Health status of New Zealand children in the Auckland and Waikato Regions

Health status of New Zealand children in the Auckland and Waikato Regions

An important recent publication by researchers for the Waikato District Health Board, ‘The Top 10 Report’, provides the first significant overview of indicators of child and youth health in the Auckland and Waikato regions based on data from 1995-1999( ).

40% of New Zealanders under 25 live in this area which includes the most deprived (South Auckland) and least deprived (North Shore to Wellsford) regions of New Zealand. Not surprisingly its findings generally confirm the well-established relationship between poor health outcomes, poverty and inequality.

“Regional inequalities in health are large…They can be substantially accounted for by specific socio-economic factors such as overcrowding, unemployment, education and car ownership”(2).

The health status was determined by a complex interplay of ethnicity, socioeconomic status, and whether they lived in rural or urban communities. Children and young people in rural Waikato and South Auckland lived in the areas of greatest deprivation and suffered the poorest health of the groups studied.

Rural children and young people had greater rates of death and deprivation. However their disease- specific hospital discharge rates were lower, suggesting poorer access to hospital and health services. North Auckland children and young people were the least deprived and enjoyed the best health.

The Top 10 Report broadly highlighted the top 10 health issues that must be acted upon to improve the health and well being of children and young people. These are:
•    infant mortality (6.6/1000 live births in 1998) which remains high by comparison with other similar countries. The infant mortality rate in NZ declined steadily until 1992, but has levelled off since, and not improved at the same rate as ion other developed countries. In 1960 NZ ranked 6th out of 21 OECD countries for infant mortality, but in 1995 ranked 15th of 21 OECD countries (3).

•    mortality in Maori who had the highest death rates within almost all age ranges (90% of age standardised mortality rate was potentially avoidable);youth mortality (very high deaths from motor vehicle crashes and suicide, especially in rural Waikato); avoidable hospitalisations which are high and rising from 1995-1999 (ENT infections, gastroenteritis, dental conditions, acute bronchiolitis, pneumonia, cellulitis, and other respiratory infections);infectious diseases rates (meningococcal disease, measles, pertussis, tuberculosis, rheumatic fever);asthma admissions; lower respiratory tract admissions;births to teenage mothers (31/1000 women 15-19 years in 1998. (Out of 44 countries with available statistics, NZ had the 12th highest rate of teen pregnancy)( ) dental health (high rates of missing and filled teeth) high rates of hearing loss.

Motor vehicle crashes and suicide have become the largest categories of potentially avoidable mortality. The highest mortality was in young adults15-25 years. While Japan and most Western European nations have relatively low rates of youth suicide - fewer than 15 cases a year for every 100,000 young males, between 1991 and 1993 New Zealand had one of the highest rates of youth suicide in the world - more than 30 cases per 100,000 - along with Latvia, Finland, Lithuania, the Russian Federation, and Slovenia (5).

Lower respiratory tract infections are increasing. Almost one in five infants in South Auckland required hospitalisation with lower respiratory tract infection, 70% higher than the national rate, whereas in North Auckland only 3.6% were admitted, one third the national rate. Pneumonia is one of our major health issues, affected by housing, access to health care, health knowledge and beliefs, the quality of primary care, and the nutritional status of children( ).

Although there have been reductions in rates of infant mortality, rheumatic fever and hearing loss, and relatively constant rates of pertussis and meningococcal disease during the 5 year period of the study, the baseline rates in New Zealand are still very high compared with similar countries. The indications are that the poor health status of New Zealand children and young people is related to poverty and poor access to primary health care.

“Health impairment is associated with relative poverty as well as absolute deprivation… The sheer size of the effect seems not to be generally appreciated. It far exceeds, for example, the effects of environmental pollution, which, however, attracts a great deal more publicity”(2)

Poverty related diseases
The health of New Zealand children and young people is now among the poorest in the “developed” world. In considering the causes it is hard to overlook worsening socio-economic environment for a large minority of New Zealand children and young people in the last 10-15 years. There are many examples of poverty-related diseases that have worsened in incidence since the early 199s, especially in the Auckland region.

Meningococcal disease
There is a disturbing coincidence with onset of this epidemic and the severe cuts to social welfare benefits in 1991, along with a raft of other changes such as market related housing rents that followed soon after. The epidemic of meningococcal disease began in 1992, when cases rapidly increased to 9 times the baseline rate, and have remained at this level as illustrated in Figure 1.

In the non-epidemic years 1988-1991 the rate was 1.5/100,000, which is the usual rate for most developed countries (Figure 2). The New Zealand rate in 2000 was 13.3/100,000. The provisional figures for 2001 were the worst in New Zealand’s history - 660 people were sick with meningococcal disease and 26 died, compared with 480 cases and 17 deaths in 2000( ).

Meningococcal disease spreads by droplets from person to person, especially from older to younger people, and therefore is most common in winter when families are indoors. The organism can cause blood infection, which progresses to clotting in small blood vessels, sometimes causing and gangrene, or meningitis. At least 20% of the victims suffer death or serious disability, such as loss of limbs, brain damage and deafness.

The highest rate of meningococcal disease is under one year of age, with South Auckland having the highest rates, about 1 in 300 children - 346 cases per 100,000 1997-1999(4).

The Ministry of Health is working on the provision of a vaccine against meningococcal group B (responsible for > 90% cases). Although this will be a great help, overseas studies suggest that vaccination may prevent only up to 50-60% cases ( , ), and therefore New Zealand rates may remain unacceptably high compared to other countries, unless key underlying factors are improved. Household crowding is the strongest risk factor for meningococcal disease ( ). The most important measure was number of people >9 years per room, with an exponential increased risk with more than twice the number of people> 9 years, (so that when there was a 6 fold increase in people >9 years there was 10 times the risk). Household crowding is strongly influenced by income poverty because of the high cost of housing.( )

Cellulitis
Cellulitis occurs when a scratch or insect bite in the skin progresses to an infection of the surrounding flesh. There is diffuse inflammation of the skin or soft tissues due to infection, and the skin is red, warm and tender. There may be associated fever, chills or sweats, regional lymph node involvement, and proximal red streaking. Complications include ulceration, abscess, extension deeper to fascia and muscle, and bacteraemia or sepsis.( )

Nationally hospital admissions for cellulitis have increased and in the Auckland region rates of hospitalisations have more than doubled since 1994. Cellulitis is now the third most common reason for admission to Starship Children’s Hospital (Figure 3) and the rate continues to increase (Leversha personal communication). Hospitalisations were highest for Pacific children, 3-4.5 times more than European children, but the increase was seen in all ethnic groups.

Children under 5 years are at particular risk, with hospitalisation rates twice that of older children. Once admitted, all children require intravenous antibiotics, 50% require surgery to release the pus from an abscess, and 40% children stay in hospital more than 2 days (range 1-21 days).

Exposed surfaces, particularly the legs, are most commonly affected, and most admissions occur in the summer months ( ). The process of cellulitis takes several days to evolve, with several factors influencing whether a child develops a skin infection or requires hospitalisation. These include the infecting agent, host and environmental factors, access to primary health care, and characteristics of the health system. Research is being undertaken to establish the relative importance of these factors.

However some factors in the development of cellulitis are likely to be parental awareness of the integrity of their children’s skin, the initial home management provided once the skin has been breached and seeking healthcare if redness develops. Historically skin infections were said to be associated with crowding, poor hygiene, and neglect of minor trauma ( ).

Factors potentially implicated include hand washing, and hygiene behaviours, such as the sharing of towels and bedding, cold washing or hand washing of towels and bedding of infected children, not covering draining purulent lesions, or leaving lesions covered with non-breathable plaster for several days. Communal use of linen, towels, wash cloths, and clothing may also be important. Environmental reservoirs of streptococci and staphylococci (the causative organisms) have been found in clothing, bedding, fingernail dirt and schools. Moisture left on hands after washing facilitates transfer of large numbers of bacteria from hands to other surfaces, and drying reduces this by 99%, with clean towels being more effective than used towels (12).

In addition an unhealthy diet with little fruit and vegetables decreases the child’s resistance to infection. All of these environmental factors are more likely in households where there is lack of income for the materials and running costs of personal hygiene, where there is overcrowding and lack of adequate washing facilities in the home and parents are tired, stressed, or inadequately educated.
Once skin infection occurs the child needs topical antibiotic ointment, and if it progresses, oral antibiotics. This requires visiting a general practitioner, which is most likely to occur if the parents know when and where to go, the service is affordable, accessible, available, and acceptable (12).

We argue that this is not the case for many low-income families in New Zealand.

“The best predictor of infant mortality in a country is maternal education. It is through education that people learn how and where to acquire information to guide their choices, how to interpret and judge that information, and how to make and implement their choices. It is the foremost enabler of health”(2).

If the family doctor is visited, the antibiotics need to be bought from the pharmacist, and then a full course taken. For some families this cost is prohibitive, and sometimes antibiotics are shared among family members, so no one gets a therapeutic course. We contend that income poverty, overcrowding and poor access to primary health care are likely to be significant factors contributing to the increase in cellulitis. Although visits to the GP and the medications prescribed are fully subsidised for all children under 6 years old under present government policy, this is not the case for older children affected by this and similar diseases.

“Political effort should be focused on three broader components of deprivation, each of which profoundly influences health and where progress would be possible even in the face of economic inequalities: these are education, housing and unemployment”(2).

Bronchiectasis

Bronchiectasis (damaged, dilated airway walls) is most likely to occur as a result of under treated chest infection or pneumonia in early childhood, with persistent infection in the lung causing damage to the airway wall. The first symptom is cough, becoming a wet productive cough, which persists for more than 3 months, and becomes lifelong. In established bronchiectasis, there is cough with phlegm, usually during the day rather than the night, and as the condition progresses there is reduced ability to exercise, and breathlessness. Profuse sputum, up to a cup a day may be coughed up in the most severely affected children. It is important to know that this disease cannot be caught from others - it is a person’s own germs untreated which damage the lungs, not catching germs from others. If left under treated, this condition leads to respiratory failure. Adults with bronchiectasis are often too tired and sick to work, and their only income is the sickness benefit. Progression of the disease leads to premature death at 20-40 years of age, with more deaths in this age group in Auckland than from asthma ( ).

Although the absolute numbers of children and young people affected with bronchiectasis is small compared with many other diseases - about one in 5000 currently diagnosed - the number of children diagnosed with this condition is increasing rapidly. In Starship Children’s Hospital the numbers have doubled in the last year, and there is one new case diagnosed almost every week. While some of this increase may be to increased awareness and diagnosis (CT scan), paediatricians working in Auckland for the last 2 decades recognise higher rates now compared with the 1980s (Byrnes personal communication).

New Zealand children are much more severely affected with bronchiectasis than other countries because most or all lobes of the lung are diseased with bronchiectasis, as illustrated in Figure 4 ( ).

There is no evidence that Pacific or Maori children, who have the highest rate of bronchiectasis, have any intrinsic underlying abnormality in their airways which predisposes to the condition ( ).

Bronchiectasis has always been recognised by the medical profession as a disease of poor living conditions, overcrowding, poor immunisation, and poor access to antibiotics (15) and has become a rare condition in the rest of the “developed” world. We speculate that the increase in bronchiectasis is a further poor outcome of income poverty and poor access to primary health care in New Zealand.

In summary there is abundant evidence that New Zealand children and young people have experienced deterioration in many indicators of health over the last 11 years, especially in the diseases aggravated by poor household income, overcrowding, and poor access to primary health care.

These underlying factors have been recognised and reported on, but little has happened to improve the socio-economic environment of those affected. These issues must be urgently addressed by government policy changes. We cannot afford to wait any longer.

Footnote

*Definition of NZDep96: Proportion of people
• with no access to a telephone;
• aged 18-59 receiving a means tested benefit;
• aged 28-59 who are unemployed;
• living in households with equivalised household income below a defined income threshold;
• with no access to a car;
• aged <60 living in a single parent family;
• aged 18-59 without any qualifications;
• not living in own home;
• living in households below equivalised bedroom occupancy threshold

(2)Rose G. (Emeritus Professor of Epidemiology, London School of Hygiene and Tropical Medicine). The strategy of preventive medicine. Oxford: Oxford University Press; 1992

Child Poverty Action Aotearoa NZ Box 56150 Mt Eden Auckland
http://www.cpag.org.nz