Communication of the diagnosis of Down's syndrome in New Zealand, 1972-88.

A postal questionnaire was sent to 117 mothers of Down's syndrome children born between 1972 and 1988 in New Zealand, and the response is compared to a similar study of 123 mothers in Scotland whose children were born between 1972 and 1981. Highly significant differences were found in the number of New Zealand children delivered by general practitioners and in the rate of breast feeding amongst New Zealand Down's syndrome children. Significant differences were also found in the later New Zealand cohort with respect to the mothers having seen a social worker, having been given literature and been given an appointment to see a paediatrician. In common with the Scottish study, only half of the mothers felt that their general practitioner or Plunket nurse had been helpful to them after the birth of their child. The implications of the results for the care of Down's syndrome children in New Zealand are discussed.     

The extent of breast feeding in Dunedin 1974-83

This study examined breast feeding practices in Dunedin, and aimed to identify determinants of breast feeding in this population. Infants' records were used for a 10 year period (1974-83) from the Royal New Zealand Plunket Society. An upward trend in breast feeding prevalence was observed. Breast feeding was more common in mothers of high socioeconomic status (p less than 0.001), in those who were living with a spouse (p less than 0.001) and when mothers attended parental classes (p less than 0.025). First time mothers tended to breast feed for a shorter time (p less than 0.05). Early introduction of other foods shortened the duration of breast feeding (p less than 0.001). The increase in breast feeding which has occurred in many parts of the western world was also found in Dunedin.     

Whooping cough: Christchurch 1982

Whooping cough continues to be a major health problem in New Zealand. In a twelve month period, 64 cases were admitted to the paediatric wards of Christchurch Hospital. Of these 64 patients, 24 (37.5%) were fully immunised. The possible explanations for the large number of children contracting whooping cough, who have been immunised according to the schedule used in New Zealand, is discussed.     

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

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

Proceedings of the Meningococcal Vaccine Strategy World Health Organization satellite meeting, 10 March 2004, Auckland, New Zealand

From 1991 to the end of 2003 there have been 5293 cases and 216 deaths from meningococcal disease in New Zealand. On 10 March 2004, the New Zealand Ministry of Health hosted a special meeting to release the first results of the clinical trial in 16 to 24 month olds of a new vaccine (MeNZB), which has been tailor-made to provide protection against the New Zealand epidemic strain. These proceedings summarise the key points from the meeting presentations and highlight some of the important issues considered in the subsequent discussion. In the toddler age-group trial, 75% of the MeNZB recipients exhibited a four-fold or greater rise in serum bactericidal antibodies after three doses of MeNZB--compared with 4% of the control vaccine recipients. Local reactions to MeNZB and the control vaccine were common, especially injection site tenderness. These data, along with data from New Zealand clinical trials in four other age groups and efficacy and safety data from the Norwegian parent vaccine, were used to support the application for a licence to use MeNZB in a proposed mass immunisation programme for 0-19 year olds. During the immunisation programme, a comprehensive safety monitoring programme will be in place to monitor for any adverse reactions following MeNZB immunisation. This will include real-time hospital-based monitoring in the regions first to roll out the vaccine.     

The incidence of breast feeding and reasons for weaning

All 186 mothers delivered in a one month period at St Helens Hospital, Auckland, were interviewed on admission to hospital regarding their attitude to breast feeding and were followed until the infant was weaned or six months of age to determine the reason for weaning. One hundred and fifty-two (82%) of mothers were breast feeding on discharge, 34 (18%) were artificially feeding and only three of these had planned to breast feed before delivery. Racial characteristics were important, with only 7.5% Pacific Island mothers leaving hospital bottle feeding compared to 20% European and 29% of the Maori mothers. Marital status also influenced feeding as 14% of the married mothers left hospital bottle feeding compared to 20% of those in a de facto relationship and 29% of the single mothers. Only 23% of the mothers were still breast feeding at six months of age. The mean age of weaning was 15 +/- 9 weeks and the major reason for weaning was that of an inadequate milk supply in 54%. Despite the high proportion of mothers breast feeding on discharge from hospital, the rapid falloff in breast feeding following discharge highlights the need for improved education of the mothers.     

A prospective study of immunisation for a cohort of children

AIMS: To determine rates of immunisation by 24 months of age, the number of times children were recalled and the cost of immunisation for a cohort of children in general practices in Wellington. METHODS: A prospective study of 979 children registered with 27 general practices. Children in the cohort were followed from 9-24 months old. Data collected included immunisation status, the number of times children were recalled and demographic data. RESULTS: At the end of the study period (when children reached 24 months of age) 803 (82%) remained with the practices and 176 (18%) had left. At 24 months 724 (74%) of the total cohort and 685 (85.3%) of registered children who stayed with the practice were fully immunised for the early childhood vaccinations. 54% of the cohort were fully immunised after a standard recall process. The average cost per child immunised was $13.33. CONCLUSION: It is possible to achieve high rates of full immunisation in children registered with a general practice using an effective system of facilitation and support.     

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.     

Breast feeding preterm infants

Breast feeding is the optimal way to feed infants but may be difficult in preterm infants. In a study of 43 mothers with 49 preterm infants admitted to a neonatal unit during a 10 week period-84% (36 of 43) wished to breast feed and 92% (33 of 36) of these mothers left hospital breast feeding. Their infants were from 30 to 36.5 weeks gestation, weighing a mean 2590 (SD 530) g and were in hospital 16 (11) days. Only three mothers who wished to breast feed failed to do so. The 10 bottle fed infants were smaller, younger and remained longer in hospital. The majority of mothers (88%) who were discharged breast feeding were still successfully breast feeding their preterm infants three months later. This is in marked contrast to a previous study of mothers, of full term infants, where there was a marked decrease in breast feeding by three months. The mothercraft teaching described is an effective method of providing preterm infants and their mothers with the advantages of breast feeding.     

The ABC of New Zealand's Ten Year Vision for Pharmacists: awareness,barriers and consultation

Objectives This study aimed to determine New Zealand pharmacists' awareness of, recall of consultation about, and potential barriers to the implementation of the Focus on the Future: Ten Year Vision for Pharmacists in New Zealand: 2004–2014 document. Method A national postal survey was carried out in New Zealand of practising pharmacists registered with the Pharmacy Council of New Zealand (n = 1892). The survey was conducted between September and December 2006. Key findings The response rate was 51.8% (n = 980 usable surveys). Approximately three‐quarters (73.4%) reported being aware of the 10‐year vision document and 40.9% recall being consulted. Fewer than one‐third (29.8%) had read the document prior to completing the survey. Thirty‐two variables describing potential barriers to implementing the 10‐year vision were reduced, through factor analysis, to seven factors with significant eigenvalues (>1.0). The factors describe the underlying themes of barriers identified in the survey, including pharmacist humanistic, integrated systems of care and teamwork, funder stakeholder relationships and remuneration, lack of appreciation of knowledge and skills, lack of research support, current expertise and continuing professional development, and lack of voice. The majority of barrier variables within the seven factors were rated as extremely or quite important. Conclusions There was a high level of awareness and moderate level of recall of consultation on the document among respondents. Although 40% recall being consulted on the document, fewer than one‐third reported having read the document prior to completing our survey. Pharmacists highlighted a significant number of potential barriers to the implementation of the 10‐year vision. If the pharmacy profession in New Zealand is to move forward towards the state described in the 10‐year vision document then these potential barriers need to be better understood and addressed.     

Prevention of group B meningococcal disease by vaccination: a difficult task

New Zealand has embarked on an immunisation program to reduce the incidence of disease caused by serogroup B Neisseria meningitidis. Similar immunisation programs in Norway and South America have shown good efficacy in older vaccinees (ie, persons receiving vaccinations), but variable efficacy in younger vaccinees. Protective efficacy correlates well with the ability of the vaccine to stimulate a fourfold rise in serum bactericidal antibodies. Unfortunately, second and third doses of serogroup B N. meningitidis vaccines do not boost serum bactericidal antibody titres to very high levels; consequently protective efficacy wanes within a few years of immunisation. The overall outcome of the immunisation program will reflect both the immunogenicity of the vaccine and the uptake of the vaccine by the target population. The especially high incidence of meningococcal disease in Pacific and Maori children means that particular efforts will need to be made to reach these groups.     

Quality improvement within Independent Practitioner Associations: lessons from New Zealand

AIMS: To ascertain what quality improvement activities are being performed by associations of general practitioners (GPs) in New Zealand, to find out how they are supporting these activities, and learn about their experience of the process. METHOD: A cross sectional questionnaire study of 25 independent practitioner associations (IPAs) in New Zealand. RESULTS: All respondents (n=25) believed quality improvement was a responsibility of their organization, and for 48% it was their highest priority. All organizations carried out and supported a range of quality improvement activities. The major perceived barriers to quality improvement were negative attitudes and lack of time and money to support the process. Strategies to overcome these barriers included providing comparative data to staff in a peer group setting and providing financial incentives, management support and education. CONCLUSIONS: Considerable quality improvement activity is occurring in primary care in New Zealand. A variety of barriers to the process and methods of overcoming them have been identified by some, but not all IPAs.     

Issues relating to early detection and diagnosis of breast cancer in New Zealand general practice.

AIM: This study describes current practice in New Zealand general practice with emphasis on identifying problem areas in the early detection of breast cancer. The study is focused on women outside the age group for the New Zealand breast screening programme (50-64 years). METHOD: Thirty selected general practitioners throughout New Zealand were interviewed in depth to identify the key issues relating to the early detection and diagnosis of breast cancer in the primary care setting. Attitudes to key issues were quantified in a later postal survey of 656 general practitioners randomly sampled from the RNZCGP database. RESULTS: The response rate to the quantitative study was 82%. General practitioners were generally well informed about risk factors for breast cancer and the relative sensitivity and specificity of screening and diagnostic tools. Diagnosis and management were influenced by the limitations of screening and diagnostic tools, as well as access to, and confidence in, services. The appropriate level of investigation and follow-up for young women was an area of uncertainty. CONCLUSION: The study provided data to inform guideline development and a baseline measure of current practice against which the impact of the implementation of guidelines could be measured.     

Thiomersal in vaccines: balancing the risk of adverse effects with the risk of vaccine-preventable disease.

A number of affluent countries are moving to eliminate thiomersal (thimerosal), an ethylmercury preservative, from vaccines as a precautionary measure because of concerns about the potential adverse effects of mercury in infants. The WHO advocates continued use of thiomersal-containing vaccines in developing countries because of their effectiveness, safety, low cost, wide availability and logistical suitability in this setting. The guidelines for long-term mercury exposure should not be used for evaluating risk from intermittent single day exposures, such as immunisation using thiomersal-containing vaccines. Similar or higher mercury exposures likely occur from breast feeding and the health benefit of eliminating thiomersal from a vaccine, if any, is likely to be very small. On the other hand, the benefits accrued from the use of thiomersal-containing vaccines are considerably greater but vary substantially between affluent and developing regions of the world. Because of the contribution to overall mercury exposure from breast milk and diet in later life, the removal of thiomersal from vaccines would produce no more than a 50% reduction of mercury exposure in infancy and <1% reduction over a lifetime. Different public policy decisions are appropriate in different settings to achieve the lowest net risk, viewed from the perspectives of the individual vaccinee or on a population basis. In developing regions of the world, at least over the next decade, far more benefit will accrue from protecting children against widely prevalent vaccine-preventable diseases by focusing efforts aimed at improving infant immunisation uptake by using current, inexpensive, domestically-manufactured, thiomersal-containing vaccines, than by investing in thiomersal-free alternatives.     

Community pharmacists'' perspectives on pharmaceutical care implementation in New Zealand

Objective: There were three objectives to this study: to establish New Zealand community pharmacists' level of understanding of the pharmaceutical care process; to determine their attitudes to the concept of pharmaceutical care; and to determine the barriers to commencing pharmaceutical care practice. Comparisons were made between proprietors (pharmacy owners) and employees, males and females, and younger and older pharmacists. Method: The research tool was a questionnaire instrument, encompassing a total of 67 questions designed to determine community pharmacists' understanding, attitudes and appreciation of the opportunities and barriers inherent in the pharmaceutical care process. A total of 490 pharmacists representing 286 proprietors and 204 employees randomly selected from the Pharmaceutical Society register were sent a questionnaire. Results: The total responses numbered 377, which was a 76.9% overall response rate. Over 60% of the pharmacists surveyed had a correct understanding of pharmaceutical care. Approximately the same percentage felt the future of pharmacy would depend on the provision of services other than dispensing. Insufficient time, as a barrier to implementation, was identified by 87% of respondents, and an absence of a reimbursement system by a further 82%. Lack of: therapeutic knowledge; clinical problem solving skills; finance; appropriate space; patient demand; access to patient medical records; and data on the value of PC were identified as major barriers by over 50% of all respondents. There were significant differences in response to a number of issues recorded by males and females, proprietors and employees, and pharmacists above and below the mean sample age of 45 years.Conclusion: This study found that the community pharmacy environment in New Zealand had a high level of understanding of the pharmaceutical care process, but identified some significant barriers to implementation.     

Community pharmacists' perspectives on pharmaceutical care implementation in New Zealand

Objective: There were three objectives to this study: to establish New Zealand community pharmacists' level of understanding of the pharmaceutical care process; to determine their attitudes to the concept of pharmaceutical care; and to determine the barriers to commencing pharmaceutical care practice. Comparisons were made between proprietors (pharmacy owners) and employees, males and females, and younger and older pharmacists. Method: The research tool was a questionnaire instrument, encompassing a total of 67 questions designed to determine community pharmacists' understanding, attitudes and appreciation of the opportunities and barriers inherent in the pharmaceutical care process. A total of 490 pharmacists representing 286 proprietors and 204 employees randomly selected from the Pharmaceutical Society register were sent a questionnaire. Results: The total responses numbered 377, which was a 76.9% overall response rate. Over 60% of the pharmacists surveyed had a correct understanding of pharmaceutical care. Approximately the same percentage felt the future of pharmacy would depend on the provision of services other than dispensing. Insufficient time, as a barrier to implementation, was identified by 87% of respondents, and an absence of a reimbursement system by a further 82%. Lack of: therapeutic knowledge; clinical problem solving skills; finance; appropriate space; patient demand; access to patient medical records; and data on the value of PC were identified as major barriers by over 50% of all respondents. There were significant differences in response to a number of issues recorded by males and females, proprietors and employees, and pharmacists above and below the mean sample age of 45 years.Conclusion: This study found that the community pharmacy environment in New Zealand had a high level of understanding of the pharmaceutical care process, but identified some significant barriers to implementation.     

Infant bed-sharing among Pacific families in New Zealand

AIM: To describe infant bed-sharing among Pacific families in New Zealand. METHODS: The data were gathered as part of the Pacific Island Families: First Two Years of Life (PIF) Study in which 1376 mothers were interviewed when their infants were six-weeks-old. Maternal reports of infant bed-sharing practices were assessed by questions about infant sleep location and the number of people who usually shared a mattress with the infant. RESULTS: Over half of the mothers (54.9%) reported that their infants shared a mattress with other people, 44.2% sharing with one other person, the remainder sharing with two or more people. Of the bed-sharing infants, 4.7% slept on a mattress on top of the bed, and 4.7% only slept part of the night in the shared bed. CONCLUSIONS: Together with effective information delivery, the educational and housing issues that many Pacific families in New Zealand face need to be addressed so that parents can make informed decisions about infant care practices.     

Whooping cough after stopping pertussis immunisation.

An epidemic of whooping cough occurred in a rural practice in Shetland, containing 144 children under 16. Before July 1974 all children were immunised against pertussis, but after that date immunisation was stopped. Of the 134 children studied, 93 had been immunised. Sixty-five of the children developed whooping cough. The incidence of infection was similar in those who had and had not been immunised. The incidence was also similar in those born before and after July 1974. There was no evidence to support the routine use of pertussis immunisation in rural Shetland.     

Hepatitis B vaccine boosters: further studies in children

Two groups of children were given reduced dose boosters with Merck Sharp and Dohme (MSD) recombinant DNa, yeast derived hepatitis B vaccine (YDV), 30 and 34 months respectively after primary immunisation with MSD plasma derived vaccine (PDV). In the first group of unselected children the geometric mean titre (GMT) rose from 387 to 8346 IU/L, with all children protected. The second group were selected as the poorest responders to their primary course of vaccine. The booster raised the GMT from 14.6 to 325 IU/L, with 95% having protective levels of anti-HBs (greater than 10 IU/L). This study confirms that the vaccine used by the New Zealand Department of Health for the hepatitis B immunisation programme in preschoolers, will provide protection for the great majority of children for at least three years.     

Induction of protective and specific antibodies against cocaine by intranasal immunisation using a glyceride adjuvant

The goal of this study was to investigate an intranasal cocaine vaccine containing the mucosal adjuvant macrogol-6-glycerol capylocaprate (RhinoVax). Cocaine-KLH conjugate was prepared and administered in two formulations. Ten mice were immunised intranasally using RhinoVax as adjuvant and ten subcutaneously using aluminium hydroxide as an adjuvant. A negative control group (n=10) received unconjugated KLH with RhinoVax intranasally. Specific cocaine antibodies in serum were measured following primary and booster immunisation. Relative antibody responses in serum indicated that the immunisation was successful. Animals were then challenged with cocaine either intranasally or intraperitoneally with subsequent measurement of drug distribution into the serum, brain and olfactory bulb. The cocaine-immunised groups revealed significantly lower cocaine levels in the brain compared to the negative control group. The inhibition of cocaine distribution to the brain in the intranasal immunised group was comparable to that of the subcutaneous immunised group. This was unexpected because the cocaine specific antibody levels in serum were fivefold lower in the intranasal immunised group. However, the presence of mucosal cocaine specific antibodies after intranasal immunisation could play an important role in hindering direct access of cocaine into the brain via the olfactory bulb.