A longitudinal approach to com m unicable disease prevention Centre for Longitudinal Research-He Ara ki Mua School of Population Health, Tamaki Campus, 4 th April 2011 Dr. Cameron Grant Associate Director Growing Up in New Zealand Associate Professor, University of Auckland Paediatrician, Starship Children’s Hospital cc.grant@auckland.ac.nz | www.growingup.co.nz
N N O O M M A A M M M M A A L L S S
….until about 1 1 0 0 AD
Epidem ic disease in New Zealand prior to colonisation “beyond a vague account of an epidemic that swept through the Taiamai district in the North about 150 years ago, there are no accounts of epidemics occurring in pre-European times” Te Rangi Hīroa ( Buck PH). Medicine amongst the Maoris in ancient and modern times by "Abound" [pseudonym] [A thesis for the degree of Doctor of Medicine]. Dunedin, New Zealand: University of Otago; 1910.
Epidem ic disease in New Zealand prior to colonisation “Yaws and filariasis with its attendant elephantiasis which were prevalent in Polynesia were not introduced. Typhoid, tuberculosis, measles, and venereal disease were all introduced after European contact”. Te Rangi Hīroa ( Buck PH). The coming of the Maori . Wellington: Maori Purposes Fund Board; 1950.
And then a second wave of migration
The first epidem ic described by the M ā ori w as “Rew harew ha” • somewhere in the time period from 1790 to 1802 “The epidemic spread with extraordinary virulence throughout the North Island and even to the South. From the rapid manner in which it spread it seems to have been influenza. The fact that rewharewha is used to denote coughing points to the fact that bronchitis and chest symptoms were some of the outstanding features of the epidemic.” Buck PH. Medicine amongst the Maoris in ancient and modern times [A thesis for the degree of Doctor of Medicine]. Dunedin, New Zealand: University of Otago; 1910.
Epidem ic diseases in the decades follow ing colonisation • “various epidemics were introduced by civilisation and have remained with us ever since” … • “measles, typhoid, scarlet fever, whooping cough and almost everything, except plague and sleeping sickness, have taken their toll on M ā ori.” • “Without doctors and medicines the ravages of introduced diseases in the early days were frightful.” Buck PH. The coming of the Maori . Wellington: Maori Purposes Fund Board; 1950
National epidem iological descriptions of epidem ic disease in M ā ori in the decades follow ing colonisation How many epidemiological descriptions were there? Availability of annual population, m ortality and m orbidity statistics for M ā ori Total population 1920 - Total births and deaths 1920 - Deaths by diagnosis (subsequently ICD code) 1920 -
It’s also really bad for birth cohort studies W hat w ould w e have seen if w e had the data?
Pertussis mortality rates in New Zealand Maori versus non-Maori 1920 to 1997 Maori non-Maori Number of deaths per 100,000 120 Pertussis vaccine 100 introduced 80 60 40 20 0 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Grant CC. PhD thesis University of Auckland, 2004
So here we are today Launching a centre that seeks to provide relevant evidence to improve the health and development of today's children
Overview of presentation 1. Communicable diseases in New Zealand today 2. What do we know about communicable disease prevention? 3. What can we learn from Growing Up in New Zealand?
In which direction are we heading? Com m unicable diseases in New Zealand today
Most common cause of acute hospitalisation in New Zealand I nfectious diseases hospitalisations New Zealand 1 9 8 9 -2 0 0 8 Baker M, University of Otago, 2010.
Close-contact infectious diseases • Humans are the only or the most important source • Transmission is by direct physical contact, respiratory or faecal-oral spread Largest contributor to the • Infections are increase in infectious predominantly acquired in diseases in NZ the community over past 20 years Mills CF et al. NZMJ 2002;115:254-7
Close contact infectious diseases as a % of all cause hospital adm issions Increase over 20 years of 15% for European/Other 20% for Māori 26% for Pacific peoples Date Baker M, Close-contact infectious diseases in NZ University of Otago, 2010
Close contact infectious diseases hospitalisations New Zealand 1 9 8 9 - 2 0 0 8 age 0 to 5 years Rate per 100,000 Age 0 to 5 years close contact infectious diseases % of hospitalisations • 40% 1989 to 1993 • 53% 2004 to 2008 Baker M, Close-contact infectious diseases in NZ. University of Otago, 2010
Are we alone?
NZ hospital adm ission rates serious skin infections age 0 -1 4 & 1 5 -2 4 years 1 9 9 0 -2 0 0 6 Cellulitis hospital admission rates twice those in Australia, USA Craig E et al. Monitoring the Health of New Zealand Children and Young People 2007 O’Sullivan J Paed Child Health 2010;46:176-83.
NZ hospital adm ission & m ortality rates bronchiolitis infants 1 9 9 0 -2 0 0 6 NZ rate 2002-06 More than twice that in USA & UK Craig E et al. Monitoring the Health of New Zealand Children and Young People 2007 Grant CC et al. J Paed Child Health 2010 DOI 10.1111/j.1440-1754.2010.01868.x.
International comparison infant pertussis hospitalisation rates New Zealand rate 3 to 6 250 times greater than New Zealand Rate per 100,000 200 England, Australia or 150 USA 100 England Australia 50 USA 2004 1995 2001 1990s 0 Somerville et al. J Paed Child Health 2007;43:617-622 Elliot E. PIDJ 2004;23:246-52. Van Buynder P. Epidemiol Infect 1999;123:403-11 Tanaka M. JAMA 2003;290:2968-75.
Developed w orld pneum onia m orbidity: hospital adm ission rates per 1 0 0 0 : preschool ( < 5 yrs) * NZ rate 20 2 to 5 times 18 NZ greater 16 Rate per 1,000 14 12 10 8 USA Hong Kong 6 Australia 4 UK 2 1994 1997 1992 1997 2001 0 * All pre-conjugate pneum ococcal vaccine ■ Grant CC J Paed Child Health 1998;34:355-9 ■ Williams P Int J Epid 1997;26:797-805 ■ Henrickson KJ PIDJ 2004;23:S11-8 ■ Clark JE Epidemiol & Infect 2007;135:262-9 ■ Sung RY Clin Infect Dis 1993;17:894-6
Are we alone? No but we are in the least safe orbit
Adult ‘non-com m unicable’ disease Rheum atic heart disease Bronchiectasis • Rheumatic fever • 4 per 100,000 < 15 incidence 15/ 100,000 years old • Ethnic disparity • 7 times more prevalent increasing than Finland – Pacific (60 fold) • Symptoms < age 5 yrs – Māori (30 fold) • 150 deaths per year Significant causes of premature death in New Zealand Twiss J. Arch Dis Child 2005;90:737-40 Wilson N. Heart Lung Circ 2010; 19: 282-8. Kolbe J. Respirology 1996;1:221-5 Atatoa-Carr P . NZ Med J 2008; 121: 59-69.
Adult non-com m unicable disease: Do infections in early childhood contribute to the developm ent of atherosclerosis? • William Osler 1908 • Atherosclerosis is an inflammatory condition • Infection produces a systemic inflammatory insult • Acute infections in childhood cause reversible derangements in endothelial function Charakida M, Atherosclerosis 2010;208:217-21 .
Adult non-com m unicable disease: Do infections in early childhood contribute to the developm ent of atherosclerosis? Pesonen Eur Cardiovas Dis 2006
Com m unicable diseases in New Zealand today • Most common cause of acute hospitalisation – Rates of hospital admission are increasing – Proportion of all hospitalisations is increasing • Marked ethnic differences which are increasing – Especially for close-contact infectious diseases • Greatest burden in the youngest children • Respiratory infections and bacterial skin infections are big players • National shame diseases: slow progress – Rheumatic heart disease – Pertussis in infants • Potential role in adult non-communicable diseases
W hat do w e know about com m unicable disease prevention?
Child death, communicable True False diseases and nutrition Approximately 10 million children less than 5 years old die every year in the world Communicable diseases cause more than half of the deaths in children less than 5 years old Malnutrition is an underlying cause of half of all deaths in children less than 5 years old
Child death, communicable True False diseases and nutrition Approximately 10 million children less than 5 years old die every year in the world Communicable diseases cause more than half of the deaths in children less than 5 years old Malnutrition is an underlying cause of half of all deaths in children less than 5 years old Bryce, J et al. Lancet 2005;365:1147-52
Look to the developing w orld for answ ers “Other”
Look to the developing w orld for answ ers Nutrition Immunisation Case Living management environments
Using nutrition as an exam ple
Global im pact of m aternal and child m alnutrition 11% of global disease burden 35% of DALY age <5 years Malnutrition All other causes 35% of deaths age <5 years DALY = the number of years lost due to ill-health, disability or early death Black RE, et al. Lancet 2008;371:243–60.
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