Directors' Blog

In another life I used to sit on teams that developed something called ‘clinical guidance’. We would draw together published evidence and make recommendations on what best practice should look like. I sat on one such group for rheumatic fever.

Rheumatic fever (RF) is a disease now seen mainly in developing countries (apart, of course, from the poor pockets of New Zealand where it runs at near epidemic rates). If rheumatic fever is not caught early, it leads to rheumatic heart disease (RHD) that in turn leads to serious heart damage – the sort of damage that can see people die in their late 30s.

On this rheumatic fever clinical guidance group that I sat on, I heard a story about the antibiotics that are used to treat the disease. I heard that many of the kids with rheumatic fever live rurally and getting treatment to them is a challenge. I heard that the antibiotics needed to be kept at temperatures lower than a few degrees. I heard that these antibiotics are often driven around the dusty roads of rural New Zealand in the height of a Kiwi summer, eventually getting to families warm and possibly no longer effective. What I heard was that kids who needed the antibiotics the most were being let down by basic logistical stuff-ups.

Is this story representative? Are vulnerable low-income children missing out on antibiotics? And if children are already missing out on antibiotics when they need them in New Zealand, how will population-wide antibiotic resistance affect these children? Children who, coming from low income families, are already at greater risk of infectious disease than other children in New Zealand?

The story for low-income kids and antibiotics is complex & resistance is not going to make things better
Children living on low incomes in New Zealand have more infections (requiring antibiotic treatment) than other children. Rheumatic fever is one disease they contract at higher rates, especially as overcrowding and poor quality housing continues unabated in Auckland. But we also know from the Child and Youth Epidemiology Service, who reports on child health in New Zealand each year, that skin infections plague children from poorer communities. We also know that respiratory infections put them in hospital at a much greater rate than others. And when diseases like measles break out, they tend to do so in low-income communities, with the bulk of the health effects being felt by the children of low -income families. These are the children who need antibiotics and need them to work. Even with antibiotics, children are still dying in New Zealand from diseases of the third world.

Poor children need antibiotics more than other children, but are they getting them?
The situation is complex. We have data showing us that antibiotic prescribing in Counties Manukau in Auckland (a large low-income community) is greatest for those living in overcrowded households [1]. Overcrowding is one of the indicators of poverty in New Zealand.

Below we can see the relationship between antibiotic prescribing and overcrowded households in Counties Manukau. We see as the ratio goes up (representing more people in a bedroom) antibiotic scripts rise too. This finding is understandable in the context of how infectious diseases spread – through close contact with other infected people.

Reproduced with permission.

But does the higher prescribing rate of antibiotics for the vulnerable mean all the children who need them are also getting them? A prescription for antibiotics is not a measure of antibiotics used. We can look at the dispensing of antibiotic use for some clues.

Researchers examined the dispensing of antibiotics (pharmacies filling a prescription) in another part of New Zealand. The town was a rural town at least an hour from other towns with a pharmacy. Researchers found that individuals living in lower income areas of that community were much less likely to be dispensed antibiotics.[2]

So we see that infections are higher for low-income children in New Zealand, and prescriptions may also be higher, but that actual use may be lower for this group.

Low-income children do have the worst access to healthcare in New Zealand
The data present a complex picture, but not one those working in health are unfamiliar with. It highlights what we see across all societies – those that need healthcare the most may be accessing it the least. We call it the inverse care law.

We can speculate based on this evidence what is happening with low-income children in New Zealand. It may be that children of low-income families are getting to the GP but not getting the antibiotics on board. It may be that even getting to the GP is such a challenge that low-income children are not being seen till very late – we certainly know that low-income children see medical professionals a lot later down the path of an infectious disease making treatment more difficult and spread and recurrence more likely.

It may be that low-income families cannot easily access the antibiotics even once they are prescribed. We know that in New Zealand the children who don’t get to the GP because they have no transport (a measure of material deprivation & poverty) are the children of low-income parents, as the data below demonstrates.

New Zealand has a government funded primary healthcare system, with free GP visits for children under 13 and low cost prescriptions. But in reality, there is an imbalance in who accesses this funded healthcare. It not just healthcare itself that costs families – the opportunities to access the care also costs: time off work; access to transport; being free of other health debts and social stigma; having someone who can care for any other children. These are all resources a parent needs to be able to draw upon to access healthcare for their child. In many cases, low-income families have fewer of all of these resources. While the data has gaps, it certainly indicates that there is likely to be a problem in terms of low-income children’s access to and use of antibiotics when they need them.

What happens when we add antibiotic resistance into the mix?
Nothing good. For children who need antibiotics the most, resistance has the most serious impact. For a group of children who are already disadvantaged by being poor, we have at least always had the hope that, if they can equitably access timely treatment, we can overcome some of the disadvantage they suffer. With resistance looming this will not be the case, and the children who will die at the greatest rate from what are now just everyday infections will of course be those already getting the worst deal from the imbalance in New Zealand society. But we can do something about this.

What can be done?
As always the ambulance parked at the bottom of the cliff will not assist us here. Research into antibiotic alternatives needs funding, and a huge reduction in unnecessary antibiotic use is needed (including in animals and farming).

However, there is something we can do right now for children living on low-incomes – we can correct the imbalance in their health outcomes through strong policy. Research tells us there are many effective ways to address this imbalance, and most of them lie outside of the control of the health workforce.

Bringing families with children up over the various poverty lines using unconditional cash assistance is an area that has significant potential to improve children’s health. Housing affordability, quality and access is another area with serious potential to improve low-income children’s health. The best evidence shows that improvements to the physical aspects of the home (e.g., ensuring it is the appropriate size for a family, it can affordably be kept warm, it is insulated and not damp) improves health (especially in those with existing respiratory illness), may improve and promote relationships in the family, and may reduce absences from school or work. The findings are especially applicable in low-income households where the need is greatest.^[3]

The end of antibiotics as we know is upon us. However, in the time between their discovery and their demise, let us finally deliver for low-income children a good society, one that ensures we are all already in the same boat as we work to find solutions together.

References

[1] Walls, G., Vandal, A. C., du Plessis, T., Playle, V., & Holland, D. J. (2015). Socioeconomic factors correlating with community antimicrobial prescribing. NZ Med J, 128(1417), 16-23.

[2] Norris, Pauline, Gordon Becket, and Denise Ecke. “Demographic variation in the use of antibiotics in a New Zealand town.” The New Zealand Medical Journal (Online) 118.1211 (2005).

[3] Thomson H, Thomas S, Sellstrom E, Petticrew M. Housing improvements for health and associated socio-economic outcomes. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008657. DOI: 10.1002/14651858.CD008657.pub2.

About

Dr Jess Berentson-Shaw works at the Morgan Foundation Policy Think Tank and writes about science, children and families at The Spinoff Parents. You can follow her on Twitter @DrJessBerentson

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.

Wash your hands all you want.  Don’t touch things. Clean your cuts and grazes. Be careful all you can… but it won’t make any difference. An open wound will grow; it will cause rashes on your body and your skin to blister and weep. Once it’s in your blood stream, it goes wild, living in there like an uninvited guest crashing your dinner party.

It smells. I can smell it a mile away. Doctors laugh at you, but it definitely has its own smell. It stinks and to get rid of it, to try and get it to leave you completely, is like being entrenched in a war where no matter how hard you try the other side is always tougher.

I spit the words when I say them as it has haunted my life and my family’s life for so long. It enveloped my every waking moment, and every sleepless night, as I wished moment after moment it had never come into our lives.

It’s MRSA, a form of staph bug – a superbug which has nothing I deem “super” about it. To me, super is like a “super hero”, but the only hero when it comes to MRSA is those who battle it or those who are trying to cure it.

My little girl lived in hospital a long time battling gastrointestinal failure and the complications that accompany it. We were definitely no strangers to infections, spending weeks on end on all order of antibiotics for every different thing over years and years. That was my biggest worry then, and now. People used to say MRSA, MSBL, C.diff, and I used to just switch off; my child didn’t have them, so it didn’t matter.

Then one day, while she battled a burst gall bladder and just wouldn’t show signs of improvements as she had infection after infection, a doctor came into the room, gowned, gloved, and masked and said she has MRSA in her blood stream and it’s growing in her line and tubes.

Oh shit, I said. That’s all I said. I still didn’t register how much it would affect our lives.

We lived in the hospital and were always around and about, playing with nurses, in the play room; anything to pass the time. Now, once she recovered from the gall bladder incident, we couldn’t play; she still grew MRSA. Too many lines and tubes. No more playing with other children in hospital. No more playroom. We were stuck – isolated with a bug that was growing more resistant by the day and scared of spreading it around. And, of course, following strict hospital protocol around such bugs.

But, reality was, that’s nothing compared to the impact it had on my child physically. No longer are you just battling a medical condition but a serious infection on top. It rules your life and all the choices you make.

It leaks and oozes. Then you change a dressing and after multiple changes it then gets raw and oozy.  Years of constant infections followed, and traumatic moments that I won’t relive here.

You think with an infection that doctors just get an antibiotic and treat it. If that doesn’t work, they will have another. The thing about a bug like this is you can get to the end of antibiotics, and those IVs take longer and longer before a solution is found. Within a week, after more and more attempts, it then doesn’t work at all. The bug lays dormant then sneaks up and flares up when you least expect it. One day nothing. Then you look the next day and see the familiar pale yellow ooze leaking out from a line and your heart sinks. You know it will get worse before it gets better.

The other thing people don’t get is the toll endless antibiotics takes on a body: thrush, reactions, tummy pain, puffiness, blowing lines. Endless and yet unavoidable. The constant fear of what next eats away at you as well as the constant worry about treatments not working.  Even short term IV lines grew MRSA as we lost line after line and our vein access went from minimal to pretty much nothing.

The thing is, it’s a bug, you catch it. That brings a whole different sort of grief and anger compared to a condition you are born with or develop. Anger ruled my life. When MRSA flared up, I was often so scared as the violent convulsions from temperatures would take hold from another infection in the line. It had to be someone’s fault. I found people to blame and, to an element, I still do. But it’s nothing compared to the guilt and blame you place on yourself. As a mother, I should protect my children – the most precious things in my life.

Yet, while in my care, my child contracted a bug that was ravishing her poor little body. Did I not wash my hands enough? Did I not watch procedures close enough? Should she have sat on the ground when she did? So many stupid questions. When I’m not exhausted, and as life moves on, I know it’s a bug that’s everywhere. The longer you are in hospital, the more immune-suppressed you are, or just pot luck, you’re likely to contract a superbug.  I just wish it hadn’t grown on my child. I wish it didn’t exist at all.

We don’t have a line now. The last growth of MRSA was followed by thrush in her blood stream and it meant the final access was to be removed. Reality is, any line is going to be an area likely to grow this bug.

The not sleeping at night as you check continuously for a line infection; the constant changing of painful dressing; the fear that this could be in her blood (and not picked up earlier) all dulled, as the risk is so much lower. But, unfortunately, it still rears its head, but in more fiddly ways. A skinned knee ends up more manky, the longed-for pierced ears mucky and taking longer to heal. It’s a relief to sleep easier at night but also a battle to keep a child with gut failure line-free.

Something good I realised, just the other day, was how improved her quality of life has become now that she hasn’t got a line oozing MRSA continuously. That bug took such a toll on her body that she was bloated and puffy from constant meds.

It’s been a really big and cruel lesson to learn how important the research being done to treat and cure Staph bugs is. It’s something you just wish no one had to deal with. It’s something I wish my family never had to deal with.

We need to find a cure.

About

This post was provided by parent Tiff Mora.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.

Last week was World Antibiotic Awareness week, an initiative of the World Health Organization (WHO) to raise awareness and understanding of antibiotic-resistant superbugs. To follow, here at Te Pūnaha Matatini we are launching a week-long conversation about the health, social, economic, and environmental impacts of infectious diseases in Aotearoa New Zealand. Where possible, in collaboration with Figure.NZ, we’ll bring you publicly available data to help illustrate the issues. Welcome to #InfectedNZ!

Infectious diseases: complexity personified
The phrase ‘infectious diseases’ describes a multitude of life forms which differ in their genetic make-up, life-styles and habitats. They lurk, hidden and unseen, on our skin, up our noses and in our guts. On our pets and livestock, too. And amongst our plants, rivers and soils. And when some of them get into our bodies, or into our plants and animals, they can cause devastation to human and animal health, our environment, and our economy. So there is no one single threat from infectious diseases, or indeed, no simple one-size-fits-all solution. Like so much in life, the issue is complex and complicated.

But experts do all agree on one thing: we are running out of ways to treat infectious diseases.

The prediction is that without urgent action, within the next 5-10 years we could see a return to the pre-antibiotic era, when something as simple as a stubbed toe could mean amputation or death. That’s a big part of why we need to have a national conversation about infectious diseases and what the future holds.

Aotearoa New Zealand: we are not immune
Many people think of infectious diseases as a third world problem. And it’s not hard to see why when we are all surrounded by friends and family being diagnosed with various cancers or heart disease. But in the year July 2013 to June 2014, almost 91,000 Kiwis had infectious diseases listed as the primary cause for why they were hospitalised, accounting for around 8% of all hospitalisations that year. It’s also worth noting that many other people in hospital will also be battling an infectious disease as a result of having a compromised immune system, either because they’ve had surgery, or have a non-communicable disease like cancer or diabetes. These people will not feature in the numbers though, as their underlying disease would be listed as the primary cause for them being in hospital.

As you can see, two-thirds of infectious disease hospitalisations were for bacterial infections, with the major contributors being food and water-borne infections, Staphylococcus aureus (also known as Staph, or MRSA, which stands for methicillin-resistant S. aureus) and Streptococcus pyogenes (also known as Group A Strep, or sometimes, the ‘flesh-eating disease’, as this bacterium can sometimes carry an enzyme that can digest human flesh).

Fortunately, the majority of infectious diseases that Kiwis are exposed to are still treatable. In 2013, just over 1,200 (about 4%) of the 29,636 people who died that year had infectious diseases listed as the primary cause of their demise. As in the hospitalisations, the figures cover what was recorded on the death certificate which may not always be the immediate cause of death. For example, many of those who are recorded as having died of Alzheimer’s disease are more likely to have died of pneumonia or a urinary tract infection.

We’re bucking international trends, but not in a good way
As countries become more developed, their rates of infectious diseases fall, and their rates of non-communicable diseases like cancer and heart disease rise as people live longer. Most Kiwi’s will probably be surprised to find out that here in Aotearoa New Zealand we are bucking those international trends: our rates for many infectious diseases are going up, not down. We wanted to show you the data, but can’t. It is publicly available on the web but Figure.NZ were denied permission to turn it into nice charts for you to see. What we can tell you is that a study of hospital admissions over the last twenty years, carried out by Prof Michael Baker and colleagues and published in the prestigious medical journal The Lancet, showed that while overnight admissions to hospital due to non-communicable diseases have increased by 7%, those due to infectious diseases have gone up by a staggering 50% (1).

“Surely it’s them, not us?!”
What you might also be surprised to hear is that we have higher rates of many infectious diseases than the USA, Australia and the UK. And just in case the thought crosses your mind that perhaps all those infectious diseases are being imported into New Zealand by ‘foreigners’, and if we curb immigration infectious diseases will all go away…How can I put this politely?! I think you’ll find it’s a little more complicated than that!

Yes, some infectious diseases can be ‘imported’ into New Zealand by ‘foreigners’. But guess who also goes overseas? We do. In droves. According to Statistics New Zealand, in 2014 there were more than 700,000 overseas departures from Auckland Airport by resident New Zealander’s going on holiday. Another 600,000 were people going to visit friends and relatives overseas. As an island nation, we travel a lot. And each of those trips is an opportunity to bring back an invisible infectious passenger. So, unless you never want to go on holiday again, or visit friends and family overseas, let’s nip that line of thinking in the bud. The reality is, we don’t need travel or foreigners to bring infectious diseases or antibiotic-resistant superbugs to our Clean Green/100% Pure(TM) island paradise.

So, to sum up. Not only are infectious diseases becoming more widespread here, they are also becoming more difficult to treat. It’s time we stopped thinking of infectious diseases as a third world problem, and have a national conversation about how we all, the public, health workers, policymakers and the agricultural sector, can solve this crisis. I hope you’ll join us across the week to participate in this important discussion. Follow #infectedNZ on Twitter or Facebook, or leave a comment below.

Reference:
(1) “Baker MG, Barnard LT, Kvalsvig A, Verrall A, Zhang J, Keall M, Wilson N, Wall T, Howden-Chapman P (2012). Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study. Lancet. 379(9821):1112-9. doi: 10.1016/S0140-6736(11)61780-7.

About:

Dr Siouxsie Wiles is Deputy Director (Outreach and Public Engagement) of Te Pūnaha Matatini. She describes herself as a microbiologist and bioluminescence enthusiast. As Head of the Bioluminescent Superbugs Lab at the University of Auckland, Siouxsie combines her twin passions to understand infectious diseases.

What is InfectedNZ?

Hey, Aotearoa. It’s time we had a chat about infectious diseases and what we’re going to do about the looming antimicrobial armageddon. That’s why we’ve asked leading health, social and economic researchers, and people with personal stories, to help us get real about our vulnerability and discuss solutions. Follow their blogs right here at tepunhahamatatini.ac.nz and watch the conversation spread across social media with #infectedNZ.

Backing it all up, wherever possible, is data from the good folk at Figure.NZ. Their super duper charts are based on data sourced from public repositories, government departments, academics and corporations. Check out their #infectedNZ data board and sign-up to create your very own data board on any topic that floats your boat.