AlthoughdeathsoverallfromrespiratorydiseasesdecreasedintheUSAfrom1979–1997, theproportionof bronchiolitis associateddeaths did not vary203.“Thismakesreducingbronchiolitismortalityand morbidity among infants an important goal for publicintervention”190.
9.5 Financial Costs
IntheUSA,parametersof hospitalisation,hospitallengthof stay,generalpractitionerconsultations,anddaysof lostworkraisethecosttoUS$2,913perchildhospitalisedforanRSVinfection204. One of the contributions to the cost of the children admitted is theinvestigationsandtreatmentthattheyreceive.AnewguidelinewasdevelopedinNewZealandin2005–“WheezeandChestInfectionin the less than 1 year old”205.Thisisanevidencebasedguidelinecommissioned by theMinistry of Health through the PaediatricSocietyof NewZealand.IthasbeenendorsedbytheNewZealandGuideline Group, the New Zealand Paediatric Society and theCollege of General Practitioners as well as a number of otherinfluentialgroups.Basedonevidencethathasbeencarefullyscored–theconclusionforbronchiolitisisthatinvestigations(bloodtests,bloodcultures,nasopharyngealaspirates,x-rays)areof nobenefitin diagnosis (in particular differentiating bronchiolitis frompneumonia)orinthemanagementof thetypicalinfantbronchiolitisillness.
Inthisagegroupitisdifficulttoaccuratelydiagnosetheveryfewinwhom this illness is the commencementof asthma, asmostwillhaveanepisodeof wheezyillnessorillnessesthatwilldecreaseinfrequencythroughearlychildhood.Eventhosethatwillgoontobecomeresponsivetoasthmatreatment,maywellnotrespondatthis time. Despite continued research, there is no available specific treatment for this disease at the current time.Onerecentstudysuggeststhatreduceddaysof wheezeoccurredinchildrengivenoneanti-inflammatorydrug (montelukast)206, but this is only available as purchasedchewabletabletswhichseeminappropriateinthisgroup,andmoreresearch is needed to confirm these findings, particularly in theinfants aged less than one year.
The problem does not just stopwith bronchiolitis alone. SevereRSVisassociatedwithincreaseinwheezing,lowerrespiratorytractinfections and asthma diagnosis up to 6 years of age83. There is increased risk of respiratory symptoms and chronic productivecoughcontinuingatage5-8yearsinfigurestakenfromacasecontrolstudy207.Areviewof 6studiesof childrenlessthan12monthsof age hospitalised with proven RSV infection and comparing them to controlsshowedthat40%affectedversus11%controls reported
Within the TOP TEN causes of
potentially avoidable hospitalisations in children – asthma,
bronchiolitis, pneumonia and
‘other’ respiratory infection are all
listed separately. This indicates the
significant morbidity of respiratory disease
in New Zealand.
Many of the infant and maternal
characteristics that are associated with morbidity mortality
of this disease in otherwise healthy
children can be attributed to low
socioeconomic status and poor education.
Despite increasing admissions to
hospitals – there is a suggestion that the threshold for
admission has risen over the last 10 years.
44
wheezingupto5yearsand22%versus10%reportedwheezingat5-10yearsaftertheinitialillness208.Whilemostchildrenwithwheezewillnotgoontohaveasthma;at3yearsof age,11of 47childrenwithRSVhadasthmacompared to1of 93 in thecontrolgroupsuggestingariskfactorforasthmadevelopment209. Atamedianof 19yearsof age,physiciandiagnosedasthmawasreportedin30%withabronchiolitishistory,41%withapneumoniahistorybutinonly15%incontrols207.
9.6 Prevention
ThereisnospecifictreatmentforRSVbronchiolitis,howeverthereisthepossibilityof prevention.Anumberof highqualitystudiesin a variety of settings involving large numbers of infants haveconfirmed the risks of smoke exposure for generating increasedlower respiratory tract infections in infants210,211.Inuteroexposureresultsinthedevelopmentof smallerairwaysandthereforeahigherriskof developingwheezeininfancy.However,somestudieshavealsoshownincreasedepisodesof wheezeininfantsfromahouseholdwherethefatherisasmokerandthemotherisnot,indicatingthattheeffectisnotonlycausedbyinuteroexposure.
Breast-feeding strongly protects against lower respiratory tractinfection.A substantial bodyof evidencewith largenumbersof infantsboth indevelopinganddevelopedcountriesconfirms theprotective effect of anybreast-feeding.Ananalysisof severalstudiesshowed a more than tripling of hospitalisations for severe respiratory tractinfectionsforinfantsnotbreast-fedcomparedtothosebreast-fed for 4 months212.
There is no current vaccination available. However there is thepossibilityof givingpassiveprotectionbygivingimmunoglobulintherapy, which acts by giving the infant antibodies that will actagainst the RSV antigen when the infant is exposed. The firstavailableinNewZealandwasPalivizumab,ahumanisedmonoclonalantibody.Alargemulti-centrerandomisedcontrolledtrial213 enrolled 1502childreninwhom1002receivedPalivizumaband500placebogivenasmonthly intramusculardoses fora5monthperiod.Thedrug reducedRSVhospitalisationby 55%, hospital days by 42%andtimereceivingoxygenby40%comparedwithplacebo.Inthestudy17childrenrequiredtreatmenttopreventoneRSVadmission.PalivizumabwaslicensedintheUSAin1998,andinNewZealand1999. Averysmallnumberof infantsreceiveprophylaxis inNewZealandeachwinter,usuallyfundedby individualhospitalboardsonacasebycasebasis.Thisisduetohighcostof themedication–approximately NZ$6560 for 5 doses for an infant averaging 5kilograms.TheAmericanAcademyof Pediatrics214 recommended itsuseinprematureinfantslessthan28weeksgestationfor2winters,less than 32 weeks gestation for 1 winter and in children with chronic lungdiseaseonoxygenfor2wintersfollowingdischargefromtheneonatalunit.TheestimatedRSV readmission ratebefore1 yearcorrected age in infants less than 32 weeks gestation discharged on homeoxygenwas42%215. InNewZealandacostanalysiswithin
Although deaths overall from respiratory disease decreased in the USA between 1979 and 1997, the proportion of bronchiolitis associated deaths did not vary. This makes reducing bronchiolitis mortality and morbidity among infants an important goal for public intervention.
Wheeze and Chest Infection in the less than 1 year old’ is a new evidence based guideline developed with NZ Paediatric Society and Ministry of Health support and is available on both these websites (www.paediatrics.org.nz and www.moh.govt.nz).
The problem does not stop with RSV infection in infancy alone – there is increased wheezing, lower respiratory tract infections and asthma in those children up to 6 years of age.
45
theseparameterswasundertaken216andfoundthatthecostpercaseaverted averaged $NZ60,000 (range $28,000-$166,700 in thedifferinggroups).Thesehighcostsmaybereducedwith:
areducedcostof thedrug;use of longer intervals between injections (e.g. 6 weekly) if adequateprotectionisconferred;coverageof ashorterperiod(e.g.3-4wintermonths)insteadof 5monthsif sufficient;anduseof smallervials(previouslynotavailableinNewZealand)toavoidsignificantwastageof themedication.
With these changes and in the face of increasing RSV admissions thecostanalysisnow(5years later)maybedifferent.Also inthecontextof childrenwhoareex-prematureinfants,itwasnotedthatthe health care costs for these children are in the realms of $NZ150,000and$6560isarelativelysmalladditionalsmallcost216.
9.7 Summary
NewZealandhasahighrateof hospitalisationforbronchiolitisandthis contributes to the numbers of preventable hospitalisationsparticularlyincertaingroupssuchasruralWaikato,SouthAuckland,MaoriandPacificIslandcommunities.Mortality and hospitalisation is increasedinhighriskgroups(prematurity,chronic lungdisease,congenitalheartdisease,immunecompromiseandinfantslessthan3monthsof age) althoughmostdisease stilloccurs inotherwisenormal infants. Improvement of the socioeconomic standing of our poorest communities, reducing domestic crowding, reducingcigarettesmokeexposureandpromotionof breast-feedingmaybecosteffectivemeasurestoreducediseaseratesand,inparticular,theseverityof disease.Awarenessof,andadherenceto,thenewbestpracticeevidencebasedguidelinefor“WheezeandChestInfectionin the less than 1 year old”217maycontributetocostreductionbyreducingunnecessaryinvestigationsanddrugtreatmentwhereonlysupportive treatment is appropriate. Prevention by use of prophylactic immunoglobulinmay become cost effective in highriskinfantsandrevisitingthecostanalysisshouldbeconsidered.
9.8 Recommendations
Policies, education and programmes to aid smoke addictedpeople to reduce and give up smoking to reduce the smokeexposureof infants.Policiesandeducationtoimprovebreast-feedingrates.Improve socioeconomic conditions particularly to reducedomestic crowding.Awareness and implementation of the best practice evidencebasedguideline“WheezeandChestInfectioninthelessthan1 year old” which suggests that in the infant with a straight-forwardbronchioliticillness,investigationsanddrugtreatmentareunnecessary.Re-examinethecostanalysisfortheuseof prophylaxisinhighrisk infants.
••
•
•
•
••
•
•
Prevention of severe disease is
possible with: reduced
environmental tobacco smoke
exposure and promotion of
breast-feeding.
Cigarette smoke exposure increases hospital admissions
for lower respiratory tract infection.
Breast-feeding strongly protects
against lower respiratory tract
infections and sustained breast-
feeding longer than 4 months of age provides greater
protection.
46
Acknowledgements:
DrAlisonVogel for suggestionsandediting.Theauthorsof theTopTenReport(DrDavidGraham,DrAlisonLeversha,DrAlisonVogel).
47
Chapter 10: Tuberculosis in Children
Tuberculosis (TB), also historically known as “consumption”,“phthisis”and“wastingdisease”,wasthoughttobeconquerableinthe1940s and50swhen streptomycin and isoniazidfirstbecameavailable.Thisresultedinasteadydeclineinnumbersof reportedcasesinthedevelopedworldformanyyears.Then,inthe1980s,aworldwide resurgence in TB was reported. By the 1990s it wasestimatedthatathirdof theworld’spopulationwasinfectedwithTB, leading to theWorldHealthOrganisation declaring a globalcrisis in 1993218. In New Zealand (NZ) there were significantdecreasesintherateof TBfromthe1960sbutsincetheearly1990sthisdeclinehasreachedaplateauandtheratehasremainedaround10-11per100,000populationperyear219(Figure10-1).
Childrenaccountforapproximately5%of allreportedclinicalcasesof TB.Youngchildren infectedwithMycobacterium tuberculosis (TBinfection = a positive tuberculin test without clinical or x-rayabnormalitiesof TB)areathighriskof developingactivedisease(TBdisease=clinical,x-rayorlaboratoryevidenceof pulmonaryorextrapulmonaryTB)andhaveahigherriskof disseminateddisease
ormeningitis.TBinchildrenoccursinmostcasesbycontactwithaninfectiousadult.Asaresult,therateof TBdiseaseinchildrentends to reflect a similar pattern to that happening in the adultpopulation. Overa10yearperiodfrom1992to2001,401childrenunder16yearswerenotifiedwithTBdiseaseinNZ.Atotalof 269caseswereevaluated indepthaspartof a retrospectivestudy220. Disproportionatelyhighrateswerefoundintheunder5yearoldswithanoverallrateof 6.2per100,000.EthnicdisparitieswerealsoseenwitharateinPacificchildrenunder16yearsof 15.2per100,000and inAfrican children under 16 years of 575per 100,000.Therates in theAfrican group are not unexpected asmost of thesechildrenarerecentarrivalsinNZandreflecttheTBincidenceinthecountryof birth.TherateinPacificIslandchildrenunder16yearsis significantly higher than that in Maori (6.4 per 100,000) andEuropean(0.6per100,000).
Lesley Voss
19721974197619781980198219841986198819901992199419961998200020022004
Year
19700
100
200
300
400
500
600
700
800
900
1000
Numberof Cases
Total casesCases <15 yrs
Figure 10-1: Incidence of Tuberculosis by
Year New Zealand, 1970-2003219.
TB infection = positive tuberculin test
without clinical or x-ray abnormalities
of TB.TB disease = clinical,
x-ray or laboratory evidence of
pulmonary (lung) or extrapulmonary TB.
48
Changes in the incidence within the NZ population has beeninfluenced less by theHIV pandemic andmore by immigration,with60-70%of totalcasesnotifiedinrecentyearsbeingborninaforeigncountryandwith60%of diseaseoccurringwithin1yearof arrival219.Twenty-eightpercentof childreninthisstudywerenon-NZborn,91%of whomdevelopeddiseasewithinthefirst5yearsof arrivaland64%within1yearof arrivalinNZ.Thelowernumberof childrenbeingnon-NZbornreflectsmanychildren,particularlyPacificchildren,beingborninNZbutlivingwithparentsandfamilywho are born overseas. They remain at higher risk of TB fromexposuretohouseholdcontactswhocontinuetohaveratessimilarto theircountryof origin221. Thishas resulted in thecurrentNZBCG programme which recommends children who live withhouseholdmembersfromhighriskcountriesshouldreceiveBCG222 (Table10-1). AlthoughtherearecontroversiesovertheBCGvaccineit is most effective in preventing severe forms of disease and death inyoungchildren.
Transmissionof TBisgenerallyfromaninfectiousadulttoachild.TBinyoungchildrenisrarelyinfectious.Soeverycaseof TBinachild represents a sentinel event indicating transmission of Mycobacterium tuberculosis223. OverthelasttenyearsinAucklandtherehave been at least three outbreaks of TB involving fifty-fivechildren224,225. The first outbreak was in a school and localcommunity224. Although themajority of cases were among highschool students, three younger childrenwere infected fromclosehouseholdexposurefromateenager.Asaresult,widespreadcontacttracinghadtobeundertaken intheschoolsetting,withover500pupilsandteachersneedingtobescreenedforTB.Anoutbreakin1999 in a Pacific Island church community resulted in disease inthreeadultsandtwenty-fourchildrenwithover160people,mainlychildrenbeing investigated225. Amorerecentoutbreakwhichwaslinkedtooneinfectiousadult,whomovedhomefrequently,resultedin twenty-four further cases of TB in young children, with anaverage age of 5.7 years226.Theseoutbreaksreflecttheburdenof diseaseinchildrenresultingfromongoingdiseasetransmissionintheadultpopulation.
In the 1940s and 1950s TB was thought to be conquerable – this has not proven to be the case with a resurgence in the 1980s and 1990s.
In the 1990s it was estimated that a third of the world’s population was infected with TB.
Neonatal BCG should be offered to infants at increased risk of TB, defined as those who:
Will be living in a house or family/whanau with a person with either current TB or a past history of TB;
•
Have one or both parent who identify as being Pacific people;•
Have parents or household members who within the last 5 years have lived for a period of six months or longer** in countries where there is a high incidence of TB*; or
•
During their first five years will be living for three months or longer in a high-incidence country.
•
* All countries except Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Holland, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, New Zealand, Norway, Slovakia, Switzerland, the UK, and USA.
** This indication is not absolute.
Table 10-1: Neonatal BCG Eligibility Criteria 2002222.
The World Health Organisation declared TB to be a global crisis in 1993.
TB has frequently been associated with poverty – overcrowding and poor living conditions have been found to be risk factors.
49
Youngchildren,whenexposedtoTB,aremore likelytoprogressfrom latent infection to disease and are more likely to develop severe disease223. In the269 children studied, although themajorityhadrespiratory disease, there were fifty-three cases where sites otherthanthelungswereaffectedandof these,twenty-threecaseshadsevere forms of disseminated disease or meningitis220. All thechildren(269)requiredtreatmentwithaminimumof threedrugsforsixmonths,withthosewithseverediseaserequiringuptotwelvemonths and often four drugs in the early stages. This is a hugeburdenof medicationfortheyoungchildtotolerateandrequiresintensivecommunitynursingandsupport.Thosewithseverediseaseoftenrequiredprolongedhospitalstaysandtendtobearthemajorityof long-term morbidity, particularly neurological complications.Childrenwithseverepulmonarydiseasecanprogresstolong-termchronic lung problems with the development of bronchiectasis(lungscarring–Chapter11).Twochildren,bothunder5yearsold,diedasadirectresultof TBduring thisstudyperiod,bothfromdisseminateddisease,onecasediagnosedonlyatpost-mortem.
TBhas frequentlybeenassociatedwithpoverty. In thisgroupof childrenTBwasassociatedwithsocioeconomicdeprivationwithamedianNewZealandDeprivationindex(NZDep96)scoreof 9(10beinglowest,1highest)227(Figure10-2).TheNZDep96scoreusedpooled census data from 1996 from 8 domains of material andsocial status, including household crowding, to measuresocioeconomicstatusattheneighbourhoodlevel.Althoughsocialfactors were not looked at in association with TB in this study,overcrowding and poor living conditions have previously beenfoundtobeimportantriskfactorsforTB.Otherinfectiousdiseases,most recentlymeningococcaldiseasehavealsobeen found tobeassociated with household crowding228. However, with the highnumbersof recentimmigrantfamilieswithinthisaffectedpopulation,who tend to be concentrated in poorer suburbs for economicreasons, it is difficult to disentangle poverty from ethnicity andimmigrationstatus229,230.
Althoughwecanrecordnumbers,wehavelittleinformationontheindirect costs to the family and the communityof a caseof TB.Thereisthedirectfamilyburdenof gettingchildrentotakedailymedicationforsixmonths(frequentlywithmorethanonechildinahouseholdbeingtreated)andtheeconomicpressuresthatoccurwithhospitalisationandregularvisits tohealthcareservices.Thesocietalimplicationsof thisdiseaseareimmeasurable,withstigma,isolationandfearof exposurebeingaveryrealconcernforafamilylivingwithTB.StigmaaroundTBisrelatedtobasichealthbeliefsandculture - lackof knowledgeaswell as associationswithpastnegativememories,suchasdeath,spitting,uncleanliness,poverty-allcontributingtowarddifficultiesinaccessinghealthservices,delayindiagnosisanddifficultiesforhealthservicesinprovidingeffectivemanagement and contact tracing224,231.
WhileTBcontinuesinouradultpopulation,childrenwillcontinuetosuffer,particularlytheveryyoungwhoareatmostriskof severe
In New Zealand, disproportionately
high rates of TB were found in children aged
less than 5 years at 6.2/100,000.
Young children, when exposed to
TB, are more likely to progress from
infection to disease, and are more
likely to develop severe disease.
Ethnic disparities for TB disease were seen
in Pacific Island and African children less than 16 years of age.
The BCG vaccination programme in New
Zealand recommends that children who
live with household members from high
risk countries should receive the BCG. It
is most effective in preventing
severe forms of disease and death in young children.
50
disease,andthoselivingindeprivedenvironments.TheNZMinistryof Health2001publication“Anintegratedapproachtoinfectiousdisease:Prioritiesforaction”placesTBinthehighestprioritywithtargetstoreducetheTBburdeninthePacifictohalf thecurrentlevelsby2010,specificallythrougha50%reductionincurrentTBratesforMaoriandPacificpeoplesby2010232. Anumberof strategieswereputforwardtohelpworktowardthesegoals,withanumberof thesehavingbeenachieved,butanongoingcommitmentfromthegovernment,alongwithapartnershipbetweenworkerswithinthefieldandaffectedcommunities,iscrucialtoachievethesegoalsandreducetheburdenof diseaseinchildren.
10.1 Recommendations
Continuing commitment to TB treatment and surveillanceprogrammes.Continuingcooperationwithotheragencies (e.g. immigration,housing) to improve screening and help reduce spread of disease.Development of community-based educationprogrammes inatriskgroups.
•
•
•
Transmission of TB is generally from an infectious adult to a child, while TB infection in young children is rarely infective.
Over the last 10 years in Auckland there have been at least 3 outbreaks of TB requiring widespread contact tracing.
Figure 10-2: Deprivation in childhood TB cases versus all NZ children227.
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4 5 6 7 8 9 10
Dep96 Decile
%Population
TB cases
NZ children
Leastdeprived
Mostdeprived
51
Chapter11:TheBurdenof BronchiectasisinNewZealand Children
11.1 Bronchiectasis
Bronchiectasis (Bx) is a type of lung scarringwhere the airwaysbecomedilatedandcystic,resultinginmucuspoolingandrecurrentinfection in these damaged areas.While it can be caused by anyairwayobstruction(TB,inhalationof food,fluidsorforeignbody),itisusuallytheresultof eithersevereorrecurrentlowerrespiratorytractinfection.InturnBxthenleadstorecurrentpneumoniawhichresultsinincreasingmorbidityanddisability,progressionof disease,andultimatelyrespiratoryfailureanddeath.
Most of the children suffering from the diseasewere previouslyhealthy andonly 10%haveunderlying immunedysfunction.ThediscussionhereexcludeschildrenandadultswhohaveBxasaresultof cystic fibrosis. Positive diagnosis ismade by a chestCT scandoneatatimeof stability(notwhenacutelyunwell).
11.2 Rates of Disease
Inmostdevelopedcountriestheincidenceof Bxhasfalleninthe20thcenturyduetoimprovedlivingconditions,improvedvaccinationprogrammesandantibiotictreatmentof chestinfections.ButnotinNewZealand.
Highprevalencehasbeenreportedincertaincommunitiesandthisincludes Alaskan native children233, the Australian aboriginalcommunity234, children from Turkish communities235 and NewZealandchildren38.Here80%of thechildrenaffectedareof Maoriand/orPacificIslanddescent.Arecentstudyaimedtoprospectivelyestimatethenationalincidenceof Bxdiagnosesovera2yearperiodinthe0.85millionNZchildren236.Paediatriciansfromaroundthecountryparticipatedreportingallnewcasesin2001and2002.Theincidencefromthisstudywasfoundtobe3.7per100,000peryear,which is7 timesgreater than theonlyothercomparablenationalstudyinFinnishchildren237andequatesto1in1,700birthsbeingdiagnosedwithBxbeforetheageof 15years.If theincidenceratewastoremainstaticandallthesechildrensurvivetoage15,thenthefigureequatestoaprevalenceof 1 in 3,000 children overallbut,1 in 625 Pacific children.Theincidencewasfoundtobe3timeshigherinMaori children and 12 times higher in Pacific Island childrencomparedwiththoseof Europeanethnicitybutwithnodifferencesin severity or aetiology.
Highratesof BxparticularlyinMaoripeopleswerereportedaslongago as 1958238.Inamasssurveyof WesternSamoain1980itwasestimatedat1in170adults239. It is concerning is that the high rates of disease are not disappearing.
NotonlyisthisdiseasetoocommoninNewZealand,butitissevereinthoseaffected.IntheAuckland38andintheNational236studies83-93%haddiseaseaffectingbothsidesof thechestand61-64%had3
Cass Byrnes
On behalf of the Bronchiectasis team at Starship Children’s Health (Dr Elizabeth
Edwards, Dr Jacob Twiss, Lorraine Stevens/Pauline Lolohea, Sarah Butler).
“When I get sick, it feels like I’m
going to fall over and pass out.”
Pirimona Heemi, East Coast Bays Courier,
May 2005
Bronchiectasis is a type of lung
scarring that results in recurrent chest
infections and is usually life limiting.
52
ormoreof the6lobesof thelunginvolved.Thisissignificantandwidespreadscarring.Thedegreeof severitythatiscurrentlybeingseenalsoimpliesthatweareonlydiagnosingtheworstcasesthustherateof diseasegivenislikelytobeaseriousunderestimate.
Anotherareaof concernistheveryyoungageatwhichthisdiagnosisisbeingmade.TheAucklandstudyshowedamedianageof 8yearsatdiagnosisbut2yearslatertheNationalstudyshowedamedianageof only5.2years.Thirtypercentof thechildrenintheBxclinicinAucklandarelessthan5yearsof age;consistentwiththeotherpublishedpaediatricseries.Acausativeinsultatthisyoungagemayresultinquitesignificantdamageinadevelopingversusmaturelungwith a developing versus mature immune system. The delay inmakingthediagnosisremainsasignificantconcern.Thechildreninwhomadiagnosiswasmadeatanaverageageof 5.2years,theageof onsetof coughwasamedianof 2.3yearsandtheageatfirstrespiratory hospitalisation was a median of 1 year. This meant that
Figure 11-1: CT scan of bronchiectasis illustrating typical features of airway dilatation with sputum plugging.
The diagnosis is made by a CT scan of the chest during a time of disease stability.
Figure 11-2: New Zealand bronchiectasis study23.Note: Incidence in Pacific children is 4 times greater that the National incidence and 16 times greater than the European incidence. There is a trend for more severe disease in Maori and Pacific children.
In most developed countries the incidence of Bx is falling. This is not so in New Zealand.
3.7
4.8
16.1
1
5.6
0
2
4
6
8
10
12
14
16
18
Overall Maori Pacific European Other
Ethnic Group
Incidence(per 100,000
per Year)
53
the 1sthospitalisationwas4years,andcommencementof persistentcoughwasmorethan2yearsbeforethediagnosiswasmade.Thedegree of disease progression possible in that time frame iscompletelyunknown.
11.3 Aetiology
Studiesworld-wide show that despite extensive investigation, thespecific reason for the development of Bx remains unknown inup to 50% of cases38,233-236,240. In themain these are assumed tobe secondary to early, severe or recurrent lower respiratory tractinfections.Anadditional20-25%isduetoseverepneumoniawithanorganismdetectedsuchasadenovirus,pertussis,staphylococcalaureusortuberculosis.InNewZealand,thedevelopmentof chroniclungdiseasewasdescribedin60%of 43paediatricpatientsupto
Figure 11-4: Starship bronchiectasis clinic.
0
20
40
60
80
100
120
140
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Number ofChildren
Cliniccommences
Figure 11-3: X-ray illustrating bronchiectasis.
High prevalence has been described
in certain groups – Alaskan native
children, Aboriginal children, Turkish children and New Zealand children
(predominantly Pacific Island and Maori).
A recent national study in New Zealand
found an incidence that equates to 1 in
1,700 births being diagnosed with Bx
before 15 years of age.
54
13 years after being admitted to hospital with an adenovirus ‘21’bronchiolitis241.Theremainingcausesof Bx includeother insultssuch as immunodeficiency or immune suppression, aspiration of saliva, gastric contents or foreign body, and elsewhere primaryciliarydyskinesiaforwhichwecannotdowidespreadtestinginNewZealand.
11.4 Socioeconomic Considerations
Deprivation is long known to be a risk factor for this condition.Anassessmentof socioeconomicstatusof thesechildrenwithBxin the Starship Hospital clinic in 200138 gave a median deprivation scoreof ‘9’with70%classifiedinareas‘7-10’.Fortypercentof thechildrenwereclassifiedas‘10’–meaningthattheirareaof residenceisinthemostdeprived10%inNewZealand.Only70%of thesechildrenwereappropriatelyimmunisedandin58%of thefamiliesoneormoremembersof thehouseholdsmokedonadailybasis.
While the basic management strategies needed for most of thechildren(physiotherapy,oralantibiotics)arecheap,theburdenof this disease isfinancially expensive242. Firstly, in termsof days atworklostbyadultsufferersandparentsof affectedchildren,schooldayslostandlossof workingyearsinadultswhodieinthe20-50yeardecades,with theyearsprior to theirfinal respiratory failurespentbecomingincreasinglydisabled.Thewidercostof thisdiseasetaking into account these considerations has not been studied inNewZealand.Patientsattendout-patientclinics2-4timesperyearand in a recent adult series243 30% required at least one hospitaladmission per year. In2004,of the104childrenmanagedinoneclinic242,57requiredatleastonehospitaladmissionand8had3-4admissions.Thecurrentcostof a14-daypaediatrichospitalstayisapproximatelyNZ$8270and thisdoesnot includeextracostsof insertion a long-line for antibiotics, the antibiotics themselves,orthephysiotherapy.Thusbedstayalonefromthisclinicof childrenin2004wasintherealmsof NZ$736,030.
MoreharddatawithregardtoexpenditurecomesfromtheUnitedStateswheretheprevalencehasbeenestimatedinadultsat52per100,000overallandresultsinanadditional1.1billionUSdollarsof healthcareexpenditureperannum244.
11.5 Mortality
SignificantmortalityfromBxdoesn’tbeginuntiladulthoodinNZ,however itwouldappearthat inmanycasesthediseasebegins inchildhood245. Deaths fromBx are reported at 50 per 100,000 inMaori andPacificPeople246,247.Compared to asthma;Bxcauses atenth the hospital admissions and half the number of deathsoverall248,249.Insomeagegroups(earlyadulthood)moreadultsdieof Bxthanof asthma.Itresultsin75%moreadmissionsandnearlyfivetimesasmanydeathsascysticfibrosis248,249.
The prevalence is 1 in 3,000 children but 1 in 625 Pacific Island children.
The disease seen in New Zealand children is severe – suggesting we are only diagnosing the most severely affected and missing children with more mild disease.
The majority are thought to be caused by severe pneumonia in young children.
There is a delay in diagnosis. The onset of chronic cough occurred an average of 2 years and the first hospital admission for respiratory disease an average of 4 years before the diagnosis was made.
55
11.6 Future
Whiletheaimistoincreaseawareness,diagnosisandtreatmenttoimprove the current statistics and the individuals’ quality of life,prevention is the key.Thenumberof childrenwhosuffer fromthischronicdebilitatingrespiratorydiseasewillonlyreducewhentheirqualityof lifeandsocioeconomicstatusimproves.
Adecadeago,aNZPublicHealthCommissionreportonthehealthof NZPacificPeoplesidentifiedbronchiectasisasamajorcauseof hospitalisation and the 8thhighestcauseof deathinPacificwomen250. TheMinistryof Healthconcludedthereportprovidedabaselineforfuturemonitoringandpolicydevelopment251. In the same year theNZgovernmentestablishedchildandMaorihealthas“prioritygainareas”.Thefiguresgivenabovesuggestthesituationhasnotimproved from that time.
11.7 Recommendations
Prevention of the disease requires improved socioeconomicstatusof themostdeprivedareasinNewZealand;areductionindomesticovercrowding,reducedsmokingratesandimprovedvaccination coverage.Increase general public and medical staff awareness of thisdisease.Encourageearlydiagnosiswith investigationof childrenwithpersistentproductiveormucousycoughthathaslastedformorethan6-8weeks, andpossibly follow-upof children thathavehadmore thanonehospitalisationwithpneumonia thathavespecific characteristics such as being secondary to adenoviralinfection.Improved management options based on research intotreatment.A research focus on early natural history to look for specifictimes or events which mark opportunities to intervene toprevent disease development and progression.
•
•
•
•
•
•
Deprivation is a risk factor for Bx – 40% of children affected
lived in the 10% most deprived areas
of New Zealand.
The mainstay of treatment is chest
physiotherapy every day and antibiotics
with infection.
Compared to asthma, Bx causes a tenth as
many admissions and half the number of
deaths. (New Zealand Health Information
Service 2004).
56
Chapter12:ObstructiveSleepApnoeainChildren
Obstructivesleepapnoea(OSA)wasfirstdescribedinchildrenin1976252, and a case series published in 1982 described severecomplicationsof thisconditionsuchasfailuretothrive,heartfailure,permanentneurologicinjuryanddeath253.Sincethattime,knowledgeabout the condition has increased substantially, and it is nowrecognisedasbeingmorecommoninchildrenthanepilepsy,diabetesorcysticfibrosis.Recognitionof thisconditionisgrowingrapidly,buttodatethereisnospecificinformationabouttheprevalenceorimpactof thisconditiononNewZealandchildren.
12.1 Definitions
Symptomssuggestiveof OSAinsnoringchildrenincludefrequentdaytimemouthbreathing,snoringmostnights,observedcyanosisorapnoeaduringsleep,difficultybreathingduringsleepandparentalconcern about the child’s breathing254-256.Unlike the condition inadults, daytime sleepinessmay not be a feature of withOSA inchildren,andfemalesareaslikelytohavetheconditionasmales257.
OSAisaconditioninwhichbreathingduringsleepiscompromisedby obstruction of the upper airway258. The upper airwaymay beintermittently completelyobstructed (apnoea)ormaybepartiallyobstructed(hypopnoea),oftenforprolongedperiods.Episodesof airway obstruction can lead to intermittent hypoxia, hypercapnia,andfrequentbrief arousalsfromsleep.Thesearousalsleadtosurgesin heart rate and blood pressure which may have long termcardiovascular implications259,260. Arousals and consequent sleepdisturbance may also be the mechanism by which OSA affectslearningandbehaviourduringtheday258.
Snoring is very common in the adult New Zealand population,affecting 20-60% depending on age261,262. International estimates forchildrenarethat6-12%of childrenhavehabitualsnoring,alsodepending on age263-266.Probablyduetothefactthatsnoringissocommoninthecommunity,thissymptomisfrequentlyignoredinchildren,leadingtolackof recognitionof OSAandpotentialdelaysin diagnosis and treatment.
12.2 Prevalence
OSAisoneof themostcommonrespiratorydisordersof childhood,affectinganestimated1-2%of normalchildren263-266.Itoccurs inchildrenof allages,fromneonatestoadolescents.Itismostcommonin preschool children,when the tonsils and adenoids are at theirlargest size in relation to the size of the upper airway.However,thereisincreasingevidencethatOSAisverycommoninchildrenwithobesity267,268,andthustheprevalenceinolderchildrenislikelytoriseincomingyears.SomestudieshaveshownahigherprevalenceincertainracialgroupssuchasAfricanAmericans257.OSAhasbeendemonstratedtobehigheramongstMaorithannon-Maoriadults269,buttodatenostudieshaveexaminedtheprevalenceof theconditioninNewZealandchildren.
Gillian Nixon
Obstructive sleep apnoea is now recognised as being more common in children than epilepsy, diabetes or cystic fibrosis.
Symptoms suggestive of OSA in snoring children include frequent daytime mouth breathing, snoring most nights, observed cyanosis or apnoea during sleep, difficulty breathing during sleep and parental concern about the child’s breathing.
57
12.3 Morbidity
UntreatedOSA can result in significantmorbidity. Early reportsof more severe cases documented failure to thrive, right heartfailure,mentalretardationanddeathinsomecases252,253. In recent times,theseseveresequelaearelessoftenseen,butseveralstudieshave demonstrated accelerated growth after treatment of OSA,suggesting a degree of growth impairment before treatment270. Many studies have shown problems with learning, attention andbehaviourinchildrenwithOSA257,271-273,withonelargestudyintheUSAdemonstratingOSAin18%of 6-year-oldchildrenperforminginthelowest10%of theclass274.Upto25%of parentsof childrenwith OSA describe hyperactivity and behaviour problems272,275. Hypertensionandventriculardysfunctionhavealsobeenreported,proportional to the severity of the condition260,276.
12.4 Diagnosis
A sleep history including questions regarding snoring should bepartof allroutinehealthassessmentof children258. The presence of some other symptoms increases the likelihood of significantOSAinchildrenwhosnore:witnessedobstructiveapnoea,frequentdaytime mouth breathing, parent afraid/wakes child because of breathing,difficultybreathingwhileasleep, frequentwaking fromsleepinachildwhohaspreviouslysleptthrough,secondaryenuresis,daytimebehaviouralproblems,andfailuretothriveorslowingof weight gain254,255,257,277. Enlarged tonsils and nasal obstruction areassociatedwithOSA,butalinearrelationshipbetweentonsillarsizeandseverityof OSAhasnotbeendemonstrated256,277.
International standards recommend formal confirmation of thediagnosis by multi-channel physiologic recordings during sleep(polysomnography)278.Currentlywedonothave the resources inNewZealandtoprovidepolysomnographytoconfirmthediagnosisof OSAinthelargegroupof childrenwhosnoreandthusnationalguidelineshaverecommendedanalternativeapproachtoassessmentandtreatmentintheNewZealandenvironment.
OSA is one of the most common
respiratory disorders of childhood, affecting
an estimated 1-2% of normal children.
Figure 12-1: Sixty seconds of a recording during sleep, showing an obstructive event lasting 15 seconds.
During the event, the airflow (as recorded on
the SUM and PA CO2 channels) is markedly
reduced or absent, the ribcage and abdomen
move paradoxically. Following the event,
there is a fall in oxygen saturation to 78%, a
rise in carbon dioxide, and a brief arousal
from sleep (A). These types of events are
seen repeatedly during sleep in children with
obstructive sleep apnoea. (EOG = electro-
oculogram, EEG = electroencephalogram,
EMG = electromyogram, SaO2 = arterial oxygen
saturation, tcpCO2 = transcutaneous pressure
of carbon dioxide, PA CO2 = alveolar pressure
of carbon dioxide).
15 sec.
Loud Snore
90
1 2 3 4 5 6 7 8
54
54
95
A
78
58
80
40
0
80
40
0
100
80
60
200 µV
100 µV
100 µV
100 µVL EOG
R EOG
EEG (C3 - A2)
Submental EMG
SaO (%)2
tcpCO (mm Hg)2
PA CO (mm Hg)
SUM
Rib Cage
Abdomen
2
58
12.5 Treatment
AdenotonsillectomyisthefirstlinetreatmentinchildrenwithOSAandenlargedtonsilsandadenoids.Thissurgeryleadstoresolutionof OSAinthevastmajorityof cases271,279.Significantimprovementsingrowth,cognitivefunctioninganddaytimebehaviourhavealsobeendemonstrated inchildrenwhohavehadadenotonsillectomyforOSA270,271,275,279,280.
Inthoseforwhomadenotonsillectomyisnotindictedorisnotfullyeffective,continuouspositiveairwaypressurebymask(nasalCPAP)maybeindicated281,282.Thistreatmentcanbeusedinchildrenof allages283,butrequiresspecialistcaretoinitiateandadjusttotheuniquerequirementsof eachchild.Closefollow-upisneeded,astreatmentrequirementsmayvaryovertime,particularlywithincreasingageorchangesintheunderlyingcondition258.
12.6 EconomicBurden
Children with undiagnosed OSA are high users of health careservices.PublisheddatafromIsraelhasdemonstratedthatchildrenwithOSAcostthehealthsystemmorethantwicethatof controlsover one year284.ChildrenwithOSAhadmoredaysinhospital,morevisitstotheemergencydepartment,and received more prescriptions formoredrugs.Thesecostsdonot includethecostsof parentalabsencefromwork,directfinancialcoststothefamilyof affectedchildrenor costsof educationalunder-achievement secondary toOSA.
After adenotonsillectomy for treatment of OSA, the Israelidata showeda reduction in total annualhealth care costsbyonethird285.Adenotonsillectomywasassociatedwitha60%reductionin the number of new admissions, 39% reduction in emergencydepartmentvisits,47%reduction in thenumberof consultations,and22%reductionincostsforprescribeddrugs.
Thisdatasuggeststhatearlyrecognitionof OSAinchildrenwillnotonlyreducemorbidityforthechild,butwillalsoleadtoasignificantreductionincoststopublichealthcare.ThePaediatricSocietyof New Zealand has produced a new bets practice evidence basedguideline“Assessmentof Sleep-DisorderedBreathinginChildhood”whichneedspublicityandimplementation286.
12.7 Summary and Recommendations
Obstructivesleepapnoeaisacommonconditionof childhoodandcanresultinseverecomplicationsif leftuntreated.Thefollowingare recommended to improve recognition of this condition in childhood, thereby ensuring early treatment andminimisation of morbidityandeconomicburdentoNewZealand:
Publicawarenessof theimportanceof goodsleepforchildren-Parentsshouldbeinformedaboutnormalsleepinchildhood.Childrenshouldnotsnore,andthosethatdoshouldbeassessed
•
More severe cases documented failure to thrive, right heart failure, mental retardation and death in some cases.
Many studies have shown problems with learning, attention and behaviour in children with OSA.
59
byahealthprofessionalforthepossiblepresenceof obstructivesleep apnoea.Widespread education of health professionals and well childproviders - Many children presenting with OSA have hadsymptomsforsometime.Earlyrecognitionof OSAinchildhoodand provision of appropriate treatment may not only treat or preventmediumtermcomplicationssuchaslearningdifficulties,but may potentially prevent serious long-term cardiovascularcomplications.Specialist paediatric sleep medicine services - A subset of symptomaticchildrenrequireinvestigationwithpolysomnography.Some will require treatment with continuous positive airwaypressurebymaskathomeandappropriatefollow-up.Providersof theseservicesshouldbeappropriatelytrainedandaccreditedfortheprovisionof suchservicestochildren.Programmes to prevent and treat obesity - The enormousincreaseinprevalenceof obesityworldwideisexpectedtohaveflow-oneffectsforthediagnosisof obesity-relatedconditionsinchildren,suchasdiabetesandobstructivesleepapnoea.Wellresourcedandaccessibleprogrammesforchildrenandfamiliesarevitalinreducingthisproblem.Further research - Research is required in New Zealand toinvestigate the extent of obstructive sleep apnoea in NewZealand children and themorbidity of this condition in ourpopulation.Such informationwould inform thedevelopmentof sleep medicine services for children.Awareness and implementation of the best practice evidencebasedguideline“Assessmentof Sleep-DisorderedBreathinginChildhood”.
•
•
•
•
•
Adenotonsillectomy is the first line
treatment in children with OSA.
Children with undiagnosed OSA are
high users of health care services.
60
Chapter13:Asthma
NewZealandhasoneof thehighestrecordedasthmaprevalenceratesintheworld.Ratesof hospitaladmissionsduetoasthmaarehighest in children, being about double that of adults, with themajorityoccurringinthoselessthan5years.
13.1 Prevalence
ISAAC (The International Study of Asthma and Allergies inChildhood) is the largest study of the prevalence of asthma inchildrenintheworld.Thisstandardisedinternationalstudyincluded37,000 children from 6 centres inNew Zealand. The 12monthprevalence in the6–7year agegroup for those reportingasthmawas26.5%287.Thecurrentpopulationunder15isaround900,000whichsuggestsover200,000childrenareaffected288,289.
There are important ethnic differences. Studies have suggestedprevalenceof asthmaissimilarinMaoriandnon-Maorichildren290. Latest evidence from the ISAAC study has found significantdifferences289. In 6–7 year olds the prevalence of asthma forEuropeanswas25.9%,Maori31.7%andPacificchildren21.25%.The prevalence of wheeze in the last 12months was European24.2%,Maori27.6%,Pacific22%.Intheolderagegroupof 13–14year olds the prevalence of asthmawasEuropean 25.2%,Maori24.7%andPacific19.2%.Of wheezeinthelast12monthsEuropean31.7%, Maori 30.8% and Pacific 21.1%. These findings wereconsistentwithanearlierstudyonasthmaprevalenceinAucklandchildren291.
Ian Shaw
New Zealand has one of the highest recorded asthma prevalence rates in the world.
Phase OneISAAC
1998
<5%5 to <10%10 to <20% 20%
61
13.2 Morbidity
13.2.1Prevalenceof SevereAsthma
Case fatality rates for severe asthma in children are very low. Prevalenceof severeasthmasymptomsandassessmentof asthmaseverity in studies using questionnaires is difficult to quantify.Frequencyof attacksisoneaspectof severity,buttheprevalenceof chronic interval symptoms better reflects asthma management.Frequencyof wheezedisturbingsleepwasassessedintheISAACstudyas3.5%forthe6–7yearsoldsand3.2%forthe13–14yearolds289.
Afigureof casemorbidity fornightwakingcanbecalculatedbytheratioof numberswakingwithwheezetothenumberreporting“asthma”.Thiswasworkedoutasreflecting10%inEuropean6–7year old children compared to 18% inMaori and 27% inPacificchildren.Fortheolderagegroup13–14yearoldsthefigureswereEuropean11%,MaoriandPacificyoungpeople19%.Thissuggeststhatthegreatestdifferencebetweenethnicgroupsisthepresenceof moreseveresymptomsamongMaoriandPacificchildrencomparedwithEuropean.
13.2.2HospitalAdmissionRates
Asthmaremainsthecommonestcauseforhospitaladmissionsforchildren.Whilst admissions remain high, numbers internationallyand nationally fell in the 1990s249.
Therewere3210non-Maorichildrenagedlessthan15yearsadmittedwith a diagnosis of asthma in 2001 and 1486 Maori children aged less than 15 (representing 68% and 32% of asthma admissionsrespectively). The figure of 32% of all children admitted withasthmabeingMaoricontrastswiththeestimatedchildhoodMaoripopulationatthetimeof 15%.Theburdenof asthmaadmissionsishighestfortheyoungerchildren,overhalf agedlessthan5years292.
Rates of hospital admissions due to
asthma are highest in children, being about double that of adults,
with the majority occurring in those less than 5 years.
The greatest difference between
ethnic groups is the presence of more severe
symptoms among Maori and Pacific
children compared with European.
Prevalence(%)
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.01985, 8-10 yrs 1993, 6-7 yrs
Year and Age Group
No significant changes
MaoriPacificEuropean
Figure 13-2: Change in prevalence of recent
wheeze, asthma, and frequent wheeze
between 1985 study of 8-10 yr old children in Auckland291 and 1993 ISAAC study of 6-7 yr
old children in Auckland.
62
ThehospitalisationratefromJuly1999–June2004wasreasonablyconstant�. However while rates have gradually decreased in NZEuropeans,ratesforMaoriandPacificpeoplehaverisen.Inchildrenagedlessthan5hospitalisationratesper1000forNZEuropeanswere7.8whilstMaoriwere20.5andPacificchildren24.6.
ThisgivesarelativeriskforMaoritoNZEuropeansof 2.6andforPacifictoNZEuropeansof 3.2.For thoseaged5–14theratesper1000(2003–2004year)wereNZEuropean1.9,Maori4.3andPacific5.3.TherelativeriskforMaoritoEuropeanis2.3andPacifictoEuropeanis2.8292.
Admissions for Maori and non-Maori are not evenly distributedgeographically. Asthma hospitalisations in Maori and non-Maoribetween 1994 and 2000 indicated that there were significantvariations with some districts reporting high hospitalisation rates forMaoricomparedtonon-Maori.Ruralhospitalisationrateswerehigherthanurbanareas30.
13.2.3AsthmaControl
Furtherassessmentof asthmacontrolwasundertakeninthePatientOutcomesManagementSurvey (POMS)293.Children in thisstudyrangedinagefrom7–15.Definitionof asthmacontrolandundertreatmentwasbasedonthegloballystandardisedcriteriaforasthmacontrolintheGlobalInitiativeforAsthma(GINA)Guidelines.Themajorityof childrendidnothavegoodcontrolof asthmasymptoms,44%having asthma thatwas notwell controlled, and 1/20th of childrenfalling inthecategory“markedlyoutof control”.Intheprevious 3 months a third of children had had unscheduledappointmentsorcontactwithdoctorsafterhoursbecauseof asthmaand 14%hadbeen to the emergencydepartmentor admitted tohospital.
There was a marked mismatch between the patient’s perceptionof asthma control and the actual level of control as defined for* DuetosomedifferencesinshortstayadmissionreportingbyDistrictHealthBoards,thesefiguresareinfactunder-estimates.
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
0-4 years5-9 years10-14 years15-19 years20-24 years25-29 years30-34 years35-39 years40-44 years45-49 years50-54 years55-59 years60-64 years65-69 years70-74 years75-79 years80-84 years85+ yearsTotal
0
200
400
600
800
1000
1200
1400
1600
1800
AsthmaHospital
Admissionsper 100,000
Figure 13-3: Asthma Hospital Admissions in New Zealand, 1989–99.(New Zealand Health Information Service)
The burden of asthma admissions is highest for the younger children, over half aged less than 5 years.
63
this study.Over¾ thought their asthmawaswell controlled and85% reported satisfactionwith their levelof asthma control.Of thechildrenwhoseasthmawasnotwellcontrolled71%wereundertreated and for thosemarkedly out of control, 75%were undertreated.
Anotherwayof measuringasthmamanagementandcontrolisuseof medication. There are 3mainmedications used, short actingbetaagonists(SABA),longactingbetaagonists(LABA)andinhaledcorticosteroids(ICS).SABAuseishighestinyoungchildrensimilarlythere ishigheruse inyoungerpatients forICSsbutLABAshavehigheruseintheolderagegroup(50+).
IntheyoungeragegroupsLABAuseismuchhigherinNewZealandEuropeans than other ethnic groups. SABA use was highest inMaoriandlowestinPacificpatientswhichcontrastswiththeveryhigh hospitalisation rate forPacific patients.The ratio of SABA:ICSdispensingisregardedasapotentialmeasureof poorasthmacontrol and this ratio is highest in young children. The SABA:ICS ratio (suggestingpoorer control) is alsohigher inMaori andespeciallyPacificpatients.ThelowerICS:hospitalisationandLABA:hospitalisationratiosforMaoriandPacificpatientssuggestsunmetneed292.
Association of low asthma pharmaceutical use and high asthmahospitalisationratesareconsistentwithpreviousstudiesidentifyinggreatermorbidityinMaoriandPacificpatients.
Inadditiontherehasbeenanoverallreductionintheaveragedailydose for inhaled corticosteroids of over 8% for all age groups.Theaveragedailydose(ADD)of beclomethasoneequivalentsforchildrenaged0–5yearsis504mcgandforchildren6–16years705mcg.It is importanttonotethatwhilstICSuseisdecreasingSABAusehasremainedconstantwhichincreasestheSABAtoICSratiooftenused as an indicatorof diminishedquality of asthmatreatment292.
TheAustralianICSADDcontinuestobearound50%higherthanNewZealandandisstillincreasingcomparedwithNewZealand’sdecreasingrate.Australiaalsohashigherratesof SABAusethanNewZealand.
AlthoughaccesstoLABAshasimprovedsignificantlyforchildreninrecentyearsthereappearstobeverylowuptakeamongstchildrenforLABAprescriptionsdespite theaveragedailydoseof inhaledcorticosteroidsbeingover500mcgandthereportedpoorcontrolandfrequentnighttimewaking30,292.
13.3 Socioeconomic and Ethnic Factors
Therehavebeenmanystudiesattempting to relateprevalenceof asthmatosocioeconomicstatus(SES).AtopyismorecommoninhigherSESgroups.Theevidenceforasthmahasbeenconflicting.TheDunedinMultidisciplinaryHealthandDevelopmentStudyhas
Low asthma pharmaceutical use
and high asthma hospitalisation rates
identify greater morbidity in Maori
and Pacific patients.
64
beenalongitudinalinvestigationof healthandbehaviour294. It has foundthesocioeconomicstatusinchildhoodhasnoimpactontheprevalenceof asthma.Thisreportdoesnotassessindetailmorbidity,only prevalence and there are many studies that suggest thatsocioeconomic disadvantage adversely affects asthma management andresultsinincreasedhospitaladmissions.Thecostof GPvisitshas been identified as one significant barrier. Location of healthservices isanotherfactor identifiedasasignificantbarrier289.SESdid not independently explain ethnic differences in any category of asthmasymptomsina1985Aucklandstudy291.
Itisimportanttonotethatinallmeasuresof prevalenceandseverityasmeasuredbymorbidityadmissionratesandpharmaceuticaluse,Maoriaresignificantlyoverrepresented.ThereisadisproportionateburdenonMaori andPacific people and there is a lower use of bronchodilatorsandpreventeragentsinchildrenespeciallyinlowersocioeconomicgroupsdespitehigherprevalenceof reportedasthmasymptoms.Thisisconsistentwithstudiesnotinghighlevelsof suboptimalasthmacontrol.WhilesmokingincidenceandpoorhousingareevidentfactorsSESdoesnotcompletelyexplainthesedifferencesnorthegeographicdifferencesidentifiedbetweenDHBswithsomereportingmuchhigherratesof admissionsthanothers30,291. Local geographic differences would support regional services being anissueforMaori.
13.3.1EconomicCost
Economic cost will include the cost of pharmaceuticals,hospitalisationcostsaswellasaccesstoemergencyafterhourscarewithout admission. The Pharmaceutical Management Agency of NewZealand(PHARMAC)identifiedasthmaasthemostheavilyundertreateddiseasegroupintheirgapanalysisof 2002with“patient-year equivalents for pharmaceuticals dispensed for asthma beingperhapsonethirdof thatexpectedepidemiologically”.PHARMACreportsthatthepharmaceuticalbudgetforasthmamedicationwas60milliondollarsfor2002-03.Separatedataforcostsof treatingchildrenwasnotavailable.
Fortheyear2000-2001therewere4390childrenagedlessthan15years admitted with a diagnosis of asthma. The reported average lengthof staywas2.4daysresultinginapproximately10,000daysinhospital249.
Emergencydepartment(ED)visitsbychildrenmaybeextrapolatedfrom studies that found that 27-39% of people with asthmaattending emergency departments were admitted to hospital. This wouldsuggestaround12,000childrenattendEDperannumatacostof around$250pervisit(i.e.atotalcostof $3million)289.
Indirect costs for children primarily relate to days off school. This doeshaveasignificantimpactonlossof workdaysforcaregivers.AFrenchstudyof childrenaged6-16yearswithpersistentasthmafound that nearly 30%of care givers lostwork days because of theirchildren’sasthma.Morethan13%lostmorethan5daysand
There are many studies that suggest that socioeconomic disadvantage adversely affects asthma management and results in increased hospital admissions.
PHARMAC has identified asthma as the most heavily under treated disease group in their gap analysis of 2002.
65
caregiverabsenteeismwassignificantlycorrelatedwithelementsof asthmacontrol.Asignificantfindingwasan8foldriskof losingmorethan5workdaysperannumforcaregiversof childrenwhoseasthma was poorly controlled295. Given the high level of poor control identifiedbythePOMSstudyitislikelythatthereisasubstantialcost to the work force in addition to days lost from school.
ThePaediatricSocietyof NewZealandhasthebestpracticeevidencebased guideline “Managementof Asthma inChildrenAged1-15Years”296. Implementationof this guidelinewill lead to improvedasthmaoutcomes.
13.4 Summary
NewZealand has amongst the highest recorded asthma rates intheworldwithratesof hospitaladmissionsduetoasthmahighestin children being about double that of adults with the majorityoccurringinthoselessthan5years.
It is important toreducetheburdenof asthma.Thekeybarriersidentified in New Zealand are socioeconomic deprivation withimplicationsforaccesstohealthcareservicesandpharmaceuticals.Closely linked with this is poor education and issues withinfrastructure noting that a significant barrier for many Maoriincluded location of health services. Specific strategies to targetthehighneedsidentifiedinMaoriandPacificchildrenneedtobedeveloped.Whilstthiswillincludestrategiestoaddresscostthereneeds to be specific approaches to addressing issues of location,transport,communicationandeducation.
For such a strategy to succeed there would need to be majorparticipationfromwithinthecommunitiesthemselves.Itisnotedthat PHARMAC has a Maori responsiveness strategy for bothchildrenandrespiratorydiseasebutthereisnosimilarresponsivenessstrategyforPacificpeopleandthisshouldbeaddressed.
Environmental factors including air pollution, smoking and poorhousing all need separate strategies including further promotionand implementation of anti tobacco public health policies andaddressingstandardsof housing.
DistrictHealthBoardsidentifiedashavinghighhospitalisationratesand thosewith significant ruralpopulations shoulddevelop localstrategiestoreducetheburdenof asthmaandreducehospitalisationrates forMaori in their district. Similar strategieswill need tobedevelopedforPacificchildren.
13.5 Recommendations
Improvementsinchildasthmahealthcarewillrequire:
Reductioninfinancialbarrierstoaccessinghealthcare.Thesemay include freenursebasedasthmaclinics and facilitating areductioninGPfeesforchildren.
•
“In the UK if you are a child with persistent asthma the GP visits
and prescriptions are free, no matter
what time of day you need them.”
Claire Richards, Asthma Nurse Educator who
emigrated from the UK in 2002.
66
Reductioningeographicbarrierstoaccessinghealthcare.Thismaymeanprovidingmobilehealthclinicsdeliveringservicestoremote or poorly serviced areas.Improvedaccesstoasthmaeducationwithinthecommunity.Reductioninfinancialbarrierstoaccessingpharmaceuticals.ItisnotedthatPHARMAChasaMaoriresponsivenessstrategyforbothchildrenandrespiratorydiseasebutthereisnosimilarresponsivenessstrategyforPacificpeople.Addresspoorhousingtoreducerespiratoryillnessinchildren.Continuedimprovementsinsmokingcessationwithemphasisonfamilieswithyoungchildren.Continuetoaddresscleanairpoliciestoreduceairpollution.DistrictHealthBoardsidentifiedashavinghighhospitalisationratestodeveloplocalstrategiestoreducetheburdenof asthmaand reducehospitalisations forMaori in theirdistrict. SimilarstrategieswillneedtobedevelopedforPacificchildren.DistrictHealth Boards with significant rural populations willneed strategies to address service delivery and health care provisiontoremotepopulationswithlimitedaccess.Implementationof thebestpracticeevidencebasedguideline“Managementof AsthmainChildrenAged1-15Years”.
•
••
••
••
•
•
67
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