Neurodevelopmental Outcomes Following Childhood Viral Meningitis in Canterbury New Zealand

BACKGROUND

Most childhood meningitis is viral in countries with widespread conjugate vaccine use. This study assessed clinical features and neurodevelopmental outcomes in preschool children following enteroviral and parechoviral meningitis.

METHODS

Children 18-42 months of age in Canterbury, New Zealand were included, who had enterovirus (EV) or parechovirus (HPEV) meningitis from 2015 to 2021. Comprehensive neurodevelopmental assessments were completed by a psychologist using the Bayley Scale for Infant Development-3 (BSID-3). Mean composite and scaled scores and proportion below the cutoff were assessed in each domain. Clinical data was analyzed.

RESULTS

There were 79 children 18-42 months old with previous EV or HPEV meningitis. BSID assessments were completed for 33 children (55% male), median age 32 months, from 2019 to 2022 including 23 with EV and 10 HPEV meningitis. At diagnosis, 32 (97%) received intravenous/intramuscular antibiotics, and 6 received a fluid bolus. Parents reported developmental speech concerns in 6 children, and delayed motor milestones in 1 child. There was no reported sensorineural hearing loss. BSID mean composite scores were in the expected range for cognition 102 (confidence interval: 98-106), language 96 (93-100) and motor 102 (98-106) domains. Overall, 12/33 (36%) children had below expected scores in 1 developmental domain, including scores 1-2 SD below the normative mean for cognition (2/33; 6%), receptive language (6/33; 18%), expressive language (5/33; 15%) and gross motor (6/33; 18%). There were no differences between scores in EV and HPEV meningitis.

CONCLUSION

Following viral meningitis, more than a third of preschool children had a mild developmental delay with comprehensive neurodevelopmental assessment, suggesting targeted follow-up should be considered.

A Multisource Process Evaluation of a Community-Based Healthy Lifestyle Programme for Child and Adolescent Obesity

Whānau Pakari is a healthy lifestyle assessment and intervention programme for children and adolescents with obesity in Taranaki (Aotearoa/New Zealand), which, in this region, replaced the nationally funded Green Prescription Active Families (GRxAF) programme. We compared national referral rates from the GRxAF programme (age 5-15 years) and the B4 School Check (B4SC, a national preschool health and development assessment) with referral rates in Taranaki from Whānau Pakari. We retrospectively analysed 5 years of clinical data (2010-2015), comparing referral rates before, during, and after the Whānau Pakari clinical trial, which was embedded within the programme. We also surveyed programme referrers and stakeholders about their experiences of Whānau Pakari, analysing their responses using a multiple-methods framework. After the Whānau Pakari trial commenced, Taranaki GRxAF referral rates increased markedly (2.3 pretrial to 7.2 per 1000 person-years), while NZ rates were largely unchanged (1.8-1.9 per 1000 person-years) (p < 0.0001 for differences during the trial). Post-trial, Taranaki GRxAF referral rates remained higher irrespective of ethnicity, being 1.8 to 3.2 times the national rates (p < 0.001). Taranaki B4SC referrals for obesity were nearly complete at 99% in the last trial year and 100% post-trial, compared with national rates threefold lower (31% and 32%, respectively; p < 0.0001), with Taranaki referral rates for extreme obesity sustained at 80% and exceeding national rates for both periods (58% and 62%, respectively; p < 0.01). Notably, a referral was 50% more likely for referrers who attended a Whānau Pakari training half-day (RR = 1.51; p = 0.009). Stakeholders credited the success of Whānau Pakari to its multidisciplinary team, family-centred approach, and home-based assessments. However, they highlighted challenges such as navigating multidisciplinary collaboration, engaging with families with complex needs, and shifting conventional healthcare practices. Given its favourable referral trends and stakeholder endorsement, Whānau Pakari appears to be a viable contemporary model for an accessible and culturally appropriate intervention on a national and potentially international scale.

Impact of the COVID-19 related border restrictions on influenza and other common respiratory viral infections in New Zealand

BACKGROUND

New Zealand's (NZ) complete absence of community transmission of influenza and respiratory syncytial virus (RSV) after May 2020, likely due to COVID-19 elimination measures, provided a rare opportunity to assess the impact of border restrictions on common respiratory viral infections over the ensuing 2 years.

METHODS

We collected the data from multiple surveillance systems, including hospital-based severe acute respiratory infection surveillance, SHIVERS-II, -III and -IV community cohorts for acute respiratory infection (ARI) surveillance, HealthStat sentinel general practice (GP) based influenza-like illness surveillance and SHIVERS-V sentinel GP-based ARI surveillance, SHIVERS-V traveller ARI surveillance and laboratory-based surveillance. We described the data on influenza, RSV and other respiratory viral infections in NZ before, during and after various stages of the COVID related border restrictions.

RESULTS

We observed that border closure to most people, and mandatory government-managed isolation and quarantine on arrival for those allowed to enter, appeared to be effective in keeping influenza and RSV infections out of the NZ community. Border restrictions did not affect community transmission of other respiratory viruses such as rhinovirus and parainfluenza virus type-1. Partial border relaxations through quarantine-free travel with Australia and other countries were quickly followed by importation of RSV in 2021 and influenza in 2022.

CONCLUSION

Our findings inform future pandemic preparedness and strategies to model and manage the impact of influenza and other respiratory viral threats.

Pre-school wheeze hospital presentations: A demographic profile and review of clinical management

AIM

Pre-school wheeze is a common hospital presentation in Australasia. The aim of this study was to describe the regional hospital presentation and cost of pre-school wheeze.

METHODS

Audit of children diagnosed with pre-school wheeze at two hospitals in Auckland, New Zealand from October 2017 to September 2019. Guideline adherence was determined.

RESULTS

One hundred and ninety-two children made 247 pre-school wheeze hospital presentations. Pre-school wheeze accounted for a larger proportion of acute hospital presentations for Māori versus non-Māori children (rate ratio 1.76, 95% confidence intervals 1.32-2.31). Hospital representations with pre-school wheeze occurred in 38/192 (20%) children. The proportion with a pre-school wheeze representation was larger for Māori than non-Māori (30% vs. 16%, P = 0.02). Pre-school wheeze event median length of stay increased as household deprivation increased (P = 0.01). Clinical severity of 247 pre-school wheeze episodes was mild (n = 64, 26%), moderate (n = 153, 62%) and severe (n = 30, 12%). Of 244 episodes, inhaled bronchodilators only were given for 149 (61%), oxygen for 54 (22%) and intravenous treatment for 41 (17%). Hospital guideline use was evident in 164/247 (66%) episodes. Neither clinical severity nor treatment intensity varied with child sex, age or ethnicity or household deprivation. The estimated median (interquartile range) direct medical costs of each pre-school wheeze episode were NZ$1279 (NZ$774-2158).

CONCLUSIONS

In Auckland, pre-school wheeze accounts for a larger proportion of acute hospital presentations for Māori compared with non-Māori and Māori children have increased odds of pre-school wheeze readmissions. Length of hospital stay for pre-school wheeze episodes increased with household deprivation. In this audit pre-school wheeze guideline adherence was poor.

Investigating the health status of primary school children in Tonga: Lessons learnt and reflections on field work in the Pacific Islands

Globally, the child health focus has been on reducing under-5-year mortality, with large populations in low-resource regions prioritised. Children in older age groups, particularly in less populated regions such as the Pacific, have received limited attention. Child health research in the Pacific region has been lacking, and research approaches for the region have historically been from Western biomedical paradigms. We completed the study of primary school children's health over a period of 5 years. Firstly, we conducted a literature review, then we completed an audit of hospital admissions of primary school children, then we completed a two-round Delphi process and finally, we piloted the survey in three primary schools. Our results found there were high levels of oral health problems, ear health, obesity and exposure to violence and poverty impacting on the quality of health of primary school-age children. Identifying these indicators was made possible by the partnerships and trust established by the study team and provides specific and measurable targets for future work to improve the quality of child health outcomes. This paper describes key field work lessons learnt for research in the Pacific region. It must: (i) be on the platform of relationship, cultural safety and local ownership; (ii) include consideration of holistic Pacific paradigms of health; (iii) be adaptive to the context and environment; and (iv) be committed to long-term partnership and work.

Prevalence of anaemia in acutely unwell infants

Nil.

The need to nurture Aotearoa New Zealand's healthcare workforce

This commentary examines the ethical significance of recently published research demonstrating the extent to which healthcare workers experienced stress and increased challenges in the workplace due to inadequate access to personal protective equipment (PPE) during the first COVID-19 surge in Aotearoa New Zealand. The inadequate state of New Zealand's PPE stockpile and distribution system at the beginning of the pandemic was a critical signal, a "canary in the coalmine", of broader challenges facing the New Zealand healthcare system, particularly for healthcare worker safety and wellbeing. As New Zealand reforms its health system with the aim of improving access to and equity of care, an opportunity exists to apply critical lessons learnt from the COVID-19 pandemic about the need to prioritise the wellbeing of the healthcare workers we are dependent upon to deliver that care. Failure to apply this new knowledge will see the system similarly unprepared for future public health emergencies, which are likely to be imminent, and potentially with healthcare workers less willing to accept the burdens placed on them. The Nurture Framework, which has emerged from the voices of healthcare workers within this research, should be adopted as part of health reforms and ongoing emergency preparedness planning. Trust, transparency, respect and safety, the four values of the Framework, are fundamental for all workers who contribute their skills, knowledge and time to our healthcare organisations.

Investigation of the knowledge of South African high school rugby coaches on concussion and the return-to-play protocol

Background

Coaches are pivotal in the management of concussed players. Assessing the knowledge of high school rugby coaches with regard to concussion management will enable relevant future education on this topic to be covered.

Objectives

To investigate the knowledge of South African high school rugby coaches on concussion symptom recognition, knowledge and stepwise return-to-play (RTP) protocols.

Methods

A cross-sectional descriptive study involving 143 first team, high school rugby coaches was completed via an electronic questionnaire. Independent variables included coach demographics, qualifications, experience, BokSmart accreditation, and school size. Dependent variables included knowledge scores on concussion symptoms, general concussion knowledge, stepwise RTP and Maddocks questions. Relationships between total scores for different demographic groupings were established using non-parametric techniques.

Results

The coaches had high general, symptom and overall concussion knowledge scores (77% - 80%) in contrast with low RTP scores (62%) and very low Maddocks questions knowledge scores (26%). The 35-44-year age group received top scores for symptom recognition (p=0.034) and total concussion knowledge (p=0.041). Larger category school coaches (p=0.008) and BokSmart accredited coaches (p=0.041) outperformed all other coaches in general concussion knowledge and total knowledge, respectively. However, respondents were not familiar with emotional symptoms or the importance of cognitive rest after a concussion. Educational programmes were the most popular knowledge source for coaches.

Conclusion

In general, coaches presented with good general concussion knowledge but lesser expertise on emotional symptoms, cognitive rest and RTP management. Modifiable predictors of knowledge included the expansion of BokSmart accreditation, focussing information sessions on smaller rugby size schools and the education of coaches younger than 35 years or older than 45 years of age.

End-user acceptability of personal protective equipment disinfection for potential reuse: a survey of health-care workers in Aotearoa New Zealand

BACKGROUND

The COVID-19 pandemic has highlighted personal protective equipment (PPE) supply, distribution, and disposal issues worldwide. Calls to conserve PPE stocks and increase supply resulted in the rapid development of potential disinfection methods, with the possibility of improvements in medical waste reduction. However, how receptive health-care workers are to PPE reuse remains unknown. We aimed to examine the views of health-care workers who used PPE during the first COVID-19 wave in Aotearoa New Zealand, in relation to acceptability of PPE disinfection and reuse.

METHODS

In this multi-methods survey, health-care workers in New Zealand, were invited via a multimodal recruitment strategy to complete a survey regarding use of PPE during the first COVID-19 wave. Gender question options were male, female, gender diverse, or prefer not to say. Demographic differences in self-reported PPE reuse and acceptability were examined. The survey included closed (single-response, multi-response, ranking, and Likert-scale questions) and open-text questions. Any open-text comments were analysed with thematic analysis. The survey was built and deployed using Qualtrics software.

FINDINGS

1411 health-care workers completed the survey between Oct 7 and Nov 30, 2020. 1397 participants had gender data available (1140 [82%] female and 257 [18%] male) and 995 (74%) of 1347 were of New Zealand European ethnicity. PPE reuse was common and reported by 628 (45%) of the 1411 participants, with 396 (63%) of the 628 reporting reusing PPE multiple times in 1 day. Acceptability of the concept of PPE disinfection for potential reuse was high overall (1196 [85%] of 1411) but varied depending on the type of PPE. Thematic analysis confirmed that PPE reuse was already occurring and respondents recognised the potential benefits of reduced medical wastage and increased PPE supply. Important caveats for consideration included the availability of scientific evidence, level of negotiated risk, and trust in the organisation undertaking PPE disinfection, with clear communication about decontamination processes being crucial to acceptability.

INTERPRETATION

PPE reuse occurred frequently during the first wave of COVID-19 in New Zealand. Although support for the disinfection of PPE for reuse was high, the success of any future programmes to reuse PPE will require meaningful engagement and clear communication with health-care workers. Further research into PPE disinfection safety and logistics is warranted, alongside the development of standard operating procedures and clearly communicated policies for the end user, should this more sustainable health-care practice be planned for adoption in certain settings.

FUNDING

New Zealand Ministry of Business, Innovation and Employment (COVID-19 Innovation Acceleration Fund) and the Medical Assurance Society Foundation.

Mapping the maternal vaccination journey and influencing factors for Māori women in Aotearoa New Zealand: a qualitative study

Introduction Uptake of maternal vaccinations (MVs) is suboptimal in Aotearoa New Zealand, particularly for Māori. Aim To describe Māori women's journeys regarding maternal pertussis and influenza vaccinations and explore influences on uptake. Methods Semi-structured interviews were conducted in Waikato, Aotearoa New Zealand, with pregnant or recently pregnant Māori women, and separately with Māori healthcare professionals (HCPs) to understand women's decisions regarding MVs and enablers and barriers to uptake. Results Nine women and nine HCPs were interviewed. Verbal communications from midwives, general practice and pharmacy strongly influenced women's journeys. Women's decisions appeared largely straight-forward, with influences including awareness, knowledge, underlying beliefs and previous MVs. Enablers for MV uptake included HCPs' discussions, pro-vaccination beliefs, and accessibility. Barriers for MV uptake included poverty (and transport), lack of awareness, insufficient knowledge of benefits, late presentation to the midwife and other commitments or challenges in the women's lives affecting prioritisation of the vaccine. Misconceptions, seasonality, and lower HCP emphasis impaired influenza vaccination uptake. Discussion With multiple barriers to accessing MVs, HCPs who see pregnant women are the primary resource to improve awareness, knowledge, and access through kōrero (discussions) with the woman and, where possible, being able to administer the vaccinations. These HCPs need to be well-informed, aware of likely concerns women may have and how to address them, encourage these discussions and preferably be trusted.

The epidemiology of aseptic meningitis in New Zealand children from 1991 to 2020

AIM

Aseptic meningitis, including culture negative and viral meningitis, contributes a significant health-care burden, including unnecessary antibiotic use and hospitalisation to treat possible bacterial meningitis. This study analysed aseptic meningitis hospitalisations in New Zealand (NZ) children over 29 years.

METHODS

In this population-based study, aseptic meningitis hospitalisations in NZ children <15 years old were analysed from 1991 to 2020. Incident rate ratios were calculated using Poisson regression models. Variations in hospitalisations by age, year, sex, ethnicity, geographical region and socio-economic deprivation were analysed.

RESULTS

There were 5142 paediatric aseptic meningitis hospitalisations from 1991 to 2020. Most were unspecified viral meningitis (64%), followed by enterovirus (29%). Hospitalisation rates varied annually with a median of 18.4/100 000 children including a peak in 2001 of 56.4/100 000 (51.7-61.6). From 2002 to 2019, rates increased by 8.4%/year (7.2-9.5%) in infants <90 days old but decreased in all other age groups. In 2020, a reduction in hospitalisations to 9.6/100 000 (7.9-11.8) occurred, and in infants <90 days old were 0.37 times expected. Hospitalisations were 1.50 times (1.49-1.68) higher in males than females; higher in children of Māori (P < 0.001) and Pacific (P < 0.001) versus European ethnicity; and higher for children living in the most (2.44 times, (2.16-2.75)) versus least deprived households; and in northern versus southern NZ.

CONCLUSIONS

Aseptic meningitis hospitalisations increased in young infants during 29 years of surveillance, apart from 2020 when admissions reduced during the COVID-19 pandemic. In contrast, hospitalisations decreased in children aged >1 year. Further investigation into reasons for higher admissions by ethnic group, geographical location and increased deprivation are required.

Learning from healthcare workers' experiences with personal protective equipment during the COVID-19 pandemic in Aotearoa/New Zealand: a thematic analysis and framework for future practice

OBJECTIVES

Safety and welfare are critical as pandemic-related demands on the healthcare workforce continue. Access to personal protective equipment (PPE) has been a central concern of healthcare workers throughout the COVID-19 pandemic. Against the backdrop of an already strained healthcare system, our study aimed to explore the experiences of healthcare workers with PPE during the first COVID-19 surge (February-June 2020) in Aotearoa/New Zealand (NZ). We also aimed to use these findings to present a strengths-based framework for supporting healthcare workers moving forward.

DESIGN

Web-based, anonymous survey including qualitative open-text questions. Questions were both closed and open text, and recruitment was multimodal. We undertook inductive thematic analysis of the dataset as a whole to explore prominent values related to healthcare workers' experiences.

SETTING

October-November 2020 in New Zealand.

PARTICIPANTS

1411 healthcare workers who used PPE during surge one of the COVID-19 pandemic.

RESULTS

We identified four interactive values as central to healthcare workers' experiences: transparency, trust, safety and respect. When healthcare workers cited positive experiences, trust and safety were perceived as present, with a sense of inclusion in the process of stock allocation and effective communication with managers. When trust was low, with concerns over personal safety, poor communication and lack of transparency resulted in perceived lack of respect and distress among respondents. Our proposed framework presents key recommendations to support the health workforce in terms of communication relating to PPE supply and distribution built on those four values.

CONCLUSIONS

Healthcare worker experiences with PPE access has been likened to 'the canary in the coalmine' for existing health system challenges that have been exacerbated during the COVID-19 pandemic. The four key values identified could be used to improve healthcare worker experience in the future.

Determinants of exclusive breastfeeding for wāhine Māori

AIM

Breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) requiring protection and promotion. This study identifies determinants of exclusive breastfeeding in wāhine Māori.

METHODS

Wāhine Māori enrolled in the Growing Up in New Zealand child cohort study participated (n=1060). Exclusive breastfeeding duration was self-reported. Hierarchical regression analyses were framed by a model of Māori health and wellbeing.

RESULTS

Most wāhine Māori initiated breastfeeding (96%), with 12% exclusively breastfeeding for six or more months. Wāhine Māori had increased odds of exclusively breastfeeding for six or more months if they: thought it best to breastfeed for >6 months (adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI)=1.05-3.78); thought returning to work would not (aOR=2.17, 95% CI=1.17-4.24) or may (aOR=4.25, 95% CI=1.86-9.85) limit breastfeeding; were experienced mothers (aOR=2.55, 95% CI=1.35-5.06); or were undecided about vaccination (aOR=3.16, 95% CI=1.55-6.39). Exclusive breastfeeding for six or more months was less likely if mothers experienced depression during pregnancy (aOR=0.47, 95% CI=0.20-0.99) or viewed cultural traditions/practices as "fairly important" (aOR=0.53, 95% CI=0.27-0.99), compared to "very important".

CONCLUSION

Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Te Ao Māori (Māori worldview) and tikanga Māori, antenatal depression and vaccine indecision. Interventions delivered within a Kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand.

Surviving versus thriving: The wellbeing of primary school aged children in Tonga

AIM

To enable improvements in global child health, the focus must move beyond child survival to child wellbeing. In the Pacific Islands, the wellbeing of children has received little attention. This study aimed to investigate the wellbeing of children from three primary schools in Tonga.

METHODS

A cross-sectional survey was completed in three primary schools in Nuku'alofa with children aged 5-15 years. The study participants (256 children, 143 caregivers) completed the Child Health and Illness Profile - Child Edition, CHIP-CE (Version 1.0).

RESULTS

On average, >70% of children and caregivers described home and school environments as positive. From the children's reports, boys had significantly lower scores for risk avoidance than girls (3.40 vs. 3.73, P < 0.001). Children aged 5-7 versus 8-15 years had significantly lower scores for satisfaction (3.63 vs. 3.92, P = 0.002), resilience (3.34 vs. 3.56, P = 0.016) and achievement (3.25 vs. 3.62, P = 0.002). From the caregivers' report, girls had significantly lower scores for academic performance than boys (3.60 vs. 3.81, P = 0.04). Boys had significantly lower scores for individual risk association compared to girls (3.93 vs. 4.29, P = 0.01). Overall CHIP-CE scores were lower than those of comparable populations in the West, while at the same time protective factors were documented.

CONCLUSIONS

Understanding child wellbeing in the Pacific is critical for strengthening protective factors known to mitigate poor child health outcomes. Continuing to base global child health success on child survival alone misses opportunities for improving the wellbeing of nations.

Childhood pneumonia in New Zealand

While deaths from pneumonia during childhood in New Zealand (NZ) are now infrequent, childhood pneumonia remains a significant cause of morbidity. In this viewpoint, we describe pneumonia epidemiology in NZ and identify modifiable risk factors. During recent decades, pneumonia hospitalisation rates decreased, attributable in part to inclusion of pneumococcal conjugate vaccine in NZ's immunisation schedule. Irrespective of these decreases, pneumonia hospitalisation rates are four times higher for Pacific and 60% higher for Māori compared with children of other ethnic groups. Consistent with other developed countries, hospitalisation rates for pneumonia with pleural empyema increased in NZ during the 2000s. Numerous factors contribute to childhood pneumonia acquisition, hospitalisation and morbidity in NZ include poor quality living environments, malnutrition during pregnancy and early childhood, incomplete and delayed vaccination during pregnancy and childhood and variable primary and secondary care management. To reduce childhood pneumonia disease burden, interventions should focus on addressing modifiable risk factors for pneumonia. These include using non-polluting forms of household heating; decreasing cigarette smoke exposure; reducing household acute respiratory infection transmission; improving dietary nutritional content and nutrition during pregnancy and early childhood; breastfeeding promotion; vaccination during pregnancy and childhood and improving the quality of and decreasing the variance in primary and secondary care management of pneumonia.

Sensitivity and specificity of surveillance case definitions in detection of influenza and respiratory syncytial virus among hospitalized patients, New Zealand, 2012-2016

BACKGROUND

The WHO is exploring the value of adding RSV testing to existing influenza surveillance systems to inform RSV control programs. We evaluate the usefulness of four commonly used influenza surveillance case-definitions for influenza and RSV surveillance.

METHODS

SHIVERS, a multi-institutional collaboration, conducted surveillance for influenza and RSV in four New Zealand hospitals. Nurses reviewed admission logs, enrolled patients with suspected acute respiratory infections (ARI), and obtained nasopharyngeal swabs for RT-PCR. We compared the performance characteristics for identifying laboratory-confirmed influenza and RSV severe acute respiratory infection (SARI), defined as persons admitted with measured or reported fever and cough within 10 days of illness, to three other case definitions: 1. reported fever and cough or shortness of breath, 2. cough and shortness of breath, or 3. cough.

RESULTS

During April-September 2012-2016, SHIVERS identified 16,055 admissions with ARI; of 6374 cases consented and tested for influenza or RSV, 5437 (85%) had SARI and 937 (15%) did not. SARI had the highest specificity in detecting influenza (40.6%) and RSV (40.8%) but the lowest sensitivity (influenza 78.8%, RSV 60.3%) among patients of all ages. Cough or shortness of breath had the highest sensitivity (influenza 99.3%, RSV 99.9%) but the lowest specificity (influenza 1.6%, RSV 1.9%). SARI sensitivity among children aged <3 months was 60.8% for influenza and 43.6% for RSV-both lower than in other age groups.

CONCLUSIONS

While SARI had the highest specificity, its sensitivity was limited, especially among children aged <3 months. Cough or shortness of breath was the most sensitive.

Increasing Uptake of Maternal Pertussis Vaccinations through Funded Administration in Community Pharmacies

Although maternal pertussis vaccination is recommended, uptake is suboptimal in New Zealand (NZ), despite full funding in general practice and hospitals. We determined whether funding maternal pertussis vaccination in community pharmacy increases its uptake. Pertussis vaccination during pregnancy was compared between non-contiguous, demographically similar regions of NZ. The pertussis vaccine was funded at pharmacies from Nov 2016 in one NZ region (Waikato), but not in comparator regions (Northland, Hawkes Bay). Vaccinations during pregnancy were determined from the National Immunisation Register, general practice and pharmacy claims data, and a maternity database. Comparisons were made using adjusted odds ratios (OR) and 95% confidence intervals (CI) for Nov 2015 to Oct 2016 versus Nov 2016 to Oct 2019. The odds of pregnancy pertussis vaccination increased in the post-intervention versus pre-intervention period with this increase being larger (p = 0.0014) in the intervention (35% versus 21%, OR = 2.07, 95% CI 1.89–2.27) versus the control regions (38% versus 26%, OR = 1.67, 95% CI 1.52–1.84). Coverage was lower for Māori versus non-Māori, but increased more for Māori in the intervention versus control regions (117% versus 38% increase). It was found that funding maternal pertussis vaccination in pharmacy increases uptake, particularly for Māori women. Measures to increase coverage should include reducing barriers to vaccines being offered by non-traditional providers, including pharmacies.

Influences on Pregnant Women's and Health Care Professionals' Behaviour Regarding Maternal Vaccinations: A Qualitative Interview Study

The uptake of maternal influenza and pertussis vaccinations is often suboptimal. This study explores the factors influencing pregnant women's and health care professionals' (HCPs) behaviour regarding maternal vaccinations (MVs). Pregnant/recently pregnant women, midwives, pharmacists and general practice staff in Waikato, New Zealand, were interviewed. The analysis used the behaviour change wheel model. Interviews of 18 women and 35 HCPs revealed knowledge about MVs varied with knowledge deficiencies hindering the uptake, particularly for influenza vaccination. HCPs, especially midwives, were key in raising women's awareness of MVs. Experience with vaccinating, hospital work (for midwives) and training increased HCPs' knowledge and proactivity about MVs. A "woman's choice" philosophy saw midwives typically encouraging women to seek information and make their own decision. Women's decisions were generally based on knowledge, beliefs, HCPs' emphasis and their perceived risk, with little apparent influence from friends, family, or online or promotional material. General practice's concentration on children's vaccination and minimal antenatal contact limited proactivity with MVs. Busyness and prioritisation appeared to affect HCPs' proactivity. Multi-pronged interventions targeting HCPs and pregnant women and increasing MV access are needed. All HCPs seeing pregnant women should be well-informed about MVs, including how to identify and address women's questions or concerns about MVs to optimise uptake.

Vaccination information fathers receive during pregnancy and determinants of infant vaccination timeliness

The information fathers receive about infant vaccination may influence their decision to vaccinate. We describe fathers' sources of vaccination information and paternal determinants of timely infant vaccinations. Participants were from a child cohort study in New Zealand. The child cohort was established by enrolling pregnant women and their partners. During pregnancy, fathers (n = 4017) of the cohort children born 2009-2010 described information sources that encouraged or discouraged infant vaccination. The National Immunization Register provided infant vaccination data. Independent associations of the vaccination information received by fathers with the timeliness of their infant's vaccination were determined using multivariable logistic regression. Associations were described using adjusted odds ratios and 95% confidence intervals. One-third of fathers (1430/4017 [36%]) recalled receiving vaccination information, 64% of which encouraged vaccination. Most infants (2900/4017 [72%]) received all their vaccinations on time, however only 58% of Māori infants were vaccinated on time. Paternal determinants of vaccination timeliness were the father receiving discouraging or conflicting information about vaccination, father's ethnicity, father's vaccination hesitancy, and whether the mother received vaccination information. To improve vaccination uptake and timeliness, a vaccination conversation with mothers, fathers and whānau could be included in routine antenatal care, informing and supporting decision-making, and addressing concerns. Vaccination education should address present and historic distrust of the health system. Framing vaccination within a Māori model of health and including fathers and whānau in decision-making will address vaccination inequities in New Zealand.

Vision screening in New Zealand pre-school children: Is it equitable?

AIM

This study aimed to investigate the variability by ethnicity, socio-economic status and location in coverage and testability of the universal B4 School Check vision screening in children aged 4-5 years in New Zealand.

METHODS

Aggregated data from 1 July 2011 to 30 June 2015 were sourced from the Statistics New Zealand Integrated Data Infrastructure. Sourced data were attendance at vision screening and record of visual acuity measurement stratified by ethnicity, socio-economic status and region. Children who attended screening were compared with the eligible population (n = 252 279) to calculate coverage. Testability was determined by comparing the children with a recorded visual acuity measurement in each eye with those who attended screening.

RESULTS

Overall vision screening coverage was 89.5% and testability was 97.8%. Ethnic differences were evident for coverage (85.7% in Pacific children, 92.5% in European children) and testability (96.4% in Māori children, 98.4% in European children). Socio-economic differences were also observed for coverage (86.4% in most deprived areas, 92.4% in least deprived), testability (most deprived 96.3%, least deprived 98.7%) and by region (coverage range of 80.4-96.4% and testability range of 93.2-99.3%).

CONCLUSIONS

Significant disparities exist in vision screening coverage and testability for New Zealand pre-school children. Equity-focused initiatives are required to improve outcomes for children from Māori and Pacific families, and those from households in lower socio-economic areas. Understanding region-specific challenges and successes could support more equitable access to vision screening between regions. Further research is required to determine sources of inequities and to investigate interactions between ethnicity, socio-economic status and location.

Vitamin D status at birth and acute respiratory infection hospitalisation during infancy

BACKGROUND

Hospital admission for acute respiratory infections (ARIs) during early childhood is a global public health concern. Vitamin D deficiency is prevalent during pregnancy and infancy. Evidence indicates that vitamin D supplementation prevents ARIs.

OBJECTIVES

To determine whether vitamin D deficiency at birth is associated with ARI hospitalisations during infancy.

METHODS

We performed a nested case-control study in children aged 0-12 months. Cases had ≥1 ARI hospitalisation and 4 controls were individually matched to each case. Newborn 25(OH)D concentration was measured on dried blood spots using two-dimensional liquid chromatography-tandem mass spectrometry. Hospital admissions were measured using health care records. Median serum 25(OH)D concentration in cases and controls was compared, and covariates of ARI hospitalisation during infancy were assessed using conditional logistic regression analysis.

RESULTS

Six per cent of the cohort (n = 384) had an ARI hospitalisation during infancy, and 1536 controls were matched to cases. Median DBS [25(OH)D] was lower among ARI cases than controls (46 nmol/l vs. 61 nmol/L). Median 25(OH)D levels were lower for those hospitalised ≥2 times (47, IQR 36, 58) vs. those hospitalised once (52, IQR 42, 62) vs. the controls and also lower for those who stayed in the hospital for ≥3 days (45, IQR 36, 54) vs 1-2 days (48, IQR 38, 59) compared to the controls. After adjustment for season of birth and covariates describing demographic, antenatal, perinatal, and infant characteristics, DBS 25(OH)D concentration (<50 nmol/L) at birth was associated with increased odds of ARI hospitalisation during infancy (odds ratio 2.20, 95% confidence interval 1.48, 2.91).

CONCLUSIONS

Vitamin D deficiency at birth is associated with increased odds of ARI hospitalisations in infants. The findings have implications for a developed country like New Zealand where vitamin D supplementation is not routinely recommended and the burden of ARI hospitalisation in young children is high.

Respiratory Syncytial Virus-Associated Hospitalizations Among Adults With Chronic Medical Conditions

BACKGROUND

In contrast with respiratory disease caused by influenza, information on the risk of respiratory syncytial virus (RSV) disease among adults with chronic medical conditions (CMCs) is limited.

METHODS

We linked population-based surveillance of acute respiratory illness hospitalizations to national administrative data to estimate seasonal RSV hospitalization rates among adults aged 18-80 years with the following preexisting CMCs: chronic obstructive pulmonary disease (COPD), asthma, congestive heart failure (CHF), coronary artery disease (CAD), cerebrovascular accidents (CVA), diabetes mellitus (DM), and end-stage renal disease (ESRD). Age- and ethnicity-adjusted rates stratified by age group were estimated.

RESULTS

Among 883 999 adult residents aged 18-80 years, 281 RSV-positive hospitalizations were detected during 2012-2015 winter seasons. Across all ages, RSV hospitalization rates were significantly higher among adults with COPD, asthma, CHF, and CAD compared with those without each corresponding condition. RSV hospitalization rates were significantly higher among adults with ESRD aged 50-64 years and adults with DM aged 18-49 years and 65-80 years compared with adults in each age group without these conditions. No increased risk was seen for adults with CVA. The CMC with the highest risk of RSV hospitalization was CHF (incidence rate ratio [IRR] range, 4.6-36.5 across age strata) and COPD (IRR range, 9.6-9.7). Among RSV-positive adults, CHF and COPD were independently associated with increased length of hospital stay.

CONCLUSIONS

Adults with specific CMCs are at increased risk of RSV hospitalizations. Age affects this relationship for some CMCs. Such populations maybe relevant for future RSV prevention strategies.

Modelling the impact of respiratory syncytial virus (RSV) vaccine and immunoprophylaxis strategies in New Zealand

BACKGROUND

Mathematical models of respiratory syncytial virus (RSV) transmission can help describe seasonal epidemics and assess the impact of potential vaccines and immunoprophylaxis with monoclonal antibodies (mAb).

METHODS

We developed a deterministic, compartmental model for RSV transmission, which was fitted to population-based RSV hospital surveillance data from Auckland, New Zealand. The model simulated the introduction of either a maternal vaccine or a seasonal mAb among infants aged less than 6 months and estimated the reduction in RSV hospitalizations for a range of effectiveness and coverage values.

RESULTS

The model accurately reproduced the annual seasonality of RSV epidemics in Auckland. We found that a maternal vaccine with effectiveness of 30-40% in the first 90 days and 15-20% for the next 90 days could reduce RSV hospitalizations by 18-24% in children younger than 3 months, by 11-14% in children aged 3-5 months, and by 2-3% in children aged 6-23 months. A seasonal infant mAb with 40-60% effectiveness for 150 days could reduce RSV hospitalizations by 30-43%, 34-48% and by 14-21% in children aged 0-2 months, 3-5 months and 6-23 months, respectively.

CONCLUSIONS

Our results suggest that either a maternal RSV vaccine or mAb would effectively reduce RSV hospitalization disease burden in New Zealand. Overall, a seasonal mAb resulted in a larger disease prevention impact than a maternal vaccine.

Protein Intake, IGF-1 Concentrations, and Growth in the Second Year of Life in Children Receiving Growing Up Milk - Lite (GUMLi) or Cow's Milk (CM) Intervention

The relationship of protein intake with insulin-like growth factor 1 (IGF-1) concentrations in well-nourished children during the second year of life is poorly understood. The aim of this study was to explore the effect of a reduced-protein Growing Up Milk Lite (GUMLi) or unfortified cow's milk (CM) on protein intake, growth, and plasma IGF-1 at 2 y. An exploratory analysis of a sub-sample of Auckland-based children (n = 79) in the GUMLi trial (a double-blind, randomised control trial, N = 160) completed in Auckland and Brisbane (2015-2017) was conducted. One-year old children were randomised to receive a reduced-protein GUMLi (1.7 g protein/100 mL) or a non-fortified CM (3.1 g protein/100 mL) for 12 months. Blood sampling and anthropometric measurements were made at 1 and 2 y. Diet was assessed using a validated food frequency questionnaire. Total protein intake (g/d) from all cow's milk sources was 4.6 g (95% CI: -6.7, -2.4; p < 0.005) lower in the GUMLi group after 12 months of the intervention, with a significant group-by-time interaction (p = 0.005). Length-for-age (LAZ) and weight-for-length (WLZ) z-scores did not differ between groups, however, mean body fat % (BF%) was 3.2% (95%CI: -6.2, -0.3; p = 0.032) lower in the GUMLi group at 2 y. There was no difference between the intervention groups in relation to IGF-1 and IGF-BP3 (p = 0.894 and 0.698, respectively), with no group-by-sex interaction. After combining the groups, IGF-1 concentration at 2 y was positively correlated with parameters of growth (all p < 0.05), total cow's milk intake (p = 0.032) after adjusting for sex, breastfeeding status, and gestation. Randomisation to a reduced protein GUMLi resulted in small reduction in %BF and lower total protein intakes but had no effect on growth. Plasma IGF-1 concentrations were independently associated with total protein intake from cow's milk at 2 y, highlighting a potential area of the diet to target when designing future protein-related nutrition interventions. Clinical Trial Registration: Australian New Zealand Clinical Trials Registry number: ACTRN12614000918628. Date registered: 27/08/2014.

Participants' and caregivers' experiences of a multidisciplinary programme for healthy lifestyle change in Aotearoa/New Zealand: a qualitative, focus group study

OBJECTIVE

Child and adolescent obesity continues to be a major health issue internationally. This study aims to understand the views and experiences of caregivers and participants in a child and adolescent multidisciplinary programme for healthy lifestyle change.

DESIGN

Qualitative focus group study.

SETTING

Community-based healthy lifestyle intervention programme in a mixed urban-rural region of Aotearoa/New Zealand.

PARTICIPANTS

Parents/caregivers (n=6) and children/adolescents (n=8) who participated in at least 6 months of an assessment and weekly session, family-based community intervention programme for children and adolescents affected by obesity.

RESULTS

Findings covered participant experiences, healthy lifestyle changes due to participating in the programme, the delivery team, barriers to engagement and improvements. Across these domains, four key themes emerged from the focus groups for participants and their caregivers relating to their experience: knowledge-sharing, enabling a family to become self-determining in their process to achieve healthy lifestyle change; the importance of connectedness and a family-based programme; the sense of a collective journey and the importance of a nonjudgemental, respectful welcoming environment. Logistical challenges and recommendations for improvement were also identified.

CONCLUSIONS

Policymakers need to consider the experiences of participants alongside quantitative outcomes when informing multidisciplinary intervention programmes for children and adolescents affected by obesity.Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR):12611000862943; Post-results.

Vitamin D supplementation to prevent acute respiratory infections: a systematic review and meta-analysis of aggregate data from randomised controlled trials

BACKGROUND

A 2017 meta-analysis of data from 25 randomised controlled trials (RCTs) of vitamin D supplementation for the prevention of acute respiratory infections (ARIs) revealed a protective effect of this intervention. We aimed to examine the link between vitamin D supplementation and prevention of ARIs in an updated meta-analysis.

METHODS

For this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov registry for studies listed from database inception to May 1, 2020. Double-blind RCTs of vitamin D₃, vitamin D₂, or 25-hydroxyvitamin D (25[OH]D) supplementation for any duration, with a placebo or low-dose vitamin D control, were eligible if they had been approved by a research ethics committee, and if ARI incidence was collected prospectively and prespecified as an efficacy outcome. Studies reporting results of long-term follow-up of primary RCTs were excluded. Aggregated study-level data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. Using the proportion of participants in each trial who had one or more ARIs, we did a random-effects meta-analysis to obtain pooled odds ratios (ORs) and 95% CIs to estimate the effect of vitamin D supplementation on the risk of having one or more ARIs (primary outcome) compared with placebo. Subgroup analyses were done to estimate whether the effects of vitamin D supplementation on the risk of ARI varied according to baseline 25(OH)D concentration (<25 nmol/L vs 25·0-49·9 nmol/L vs 50·0-74·9 nmol/L vs >75·0 nmol/L), vitamin D dose (daily equivalent of <400 international units [IU] vs 400-1000 IU vs 1001-2000 IU vs >2000 IU), dosing frequency (daily vs weekly vs once per month to once every 3 months), trial duration (≤12 months vs >12 months), age at enrolment (<1·00 years vs 1·00-15·99 years vs 16·00-64·99 years vs ≥65·00 years), and presence versus absence of airway disease (ie, asthma only, COPD only, or unrestricted). Risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool. The study was registered with PROSPERO, CRD42020190633.

FINDINGS

We identified 1528 articles, of which 46 RCTs (75 541 participants) were eligible. Data for the primary outcome were obtained for 48 488 (98·1%) of 49 419 participants (aged 0-95 years) in 43 studies. A significantly lower proportion of participants in the vitamin D supplementation group had one or more ARIs (14 332 [61·3%] of 23 364 participants) than in the placebo group (14 217 [62·3%] of 22 802 participants), with an OR of 0·92 (95% CI 0·86-0·99; 37 studies; I²=35·6%, p_{heterogeneity}=0·018). No significant effect of vitamin D supplementation on the risk of having one or more ARIs was observed for any of the subgroups defined by baseline 25(OH)D concentration. However, protective effects of supplementation were observed in trials in which vitamin D was given in a daily dosing regimen (OR 0·78 [95% CI 0·65-0·94]; 19 studies; I²=53·5%, p_{heterogeneity}=0·003), at daily dose equivalents of 400-1000 IU (0·70 [0·55-0·89]; ten studies; I²=31·2%, p_{heterogeneity}=0·16), for a duration of 12 months or less (0·82 [0·72-0·93]; 29 studies; I²=38·1%, p_{heterogeneity}=0·021), and to participants aged 1·00-15·99 years at enrolment (0·71 [0·57-0·90]; 15 studies; I²=46·0%, p_{heterogeneity}=0·027). No significant interaction between allocation to the vitamin D supplementation group versus the placebo group and dose, dose frequency, study duration, or age was observed. In addition, no significant difference in the proportion of participants who had at least one serious adverse event in the vitamin supplementation group compared with the placebo group was observed (0·97 [0·86-1·07]; 36 studies; I²=0·0%, p_{heterogeneity}=0·99). Risk of bias within individual studies was assessed as being low for all but three trials.

INTERPRETATION

Despite evidence of significant heterogeneity across trials, vitamin D supplementation was safe and overall reduced the risk of ARI compared with placebo, although the risk reduction was small. Protection was associated with administration of daily doses of 400-1000 IU for up to 12 months, and age at enrolment of 1·00-15·99 years. The relevance of these findings to COVID-19 is not known and requires further investigation.

FUNDING

None.

Childhood asthma in New Zealand: the impact of on-going socioeconomic disadvantage (2010-2019)

AIM

To document trends in number and cost of asthma hospital admissions and asthma prescriptions in children (0-14 years) from 2010-2019 in New Zealand.

METHOD

A retrospective analysis of public hospital admission and pharmaceutical prescription data.

RESULTS

The dataset included 39,731 hospitalisations with asthma as a discharge diagnosis and 5,512,856 prescriptions for asthma medication in children ≤14 years old. From 2010 to 2019, there was a 45% reduction in the number of asthma hospitalisations and an 18% reduction in prescriptions attributable to asthma. Declines were evident for both Māori and non-Māori children. However, Māori children were hospitalised with asthma at twice the rate of non-Māori children (7.2/1,000 versus 3.5/1,000, p<0.001), and a larger proportion of Māori children had an asthma readmission within 90 days of their first admission (18% versus 14%, p <0.001). Asthma admission rates for children from families living in the highest deprivation areas were, on average, 2.8 times higher than in the least deprived areas. We estimate that the combined cost of asthma hospitalisations and prescriptions was $165m. Of this, $103m was for hospital admissions and $62m was for prescriptions.

CONCLUSIONS

Although hospitalisations and prescriptions attributable to asthma have declined, there are clear inequities in the health outcomes of New Zealand children with asthma. Our analysis indicates that many New Zealand children, particularly Māori children and those living in areas of high deprivation, are not receiving levels of primary care for asthma that are consistent with prevention.

Diagnostic accuracy of the Parr vision test, single crowded Lea symbols and Spot vision screener for vision screening of preschool children aged 4-5 years in Aotearoa/New Zealand

PURPOSE

Preschool children in New Zealand undergo vision screening to detect amblyopia at 4-5 years of age. The current test, the Parr vision test, does not meet international visual acuity chart guidelines and has not been validated against other commonly used paediatric vision tests. New Zealand vision screening protocols are also not targeted for detecting other eye conditions such as uncorrected refractive error, which may affect school performance. We compared the Parr vision test with the single crowded Lea symbols and the Spot vision screener for detecting ocular pathology, refractive error and amblyopic risk factors in preschool children.

METHODS

A cross-sectional diagnostic accuracy study recruited children aged 4-5 years via convenience sampling from the University of Auckland Optometry Clinic and through primary schools in Auckland, New Zealand. Participants received vision screening with the three different instruments administered by a lay screener. Comprehensive eye examinations were completed by a paediatric optometrist to determine the presence of vision disorders.

RESULTS

Of 197 children who received a comprehensive eye examination, 14 (7.1%) had amblyopic risk factors and 43 (21.8%) had significant refractive error (15.7% with astigmatism, 9.1% with hyperopia). The sensitivity for detecting any ocular condition did not differ significantly between the tests (50.0% for Parr, 43.5% for Lea, 42.5% for Spot). Specificity was significantly lower for the Parr vision test (80.8%) than for the Lea symbols (93.4%) and Spot vision screener (98.0%). Adding the Spot vision screener to measurements of visual acuity significantly improved sensitivity in detecting any ocular condition with the Parr vision test (67.5% for Parr/Spot vs 50% for Parr alone), but not with the Lea symbols (52.5% for Lea/Spot vs 43.5% for Lea alone).

CONCLUSION

The sensitivity of the Parr vision test for detecting ocular conditions in preschool children does not vary significantly from that achieved by the Lea symbols or the Spot vision screener. However, current New Zealand vision screening protocols could be improved by expanding the target conditions to include significant refractive error and incorporating the use of the Spot vision screener to increase the accuracy with which children with refractive error are identified. Future research should include longitudinal studies to determine the effect of preschool vision screening on later ocular and academic outcomes.

Modifiable Early Childhood Risk Factors for Obesity at Age Four Years

Background: Childhood obesity is associated with an increased risk of adult obesity and related chronic disease. Our aim was to identify modifiable exposures that are independently associated with obesity in the preschool age group. Methods: A prospective cohort study of 5734 children in New Zealand with anthropometric measurements was completed at age 4.5 years. The modifiable exposures of interest, measured at age 9 months and 2 years, were: food security during infancy; and, at age 2 years, screen time; sleep duration; and takeaway food and soft drink intake. The risk of obesity independently associated with each exposure was determined using Binomial and Poisson regression and described using adjusted risk ratios (RRs) and 95% confidence intervals (CIs), after controlling for confounding variables including gender, ethnicity, birth weight, and mother's age. The probability of obesity given cumulative exposures to the four risk factors and the population attributable fraction (PAF) were estimated. Results: Lower food security during infancy (<mean study sample score; RR = 1.32; 95% CI : 1.06-1.64) and, at age 2 years, more screen time (>1 hour/day; RR = 1.22; 95% CI : 1.01-1.48), shorter sleep duration (≤11.5 hours/day; RR = 1.30; 95% CI : 1.05-1.61), and weekly to daily consumption of takeaway/soft drink (RR = 1.25, 95% CI : 1.00-1.57) were independently associated with an increased risk of obesity at age 4.5 years. The cumulative PAF for childhood obesity was 42.9%, under an ideal scenario where all risk factors were eliminated. Conclusion: Exposure to modifiable factors by age 2 years is associated with obesity at age 4.5 years. Interventions to prevent childhood obesity need to be effective during infancy.

Correspondence: systematic reviews do not always capture context of real-world intervention programmes for childhood obesity (response to Littlewood, et al., 2020 in BMC Public Health)

In a recent issue of the BMC Public Health journal, Littlewood et al. described the results of a systematic review of interventions to prevent or treat childhood obesity in Māori or Pacific Island peoples. They found that studies to date have had limited impact on improving health outcomes for Māori and Pacific Island peoples, and suggest this may be due to a lack of co-design principles in the conception of the various studies. Ensuring that interventions are appropriate for groups most affected by obesity is critical; however, some inaccuracies should be noted in the explanation of these findings. There is a risk with systematic reviews that the context of intervention trials is lost without acknowledging the associated body of literature for programmes that refer to the ongoing commitment to communities and groups most affected by obesity.

A systematic review of asthma case definitions in 67 birth cohort studies

BACKGROUND

Birth cohort studies are a valuable source of information about potential risk factors for childhood asthma. To better understand similarities and variations in findings between birth cohort studies, the methodologies used to measure asthma require consideration.

OBJECTIVE

To review and appraise the definitions of "asthma" used in birth cohort studies.

METHODS

A literature search, conducted in December 2017 in the MEDLINE database and birth cohort repositories, identified 1721 citations published since 1990. Information extracted included: study name, year of publication, sample size, sample age, prevalence of asthma (%), study region, source of information about asthma, measured outcome, and asthma case definition. A meta-analysis evaluated whether asthma prevalence in cohorts from Europe and North America varied by the studies' definition of asthma and by their data sources.

RESULTS

The final review included 67 birth cohorts, of which 48 (72%) were from Europe, 14 (21%) from North America, 3 (5%) from Oceania, 1 (1%) from Asia and 1 (1%) from South America. We identified three measured outcomes: "asthma ever", "current asthma", and "asthma" without further specification. Definitions of "asthma ever" were primarily based upon an affirmative parental response to the question whether the child had ever been diagnosed with asthma by a physician. The most frequently used definition of "current asthma" was "asthma ever" and either asthma symptoms or asthma medications in the last 12 months. This definition of "current asthma" was used in 16 cohorts. There was no statistically significant difference in the pooled asthma prevalence in European and North American cohorts that used questionnaire alone versus other data sources to classify asthma.

CONCLUSION

There is substantial heterogeneity in childhood asthma definitions in birth cohort studies. Standardisation of asthma case definitions will improve the comparability and utility of future cohort studies and enable meta-analyses.

Two-year outcomes of Whānau Pakari, a multi-disciplinary assessment and intervention for children and adolescents with weight issues: A randomized clinical trial

OBJECTIVE

To determine whether 12-month BMI SDS reductions persisted at 24 months in a multi-disciplinary assessment and intervention program for children and adolescents with obesity, and whether secondary outcomes improved.

METHODS

This was a community-based 12-month RCT in Aotearoa/New Zealand. Eligible participants were aged 5 to 16 years with BMI ≥98th centile or BMI >91st centile with weight-related comorbidities. The low-intensity control received comprehensive home-based baseline assessments and advice, and 6-monthly follow-up. The high-intensity intervention received the same assessments and advice, but also weekly multidisciplinary sessions. Primary outcome was BMI SDS at 12 months. Secondary outcomes included cardiovascular and metabolic markers.

RESULTS

121 participants (60% of participants at baseline) were assessed at 24 months. BMI SDS reduction at 12 months was lost at 24 months in the modified intention-to-treat analysis [Control -0.03 (95%CI -0.14, 0.09) and Intervention -0.02 (-0.12, 0.08); P = .93]. However, sweet drink intake was reduced, water intake increased, and there were improvements in cardiovascular fitness in the high-intensity intervention. ≥70% attendance in the high-intensity intervention resulted in a persistent BMI SDS reduction of -0.22 after 24 months (95%CI -0.38, -0.06).

CONCLUSIONS

This trial was negative in terms of primary outcome at 24 months. However, high engagement led to sustained treatment effect, and there were multiple improvements in health measures.

Physical Conflict During Pregnancy: A Socioecological, Cross-Cultural Examination of Risk and Protective Factors for New Zealand Women

Participants were 5,831 women in their third trimester of pregnancy, part of a large, longitudinal, pre-birth national cohort study. Women reported on their experience of pushing and shoving, throwing or breaking objects within their relationship over the past month. Univariable regression models examined the association of a large number of potential risk and protective factors. Those significant at the univariable level were carried forward into final multivariable analyses, stratified by New Zealand's four main ethnic groups: European, Māori, Pacific, and Asian peoples. Relationship commitment, reduced family cohesion, and perceived stress were associated with increased risk across ethnic groups.

Vitamin D supplementation to prevent acute respiratory infections: systematic review and meta-analysis of aggregate data from randomised controlled trials

BACKGROUND

A 2017 meta-analysis of data from 25 randomised controlled trials of vitamin D supplementation for the prevention of acute respiratory infections revealed a protective effect of the intervention. Since then, 20 new RCTs have been completed.

METHODS

Systematic review and meta-analysis of data from randomised controlled trials (RCTs) of vitamin D for ARI prevention using a random effects model. Pre-specified sub-group analyses were done to determine whether effects of vitamin D on risk of ARI varied according to baseline 25-hydroxyvitamin D (25[OH]D) concentration or dosing regimen. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and the ClinicalTrials.gov registry from inception to 1st May 2020. Double-blind RCTs of supplementation with vitamin D or calcidiol, of any duration, were eligible if they were approved by a Research Ethics Committee and if ARI incidence was collected prospectively and pre-specified as an efficacy outcome. Aggregate data, stratified by baseline 25(OH)D concentration, were obtained from study authors. The study was registered with PROSPERO (no. CRD42020190633).

FINDINGS

We identified 45 eligible RCTs (total 73,384 participants). Data were obtained for 46,331 (98.0%) of 47,262 participants in 42 studies, aged 0 to 95 years. For the primary comparison of vitamin D supplementation vs. placebo, the intervention reduced risk of ARI overall (Odds Ratio [OR] 0.91, 95% CI 0.84 to 0.99; P for heterogeneity 0.01). No statistically significant effect of vitamin D was seen for any of the sub-groups defined by baseline 25(OH)D concentration. However, protective effects were seen for trials in which vitamin D was given using a daily dosing regimen (OR 0.75, 95% CI 0.61 to 0.93); at daily dose equivalents of 400-1000 IU (OR 0.70, 95% CI 0.55 to 0.89); and for a duration of ≤12 months (OR 0.82, 95% CI 0.72 to 0.93). No significant interaction was seen between allocation to vitamin D vs. placebo and dose frequency, dose size, or study duration. Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (OR 0.97, 95% CI 0.86 to 1.09). Risk of bias within individual studies was assessed as being low for all but three trials. A funnel plot showed left-sided asymmetry (P=0.008, Egger's test).

INTERPRETATION

Vitamin D supplementation was safe and reduced risk of ARI, despite evidence of significant heterogeneity across trials. Protection was associated with administration of daily doses of 400-1000 IU vitamin D for up to 12 months. The relevance of these findings to COVID-19 is not known and requires investigation.

FUNDING

None.

Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand

Stringent nonpharmaceutical interventions (NPIs) such as lockdowns and border closures are not currently recommended for pandemic influenza control. New Zealand used these NPIs to eliminate coronavirus disease 2019 during its first wave. Using multiple surveillance systems, we observed a parallel and unprecedented reduction of influenza and other respiratory viral infections in 2020. This finding supports the use of these NPIs for controlling pandemic influenza and other severe respiratory viral threats.

Multimorbidity in Early Childhood and Socioeconomic Disadvantage: Findings From a Large New Zealand Child Cohort

OBJECTIVE

In contrast with multimorbidity during adulthood, the relationship of childhood multimorbidity with socioeconomic position (SEP) is poorly understood. We aimed to describe early childhood multimorbidity and investigate the relationship of this with SEP.

METHODS

Within a diverse prospective child cohort study, we determined associations of SEP with multimorbidity (defined as the presence of 2 or more chronic conditions) at age 2 years. Maternal SEP was ranked into 5 categories using an index constructed from variables collected antenatally describing maternal education, employment, financial stress, beneficiary status, housing tenure, overcrowding, and residential mobility. Missing values were handled using multiple imputation with chained equations. Independent associations of SEP with multimorbidity were described using adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Of the 6822 women and 6853 children who were enrolled into the cohort study, 5737 (84%) mother-child dyads had complete antenatal data and were interviewed at age 2 years. Of these 5737, for 3826 (67%) dyads, there were complete data for all variables. Multimorbidity was present in 374/3838 (9.7%) of the cohort children. After multiple imputation and adjustment for maternal ethnicity, smoking, poor health, depressive symptoms, and child gender, the odds of multimorbidity being present were increased for children of mothers in the most (OR 1.74, 95% CI 1.16-2.59) and second most (OR 1.43, 95% CI 1.00-2.04) versus the least disadvantaged group.

CONCLUSION

The odds of multimorbidity are increased for children whose mothers have lower SEP. Cumulative socioeconomic disadvantage increases the potential for a chronic illness trajectory to develop in early childhood.

The health and economic burden of respiratory syncytial virus associated hospitalizations in adults

Background

Respiratory syncytial virus (RSV) is increasingly recognized as an important cause of illness in adults; however, data on RSV disease and economic burden in this age group remain limited. We aimed to provide comprehensive estimates of RSV disease burden among adults aged ≥18 years.

Methods

During 2012–2015, population-based, active surveillance of acute respiratory infection (ARI) hospitalizations enabled estimation of the seasonal incidence of RSV hospitalizations and direct health costs in adults aged ≥18 years in Auckland, New Zealand.

Results

Of 4,600 ARI hospitalizations tested for RSV, 348 (7.6%) were RSV positive. The median (interquartile range) length of hospital stay for RSV positive patients was 4 (2–6) days. The seasonal incidence rate (IR) of RSV hospitalizations, corrected for non-testing, was 23.6 (95% confidence intervals [CI] 21.0–26.1) per 100,000 adults aged ≥18 years. Hospitalization risk increased with age with the highest incidence among adults aged ≥80 years (IR 190.8 per 100,000, 95% CI 137.6–244.0). Being of Māori or Pacific ethnicity or living in a neighborhood with low socioeconomic status (SES) were independently associated with increased RSV hospitalization rates. We estimate RSV-associated hospitalizations among adults aged ≥18 years to cost on average NZD $4,758 per event.

Conclusions

RSV infection is associated with considerable disease and economic cost in adults. RSV disproportionally affects adult sub-groups defined by age, ethnicity, and neighborhood SES. An effective RSV vaccine or RSV treatment may offer benefits for older adults.

Vitamin D supplementation to prevent acute respiratory infections: individual participant data meta-analysis

BACKGROUND

Randomised controlled trials (RCTs) exploring the potential of vitamin D to prevent acute respiratory infections have yielded mixed results. Individual participant data (IPD) meta-analysis has the potential to identify factors that may explain this heterogeneity.

OBJECTIVES

To assess the overall effect of vitamin D supplementation on the risk of acute respiratory infections (ARIs) and to identify factors modifying this effect.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, ClinicalTrials.gov and the International Standard Randomised Controlled Trials Number (ISRCTN) registry.

STUDY SELECTION

Randomised, double-blind, placebo-controlled trials of supplementation with vitamin D₃ or vitamin D₂ of any duration having incidence of acute respiratory infection as a prespecified efficacy outcome were selected.

STUDY APPRAISAL

Study quality was assessed using the Cochrane Collaboration Risk of Bias tool to assess sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, completeness of outcome data, evidence of selective outcome reporting and other potential threats to validity.

RESULTS

We identified 25 eligible RCTs (a total of 11,321 participants, aged from 0 to 95 years). IPD were obtained for 10,933 out of 11,321 (96.6%) participants. Vitamin D supplementation reduced the risk of ARI among all participants [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.81 to 0.96; heterogeneity p < 0.001]. Subgroup analysis revealed that protective effects were seen in individuals receiving daily or weekly vitamin D without additional bolus doses (aOR 0.81, 95% CI 0.72 to 0.91), but not in those receiving one or more bolus doses (aOR 0.97, 95% CI 0.86 to 1.10; p = 0.05). Among those receiving daily or weekly vitamin D, protective effects of vitamin D were stronger in individuals with a baseline 25-hydroxyvitamin D [25(OH)D] concentration of < 25 nmol/l (aOR 0.30, 95% CI 0.17 to 0.53) than in those with a baseline 25(OH)D concentration of ≥ 25 nmol/l (aOR 0.75, 95% CI 0.60 to 0.95; p = 0.006). Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (aOR 0.98, 95% CI 0.80 to 1.20; p = 0.83). The body of evidence contributing to these analyses was assessed as being of high quality.

LIMITATIONS

Our study had limited power to detect the effects of vitamin D supplementation on the risk of upper versus lower respiratory infection, analysed separately.

CONCLUSIONS

Vitamin D supplementation was safe, and it protected against ARIs overall. Very deficient individuals and those not receiving bolus doses experienced the benefit. Incorporation of additional IPD from ongoing trials in the field has the potential to increase statistical power for analyses of secondary outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014013953.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A Qualitative Study of Views and Experiences of Women and Health Care Professionals about Free Maternal Vaccinations Administered at Community Pharmacies

Background: A policy to extend funding of maternal pregnancy influenza and pertussis vaccinations to community pharmacies could address low pregnancy vaccine uptake. The policy has been implemented in one region in New Zealand. This study explored the views and experiences of women eligible for the vaccines and health care professionals regarding funded maternal vaccinations in pharmacy. Methods: Women in late pregnancy or with an infant, and midwives, pharmacists, and general practice staff were selected purposively and interviewed regarding maternal vaccinations and the new policy, including their awareness and views of the funded vaccinations in pharmacies, and how this policy worked in practice. Enablers and barriers to vaccination by pharmacists were explored. Interviews were transcribed and analysed using a framework approach. Results: Fifty-three interviews were conducted. Most women and health care professionals viewed funded maternal vaccinations in pharmacies positively with respect to increasing awareness and providing delivery options. Many women received messages from pharmacies. Most pharmacies used posters, leaflets and/or verbal explanation to pregnant women to raise awareness of the vaccinations. Not all pharmacies provided these vaccinations, and frontline staff could help to raise awareness. Conclusion: Funded maternal vaccinations in pharmacies are generally well accepted and provide an opportunity to increase uptake and prevent disease.

Maternal Antenatal Depression and Early Childhood Sleep: Potential Pathways Through Infant Temperament

Objective

Maternal depression is associated with infant and child sleep patterns, and with infant temperament. Here, we examine whether infant temperament mediated an association between maternal antenatal depression and toddler sleep.

Method

Within the prebirth longitudinal cohort Growing Up in New Zealand, symptoms of antenatal and postnatal depression were measured in 5,568 women using the Edinburgh Postnatal Depression Scale (EPDS). Infant temperament was measured at age 9 months using the Very Short Form of Infant Behavior Questionnaire-Revised (IBQ-R VSF). Sleep duration and nighttime awakenings were reported by parents when children were 2 years old.

Results

Independent associations of maternal depression with child sleep patterns at age 2 years, adjusted for maternal demographics, physical health, family relationships, and child health and feeding, were determined using multivariate logistic regression analysis. The odds of having ≥2 nighttime awakenings were increased for children whose mothers had antenatal (1.36, 1.07–1.73) but not postnatal (1.22, 0.88–1.68) or both antenatal and postnatal depression (0.89, 0.56–1.36). There was no association of maternal depression with shorter sleep duration. Two of five dimensions of infant temperament (fear and negative affect) were associated with both antenatal depression scores and increased nighttime awakenings. Mediation analyses controlling for postnatal depression and other predictors of child sleep supported an indirect pathway of antenatal depression to child sleep through infant temperamental negative affectivity.

Conclusion

Antenatal depression is independently associated with more frequent nighttime awakenings in early childhood. Findings support an indirect pathway through infant negative affect characteristics.

Association of Repeated Antibiotic Exposure Up to Age 4 Years With Body Mass at Age 4.5 Years

IMPORTANCE

Antibiotic exposures in early life may affect weight by altering gut microbiota, potentially increasing the likelihood of childhood obesity.

OBJECTIVE

To examine whether repeated antibiotic exposure by age 48 months is associated with higher body mass index (BMI) at age 54 months.

DESIGN, SETTING, AND PARTICIPANTS

This research was undertaken within a prospective cohort study in New Zealand (Growing Up in New Zealand) that recruited 6853 children antenatally during 2009 to 2010. At the 54-month follow-up, 5734 of 6156 children (93%) had their weight and height measured. Community pharmacy antibiotic dispensing data were obtained from the New Zealand Pharmaceutical Collection database for children whose parents consented to external data linkage. The analytic sample comprised singletons with 54-month weight and height measurements, community antibiotic dispensing and birth weight data, gestational age greater than 27 weeks, and no congenital anomalies. Data analysis took place from 2017 to 2018.

EXPOSURES

Antibiotic exposure (yes or no), the number of dispensings, age at first exposure, and timing (age) of exposures between birth and age 48 months.

MAIN OUTCOMES AND MEASURES

World Health Organization BMI-for-age z scores; and International Obesity Task Force overweight and obesity cutoff points that pass through adult BMI values of 25 and 30.

RESULTS

Of the 5128 singletons (2622 [51%] male; mean [SD] birth weight of 3527 [542] g), 4886 (95%) had an antibiotic prescription by age 48 months and 437 (9%) had obesity at age 54 months. Adjusted mean (SE) BMI-for-age z scores increased significantly with the number of antibiotic dispensings for 4 to 6, 7 to 9, and more than 9 dispensings (unexposed, 0.87 [0.09]; 1-3 exposures, 0.92 [0.06] [P = .57]; 4-6 exposures, 1.06 [0.06] [P = .02]; 7-9 exposures, 1.06 [0.06] [P = .02]; >9 exposures, 1.08 [0.05] [P = .01]). Additionally, receiving more than 9 dispensings was associated with greater likelihood of obesity compared with no exposure (adjusted odds ratio, 2.41; 95% CI, 1.07-5.41). Children whose exposure began in the first year of life had a higher adjusted mean (SD) BMI-for-age z score than those not exposed (1.06 [0.05] vs 0.89 [0.09]; P = .03), whereas those whose exposure commenced after the first year of life did not (1.02 [0.06] vs 0.89 [0.09]; P = .10).

CONCLUSIONS AND RELEVANCE

In this study, repeated antibiotic exposure in early childhood was associated with higher mean BMI-for-age z score and an increased likelihood of obesity. Future research could examine whether interventions such as antibiotic stewardship programs, which are designed to reduce overprescribing of antibiotics, also reduce early childhood obesity.

Risk Factors and Attack Rates of Seasonal Influenza Infection: Results of the Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance (SHIVERS) Seroepidemiologic Cohort Study

Background

Understanding the attack rate of influenza infection and the proportion who become ill by risk group is key to implementing prevention measures. While population-based studies of antihemagglutinin antibody responses have been described previously, studies examining both antihemagglutinin and antineuraminidase antibodies are lacking.

Methods

In 2015, we conducted a seroepidemiologic cohort study of individuals randomly selected from a population in New Zealand. We tested paired sera for hemagglutination inhibition (HAI) or neuraminidase inhibition (NAI) titers for seroconversion. We followed participants weekly and performed influenza polymerase chain reaction (PCR) for those reporting influenza-like illness (ILI).

Results

Influenza infection (either HAI or NAI seroconversion) was found in 321 (35% [95% confidence interval, 32%-38%]) of 911 unvaccinated participants, of whom 100 (31%) seroconverted to NAI alone. Young children and Pacific peoples experienced the highest influenza infection attack rates, but overall only a quarter of all infected reported influenza PCR-confirmed ILI, and one-quarter of these sought medical attention. Seroconversion to NAI alone was higher among children aged <5 years vs those aged ≥5 years (14% vs 4%; P < .001) and among those with influenza B vs A(H3N2) virus infections (7% vs 0.3%; P < .001).

Conclusions

Measurement of antineuraminidase antibodies in addition to antihemagglutinin antibodies may be important in capturing the true influenza infection rates.

Evaluation of vision screening of 5-15-year-old children in three Tongan schools: comparison of The Auckland Optotypes and Lea symbols

Background

Comprehensive vision screening programmes for children are an important part of public health strategy, but do not exist in many countries, including Tonga. This project set out to assess: (1) the functional vision of children attending primary schools in Tonga and (2) how a new recognition acuity test (The Auckland Optotypes displayed on a tablet computer) compares to use of a standardised eye chart in this setting.

Methods

Children from three Tongan primary schools were invited to participate. Acuity testing was conducted using a standardised recognition acuity chart (Lea symbols) and the tablet test displaying two formats of The Auckland Optotypes. Measures of ocular alignment, stereo acuity and non‐cycloplegic photorefraction were also taken.

Results

Parents of 249 children consented to participate. One child was untestable. Only 2.8 per cent of testable children achieved visual acuity worse than 0.3 logMAR in the weaker eye. Results from the Spot Photoscreener suggested that no children had myopia or hyperopia, but that some children had astigmatism. The tablet test was practical in a community setting, and showed ±0.2 logMAR limits of agreement with the Lea symbols chart.

Conclusion

The sample of children in Tongan primary schools had good functional vision. A modified version of the tablet acuity test is a promising option for vision screening in this context.